The Child Confidentiality Bind

How to Involve Families When Treating Teens

Laura Kastner

Q: I find that working with teens within the confines of strict confidentiality agreements isn’t serving their best interest. What can I do to bring in parents without losing the trust of the teens?

A: It’s a tall order to maintain a teen client’s privacy and build rapport with them when you’re including their parents in the mix. But I’ve found that having the right kind of confidentiality agreement in place can make this work a lot easier. 

Sure, hammering out confidentiality agreements with clients certainly isn’t a fun part of our work, but it’s a necessary one. Although many therapists today readily accept the merits of the family systems approach and include parents in treatment, there are also many therapists who adhere to traditional confidentiality agreements that promise the teen total privacy over what’s discussed in treatment, eliminating parents from the equation altogether.

In my work as a therapist, consultant, and academic supervisor, I’ve found that therapists who use these traditional confidentiality agreements are setting themselves up for failure, ignoring years of proven results about the effectiveness of the family systems approach. Not only are these agreements wildly outdated, but they put us in a bind if evidence suggests the teen could pose a danger to themselves or others. Contrary to what some may think, the research shows that parental involvement actually improves trust between the teen client and the therapist.

In my own practice, I use what’s called a partial confidentiality agreement, which makes it clear that parents or caregivers will be involved in therapy in some fashion. From the very first session with a teen client and his or her parents, I make it clear that this is how I operate.

Why do some therapists still opt for traditional agreements instead of partial ones? For one, there’s the common notion that kids won’t share opening if their parents are present, that you’ll never be able to build rapport unless you promise them total privacy. Frankly, it’s also more time-consuming. Why go through the trouble of explaining a confidentiality agreement and possibly subjecting yourself to pushback right out of the gate when you can just get to work instead?

Granted, it does take some finesse and extra work to explain why including parents in therapy is important and to delineate what will and won’t be kept private. But I’ve found that teens gradually warm up to this way of doing therapy, and that the outcome is worth it.

To be honest, I wasn’t always a firm believer in including parents, or in partial confidentiality agreements. In fact, I spent over a decade working at a children’s clinic without including parents But when I switched to private practice and began interacting with them more frequently, it finally dawned on me that part of the reason I hadn’t thought to include them was because I felt intimidated. After all, many of these parents were no-nonsense, professional types, who simply wanted to drop off their kids at therapy and leave the rest to me. A part of me wanted to please them without bothering them. After talking and consulting with dozens of other therapists—now as a supervisor—I know I’m not alone in having felt this way.

So what changed? A few months into private practice, I made a big fumble with a teenage client. It’s a story I share with my supervisees today. 

Why Parents Matter

When I first met 14-year-old Celeste’s parents, I was impressed by their care and devotion. They desperately wanted to help Celeste, a bright, overachieving student, work through her body-image issues, depression, and negative self-esteem. 

“Whatever it takes,” Celeste’s mom told me on the first day.

Celeste agreed to work with me, but on one condition: her parents weren’t allowed to join us in the therapy room. I looked at her intake forms. Her problems seemed straightforward enough. Since her parents weren’t necessarily opposed to our therapy sessions being “Celeste’s time,” as they phrased it, I agreed, and we signed a traditional consent agreement. Under the agreement, I’d only involve Celeste’s parents if it was clear that she was a danger to herself or others. 

What a mistake that was.

Within weeks, Celeste had started high school, and with the new environment came new stresses, and new, negative ways of coping. In our sessions, Celeste admitted she’d begun drinking alcohol, smoking marijuana, and having unprotected sex with a new boyfriend. She railed against her mother and father, recalling the angry fights they’d have late into the evening. When I asked her whether she’d told them what was going on, she shook her head emphatically.

“Why would I ever do that?” she sneered.

I’d boxed myself in. By not leaving myself more wiggle room in our agreement, I couldn’t give her parents a necessary glimpse into what Celeste was dealing with and how she was managing her stress. After all, her behavior didn’t meet the standard of harm to herself or others. In Washington State, where I practiced, kids 12 and older have the right to have sex and seek contraception. Under the confidential agreement, a host of other behaviors, like self-scratching (sometimes a precursor to cutting), as well as social media and gaming addiction don’t meet the harm standard. So sure, by definition, her behaviors weren’t overtly dangerous. But left unchecked, I knew things could quickly change.

“Celeste, why don’t we have your parents join us,” I pleaded in one session. “Just one time.”

Celeste shook her head. “They just don’t get me.”

I tried dropping a truth bomb. “You know, I think this depression, this anger you’re feeling could be related to what’s going on at home—the fights that you’re getting into with your parents.”

Celeste was adamant. “They’ll only make it worse.”

I racked my brain searching for the answer. What the hell was I going to do? I felt like an unwitting partner in crime.

Soon enough, Celeste’s mother was leaving me long voicemails complaining about our lack of progress. “What’s she doing in therapy anyway?” she asked in once voicemail, apparently baffled. “Is she even trying to get better? This has gone on long enough. I’m afraid if things don’t improve soon, we’re going to have to consider other options.”

I called back. The best I could offer her was a session with her and her husband. Maybe that would help us get to the bottom of things. She declined.

“Frankly, I don’t have the time, or the money to be paying for two therapy appointments,” she snapped, clearly irritated. 

I came to dread my sessions with Celeste. It felt like I was holding my breath, just waiting for the other shoe to drop. Even though Celeste was only experimenting with drugs and sex, how long would it be before things took a turn for the worse? And if her parents—who at this point weren’t much help at all—weren’t willing to work with me, how much progress could I really make with Celeste one on one? Her behavior had worsened on my watch. I felt incompetent. I felt helpless.

