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Teens and Confidentiality in Counseling

Teens and Confidentiality in CounselingParental involvement is a key ingredient in kid client success in therapy. What this looks like will depend on your child and his/her treatment plan, your practical ability to be involved (are you a noncustodial parent? Is your child receiving services at school?) and the therapist. But at the very least, you and your child’s therapist should be communicating regularly.

Depending on the child, the parents and the treatment goals, I include parents in the following ways:

  • Parents attend sessions with their child (this is common with young children and with children who are struggling with attachment);
  • Parents come in for the first or last few minutes of session;
  • Meeting with parents separately before or after the child’s session;
  • Scheduling separate sessions with parents when needed and appropriate;
  • Arranging for phone calls to check in.

I like kid feedback for how parents should be involved, particularly with teenagers who are navigating the developmentally appropriate need to separate along with the necessary support from parents. Sometimes this means helping the teen figure out how they want to talk to parents about something and then inviting parents to session to help mediate a discussion.

I go over confidentiality with parents and teens in session with the understanding that we will all respect the teen’s privacy in the counseling relationship but that the adults will keep her safety paramount in decision-making around what to share. When kids are struggling in a gray area, I always encourage them to invite parents to the discussion but I won’t go over their heads and tell secrets unless I’m concerned for their safety.

Here’s the Ohio ACLU publication about minors and their rights. The part about counseling (this is a PDF file) starts at page 40: Your Health and the Law: A Guide for Teens.

From the file:

A minor who is at least 14 years old can request outpatient care without notifying a parent as long as the treatment does not include medication. However, such care is limited to six sessions or 30 days, whichever comes first. After that, the care must stop or the parents must be informed and must consent in order for treatment to continue. During the first six sessions or 30 days, the parents will not be informed of the treatment unless the teen consents or the care provider feels the minor is likely to harm someone. Still, before the parents can be informed, the care provider must first tell the teen that the parents will be notified.

I have not had a teen call and ask for counseling on her own but I have had other loving adults (relatives or family friends) call me to find out if they can bring the teen to counseling without parental consent. I always explain how the law works and explain that except in cases where parental involvement would be dangerous to the child, it’s really best to have parents be a part of counseling.

There are guidelines around counseling teens and maintaining confidentiality. As a counselor practicing in Ohio, my ethical guidelines come from Ohio’s Counselor, Social Worker, and Marriage and Family Therapist board and┬ámy professional organization, the American Counseling Association. Both these entities recognize that teen confidentiality is a gray area. The ACA and their sister organizations for social workers and other therapists regularly publish articles and papers on the topic.
Here’s a handful for you to check out:

As you can see, there are not definitive answers because these topics are complex and so very individual. How I might, for example, handle it if a client tells me s/he is sexually active will depend on many things including but not limited to:

  • Why the teen is in counseling in the first place;
  • With whom they are being sexually active (is it consensual? Is it legal?);
  • How old the teen is (there’s a big difference between a 13 year old and a 17 year old);
  • The family’s values around sexual activity;
  • The circumstances surrounding the sexual activity (are there pressing concerns about safety?).

My first priority is always first and foremost safety but I recognize my ideas about safety may be different than the families. For example, say I learn that a 17-year old after careful consideration and planning decides to access birth control and have sex with her long-term partner. Perhaps she comes from a strict, conservative family whose religious beliefs condemn premarital sex. I am unlikely to break confidentiality under those circumstances.

I say this to encourage parents to talk to their teen’s counselor to make sure that they understand each other. If you want a counselor who would break confidentiality then I’m not the right person to work with your teen. It’s best we all know this ahead of time.

That said, I do not ever encourage teens to lie and I do not side with them against parents.

Finally, when confronted with a sticky situation I seek supervision, meaning I go to my peers and my mentors to get feedback when I’m not sure. While maintaining confidentiality about the individual and the family, I ask for help and document these efforts accordingly. It’s dangerous for any therapist to operate in a vacuum and I am fortunate to have great counselors available to me to answer questions and help me examine ethical practice as it applies to the complicated reality that is counseling kids and teens.

A Diagnosis Discussion

toomuchthink-insideAt the community mental health center where I work every single person I see gets a diagnosis. There’s a preliminary diagnosis after the first session, which I may write without even seeing the client. (When we do an intake on a child we see the parents without the child for that first diagnostic assessment so the preliminary diagnosis is based on the parents’ report.) The preliminary diagnosis isn’t set in stone; it’s considered a starting point. Clients at the clinic use insurance or Medicaid to get services and they require a diagnosis to open the case so we give one based on the information that we have.

