Promoting safety and change while counseling adolescents can be fraught with ethical and existential dilemmas. Given my courageous disposition, I have worked with high risk situations in psychiatric hospital, home based and private practice settings.
Initially, my thoughts about confidentiality with adolescents were not nuanced. Unless the client was at significant risk of suicide or homicide, I did not inform their parents of dangerous behavior. Thus, I took significant responsibility for managing the lives of other people’s children. Over time, I began to leverage the power of family dynamics and parental influence in my work. I exclusively provided family therapy with adolescents for a time, relieved from the burden of holding important information from parents.
Faced with situations when individual therapy was indicated and wanting to do that work again, I reexperienced my challenge of defining confidentiality with minors. Balancing adolescent autonomy needs with my commitment to honor parents’ rights to know important information, I created a set of guidelines to support my individual work. Please note that these agreements vary depending on circumstances.
With adolescent referrals, I often begin treatment with a family meeting. Before agreeing to provide individual therapy, I invite everyone in the home to a session. My goal is to get to know the “problem” contextually, determining for myself whether to recommend individual, family therapy or another treatment plan. I let the parent who calls for help know my intention to understand the concerns, strengths and relationships of all involved so I can be most helpful regarding their current concerns. If there is push back, I tell them that teenagers typically talk about content in individual sessions that is different from their parents concerns. Hearing parents’ concerns in the presence of the teen and hearing kids’ concerns in the presence of their parents helps me leverage all relevant information. As part of this assessment process I sometimes meet with parents alone, but not until I meet with everyone first. I like to form my own opinions in people’s natural relational environment rather than hearing gossip in the absence of the other. Given my family therapy training and my personal style, I prefer to do individual or family work, not parent guidance.
When individual therapy makes sense, I create communication agreements with parents in the presence of the adolescent. I ask parents to tell me what risky behaviors their child has privacy to discuss with me without their needing to be informed. Then I ask what areas/levels of concern trigger their preference for being invited in to a discussion about their child’s safety. These areas consist of but are not limited to: skipping school, sexual activity, self-harmful behavior including disordered eating, substance abuse as well as suicidal and homicidal behavior.
Working this way, I feel less burdened with decisions that may not be mine to make. I honor parents’ wishes to know what they want to know. Their teens know the limits of confidentiality. These boundaries allow me to work with their parents to create more effective ways to support them, when needed. The teen shares risky behavior with the knowledge that their parents may be called in to help them. In working this way, I often find that kids are more comfortable and cooperative with their parents knowing how they are struggling than I would have imagined.
Knowing the rules, values and boundaries in the family regarding risky behavior helps me understand the context in which trouble occurs. Sometimes family norms become treatment targets if it turns out the teen is not being held well enough or is being held too tightly. I may do a little piece of family work in the context of individual therapy or refer the family to see another clinician.
Working this way minimizes my distress about what to share with parents. I feel good about not taking too much responsibility for the well-being of someone else’s child. This therapeutic stance supports my goal of respectfully understanding and working with each family’s ethos and culture.
I'd love to know your thoughts on my thoughts.
I can be reached by email here
Liz Brenner, LICSW, is the Director of Therapy Training Boston providing continuing education in the tradition of the Family Institute of Cambridge. She is the primary instructor for the Intensive Certificate Program in Family Systems Therapy. Liz sees adolescents and adults in individual, couple and family therapy in Watertown MA. She provides individual and group supervision, agency consultation and training.
Initially, my thoughts about confidentiality with adolescents were not nuanced. Unless the client was at significant risk of suicide or homicide, I did not inform their parents of dangerous behavior. Thus, I took significant responsibility for managing the lives of other people’s children. Over time, I began to leverage the power of family dynamics and parental influence in my work. I exclusively provided family therapy with adolescents for a time, relieved from the burden of holding important information from parents.
Faced with situations when individual therapy was indicated and wanting to do that work again, I reexperienced my challenge of defining confidentiality with minors. Balancing adolescent autonomy needs with my commitment to honor parents’ rights to know important information, I created a set of guidelines to support my individual work. Please note that these agreements vary depending on circumstances.
With adolescent referrals, I often begin treatment with a family meeting. Before agreeing to provide individual therapy, I invite everyone in the home to a session. My goal is to get to know the “problem” contextually, determining for myself whether to recommend individual, family therapy or another treatment plan. I let the parent who calls for help know my intention to understand the concerns, strengths and relationships of all involved so I can be most helpful regarding their current concerns. If there is push back, I tell them that teenagers typically talk about content in individual sessions that is different from their parents concerns. Hearing parents’ concerns in the presence of the teen and hearing kids’ concerns in the presence of their parents helps me leverage all relevant information. As part of this assessment process I sometimes meet with parents alone, but not until I meet with everyone first. I like to form my own opinions in people’s natural relational environment rather than hearing gossip in the absence of the other. Given my family therapy training and my personal style, I prefer to do individual or family work, not parent guidance.
When individual therapy makes sense, I create communication agreements with parents in the presence of the adolescent. I ask parents to tell me what risky behaviors their child has privacy to discuss with me without their needing to be informed. Then I ask what areas/levels of concern trigger their preference for being invited in to a discussion about their child’s safety. These areas consist of but are not limited to: skipping school, sexual activity, self-harmful behavior including disordered eating, substance abuse as well as suicidal and homicidal behavior.
Working this way, I feel less burdened with decisions that may not be mine to make. I honor parents’ wishes to know what they want to know. Their teens know the limits of confidentiality. These boundaries allow me to work with their parents to create more effective ways to support them, when needed. The teen shares risky behavior with the knowledge that their parents may be called in to help them. In working this way, I often find that kids are more comfortable and cooperative with their parents knowing how they are struggling than I would have imagined.
Knowing the rules, values and boundaries in the family regarding risky behavior helps me understand the context in which trouble occurs. Sometimes family norms become treatment targets if it turns out the teen is not being held well enough or is being held too tightly. I may do a little piece of family work in the context of individual therapy or refer the family to see another clinician.
Working this way minimizes my distress about what to share with parents. I feel good about not taking too much responsibility for the well-being of someone else’s child. This therapeutic stance supports my goal of respectfully understanding and working with each family’s ethos and culture.
I'd love to know your thoughts on my thoughts.
I can be reached by email here
Liz Brenner, LICSW, is the Director of Therapy Training Boston providing continuing education in the tradition of the Family Institute of Cambridge. She is the primary instructor for the Intensive Certificate Program in Family Systems Therapy. Liz sees adolescents and adults in individual, couple and family therapy in Watertown MA. She provides individual and group supervision, agency consultation and training.
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