The Breaking Point

Well, I wasn’t wrong about everything. Right after her mother threatened to stop therapy and yet another epic fight with her father, Celeste wound up in the emergency room with alcohol poisoning. With the standard of imminent danger met, I insisted that once Celeste had recovered, we’d be doing family sessions moving forward. I told Celeste’s parents that they needed to help me create emotional guardrails for Celeste before things got even worse. They agreed. Celeste, scared and fearing worse repercussions than family meetings, also acquiesced. 

Sessions with the family were rocky but productive. Soon, all the dirty laundry between these feisty foes came tumbling out. No wonder they’ve avoided being in the same room together, I thought. But their relief was palpable too. 

Celeste continued to be volatile at times, but her depression lifted and her risk-taking gradually subsided. Her parents, too, took responsibility for what had happened, and promised to do a better job of communicating with their daughter moving forward. 

As for me, I’d learned my lesson. When it came to working with teens, traditional agreements weren’t going to cut it.

Partial Agreements 101

As this case shows, it’s naïve to think that therapists can leave parents out of their child’s therapy. Working with teens takes ecological interventions, like involving teachers, families, and other supportive adults. After all, the teenage years can be difficult. Why not give kids, parents, and therapists all the help they can get? 

Still, partial confidentiality agreements can be a hard sell. It took me months to fine-tune mine and find a way to articulate it to clients in a way that instills confidence. As you craft your own partial confidentiality agreements, here are the six elements of mine (and the language I use) that might help you explain why this arrangement is so crucial to success. Note that if you’re looking to add legal language to your agreement, you should consult the particular laws in your state.

Therapist Accountability. “Your parents love you and will occasionally have concerns about how therapy is progressing. I may meet with them privately, but I will let you know about it. They will want to evaluate whether you are receiving appropriate care, and I need to be ready to account for myself. I will tell you what I am going to tell them, and you can have input. Ideally, we’ll update your parents together.”

Teen Privacy. “As a minor, you have a right and a need to feel secure that certain confidences will not be revealed to anyone, including your parents. However, situations may arise in which I believe that sharing information with your parents is in the interest of your health and welfare. Examples include engaging in risky behaviors or exposure to potentially harmful experiences.”

Practicing Skills. “I may recommend that we have sessions with your parents sometimes. Since there are so many prickly issues in families, practicing skills for conflict resolution and communicating complex feelings can be helpful. We all get our buttons pushed sometimes, so learning emotional regulation skills can benefit everyone in the family.”

Supporting Family Attachments. “Your parents are with you are for hundreds of thousands of hours, and I’ll be with you for only a tiny fraction of that, so whatever I can do to reduce the suffering for everybody is good. I’m supposed to be a short-termer in your life. Your parents will be with you for the long haul.”

Avoiding the Black Hole of Not Knowing. “Sometimes incidents occur that parents notify me about. You may be reluctant to elaborate on these incidents in therapy. I understand that it can be difficult to share sensitive information, but if I’m operating in the dark, I won’t be much help to you.”

Parental Guidance and Teamwork. “Since your parent(s) have never parented the unique ‘you’ that you are, I may have advice for them. I may meet with your parents alone sometimes, but I will tell you why, and I will share with you what I will be addressing.” 

Both Sides of the Street

Celeste is one of countless teens who value individual therapy and dread the idea of addressing thorny issues in front of their parents. But as Salvador Minuchin once said, it’s important to play both sides of the street. 

In the 30 years I’ve been using partial confidentiality agreements, I’ve never had a teenage client who didn’t agree to it, even if they initially balked. If we think systemically about the problems that could impact teen clients without it, the choice is clear. I’d advise any therapist who’s uncomfortable working with families to seek the supervision and training they need to get comfortable.

To be clear, there’s a difference between partial confidentiality agreements and agreements where there is no confidentiality. Partial confidentiality agreements allow the therapist to use discretion about maintaining confidentiality related to sensitive issues like sexuality, identity, or romance. They still give therapists the flexibility to keep some information private.

One of our primary objectives as therapists is to alleviate suffering. I believe that partial confidentiality agreements give us the greatest flexibility to do so. They instill confidence in all parties and help us avoid scenarios where a child could be pulled out of therapy prematurely because parents are in the dark about the progress that’s being made. They can help us head off potentially dangerous situations and address the larger family problems that contribute to them. When clients, whether young or old, sense our competence and willingness to tackle difficult subjects in their entirely, trust follows. 

***

Laura Kastner, PhD, is a clinical professor in both the psychology department and department of psychiatry and behavioral sciences at University of Washington. She’s the author of several books on parenting, teen development, and family systems.

Photo © iStock/ljubaphoto


Topic: Anxiety/Depression | Business of Therapy | Challenging Clients & Treatment Populations | Children/Adolescents | Families | Field of Psychotherapy | Parenting

Tags: Children & Adolescents | counseling teens | families | Families & family life | Invasion of privacy

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2 Comments

Friday, November 12, 2021 7:11:02 AM | posted by Cate
This was a really helpful article, thank you so much! I'm starting out in private practice and wasn't sure how to deal with confidentiality when I got a referral for a 16 year old client, I integrated a lot of what you talked about in the partial confidentiality agreement and talked it through with them and why it would be useful to them to involve their parents at points. I was a bit surprised when they agreed without complaint! It's reassuring to have this room to work with their family so everyone can work together to help them.

Sunday, January 24, 2021 1:04:25 PM | posted by Marcy Turek, LCSW
Hi there: thank you for this article. Very helpful as I often work with teens in my part-time private practice. I work full time at school with middle schoolers. Do you use a specific form for “partial confidentiality agreement?”. Or do you just do a verbal agreement with the teen? Thank you: Marcy Turek, LCSW (Illinois) Ann James Counseling