Then a few more sessions in we write the actual diagnosis. By then we’ve seen the client, we have a fairly full history and we can make a full five axes diagnosis. We base that diagnosis on the client’s symptoms and history and when we write the treatment plan we refer back to it and it all works very nicely.

The reasons behind diagnosis are pretty clear — when we make a diagnosis we are creating a picture of the client for ourselves, for other clinicians who might work with her, and for the client herself. As we design treatment plans and measure progress we can refer to the diagnosis to get a better understanding of the work we’re doing together. When we case consult at our clinical meetings we can use diagnosis to better communicate the issues for our client in order to get appropriate feedback to improve her care.

That’s all good, right? Usually it is good. But sometimes it’s frustrating.

Diagnosis is an imperfect art. You know that old joke about rabbis? Here, I’ll tell it to you: What do you get when you have three rabbis? Four opinions. Same goes for therapists. Sometimes a person is experiencing such clear symptoms that it’s very easy to say, “Ahh, yes! Recurrent, persistent and intrusive thoughts? Behaviors meant to neutralize these thoughts? Repetitive hand washing, counting and rules about light switches meant to stave off distress? That’s 300.3 Obsessive-Compulsive Disorder!” Easy-peasy. Everyone gets it.

But other times you can have a client and it’s not nearly as clear for lots of reasons. Like clients may not really know their own history. They may exaggerate or understate the length of time they’ve had symptoms or the severity of those symptoms. Sometimes I get a client’s records and find out she’s had several different diagnoses (this is especially true for children). This speaks to the fact that it is all open to interpretation.

A diagnosis doesn’t just exist in the clinical setting; our clients live with it. I’m not talking about the symptoms or history that lead to the diagnosis; I’m talking about the label. The diagnosis doesn’t just live in her file, all nice and neat and detached from real life. The diagnosis lives in her experience of herself.

Part of working with a client around her diagnosis is helping understand that she isn’t her label. She is not “a depressive” or even a “depressed woman;” she is a “woman with depression.” Even if her illness dictates some of her choices (medication, counseling, etc.) it is not HER. But it can be hard, particularly when I have a client who has been living under the shadow of a diagnosis for some time.

This is especially important when it comes to teenagers. Teens are already trying to figure out who the heck they are and getting a diagnosis in the middle of that can be heady stuff. A diagnosis can be used like a shield to protect her from expectations, to excuse herself when she hangs back, and to rationalize her failures. She may become her diagnosis, reading information on the internet and shaping herself to fit the criteria.

I have a lot of clients who come in with a self-diagnosis based on reading magazines, talking to friends or just a general understanding of what a label actually means. (Lots of clients use words like “anxious” and “panic attack” and “bipolar” without understanding their clinical definition.) They sometimes feel very defensive when I tell them that they don’t actually meet criteria. Feeling sad about a pet dying is not clinical depression; it’s appropriate grief. Feeling nervous about going on a first date is not social anxiety disorder; most of us are nervous before a first date. Feeling happy one day and sad the next is not bipolar disorder; it’s part of the human condition. Our sadness and our fears and our struggles do not need labels to be real.

When I give a client her diagnosis I first give her a rundown about how we got to it. I explain that a diagnosis is a label for a cluster of symptoms and that our focus will be on addressing symptoms. I tell them that a diagnosis is just a way for us all to communicate with each other and it’s not more real than what they’re actually experiencing. It’s a tool, I say, OUR tool, THEIR tool and we own our tools; our tools do not own us.

I don’t take insurance in my private practice and one reason is that it allows me the freedom to give or not give a diagnosis. A diagnosis should serve the client and sometimes I think a client is best served by not being given one.

Why kids cry more on the days you’re depleted

When I was a preschool teacher I noticed that the kids seemed to be extra rambunctious on those days when I was feeling lousy. On the mornings that I dragged myself into work with a bad headache, the kids were way more apt to be climbing the walls (and me). The more I needed them to be quiet, the louder they got. They were picking up on my distraction and found it scary; they were trying to drag my attention back.

It’s a mini-version of that still face study I shared before.

Those of you who have kids have likely noticed the same thing. You come home from work dragging and everyone seems whinier. Or you wake up with that sore throat that’s going around and that’s the day your toddler decides that every little thing frustrates her and she can’t manage without your help.

And I don’t know about you, but my children are psychic and can sense when I get on the phone to have a nice long chat with a friend. Nothing brings them underfoot faster, right?

It’s not your imagination; your children are trying to reestablish the balance that feels safe to them. They want your eyes back on them. For children who have experienced loss or trauma, these reactions might be stepped up.

Teens do this, too, sometimes on a much larger scale. The teen years aren’t just about hormonal upheaval. Families have developmental stages just like individuals do and the developmental stage of preparing children to move up and away is hard on the system. Everyone is doing that weaning dance — stepping towards each other, stepping away — and sometimes the steps aren’t in sync. Parents may embrace the relative freedom of having a teen a little too forcefully, relaxing the rules and the supervision too much or too fast. Teens react by revving up unsafe behavior both because they can and because they may be unconsciously asking the parents to come close again.

When you recognize that your children are working to bring back balance and aren’t just trying to drive you crazy, you can figure out ways to do that while still taking care of yourself. On the days you need some quiet, you may find that if you can give some concentrated time to your child that she’ll be more willing to let you pull away later. Same goes for a teen who seems to be wanting — however much he says he doesn’t — more of you. Building in some focused family time may help reassure him that you’re not expecting him to leave the nest just quite yet.

And for fun, here’s a song that’s about trying to talk to someone on the phone while you’ve got kids. Whether you’ve been the one trying to talk or the one trying to listen, I think you’ll find it very familiar.

A Look at Clinical Supervision

chair-insideGroup supervision is similar to group critiques in a creative writing class. You present your case and then people chime in to try to help you with it. Sometimes you need help with practical matters — like what to do ethically or what clinic protocol demands — but usually the cases you bring to supervision are the ones that have you banging your head against the wall.

Case presentation looks something like this:

My client is this age and ethnicity. My client came to counseling because of this reason. Here is what is most important for you to know. (That might include her diagnosis if she has one; her background and history; her progress so far.) This is how often I’ve seen her.

And then the big question:

Here is how I am stuck.

The point of group supervision is not to throw a bunch of theories at the presenting clinician or for participants to show off with how much more they know. The point of group supervision — and individual supervision — is a lot like the point of counseling; it’s to help the clinician to find the answers in her own experience. Sure, we share things we know with each other — research we’ve read or similar cases we have experienced — but only if doing so will illuminate the presented case for the presenting clinician. Very often we spend a lot of time asking questions not only to clarify the case for ourselves but in the hope that giving us the answers will clarify the case for the presenter.

In graduate school we used a Gestalt technique where someone would listen to the case presentation and write down aspects that seemed particularly relevent. If we were to do it for say, Harriet the Spy after her notebook was stolen and her parents take her to the psychiatrist* then the list might include: Notebook, parents, Ole Golly, spying, isolation and friendship. Then each person would pretend to be something on that list and speak as that thing out loud. I know it sounds silly (and it can feel silly doing it) but it can also lend unexpected insight.

The person playing the notebook might say, “I am Harriet’s notebook. I hold all of her secrets and keep them safe for her. I let her examine things from all sides and speak without reservation. I am a reflection of her innermost thoughts. I let her take those thoughts out and give them room to breathe. I help her open up space in her busy mind.”

It’s all open to interpretation, of course, and the person pretending to be an aspect of the case could certainly be wrong but that doesn’t matter. The exercise is meant to give the clinician a different perspective.

Perhaps the therapist listens to the person playing the notebook and she starts to think, “Without her notebook Harriet must feel so cramped and trapped. Perhaps she feels like she can’t think without it.” And it might change the course of their treatment in some small way that lets the clinician get unstuck.

While I don’t like role plays where you play the client and I play the clinician or vice versa, I did like this technique. It was often so jarring (“You be the client’s entrenched views about her mother’s religion; you be the client’s nightly vodka tonic; you be her beloved poodle; you be the man she met on the internet) that even when it wasn’t my case I was sure to learn something new to bring to my clients the next morning.

* If I remember correctly, Harriet’s therapist gives her a notebook and she spends the whole session scribbling in the corner, frantic to write because her parents have taken her others away. When she goes out to the waiting room clutching the notebook her parents remove it from her possession and she doesn’t see the therapist again. Do I have that right? Probably her dad calls the therapist a fink. There’s a lot of finking in that book.

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