Tonight in my ethics class we will be discussing the concepts of privacy, confidentiality, and privileged communications. Such fun topics to scare the students with :).
Counseling teens presents a higher order of stress and confusion when it comes to confidentiality. When should a counselor break confidence with a teen and tell his/her parents something revealed in a session? If she smokes cigarettes? Crack? If he is having unprotected sex? The law is not particularly clear here. While teens are afforded confidentiality if they pursue therapy on their own, their parents have some rights as well, especially if they were the ones to initiate the counseling. In 2002, Sullivan et al surveyed pediatric psychologists as to the various factors they considered when deciding to break confidentiality and risk damaging the relationship with the teen. Though there are some problems with the sample size (too small to have robust factor analyses), the authors suggest there are two factors acting in tension that therapists must struggle through in making their decision whether or not to break confidences:
1. How negative is this behavior (including frequency, intensity, duration) and what level of risk does this behavior place on the the teen or others? The higher the frequency, intensity, etc. the more likely the need to break confidentiality. Interestingly, these authors found that therapists were most likely to “report suicidal behavior, followed by drug use, sexual behavior, and alcohol use, with cigarette smoking to be the least likely to warrant breaking confidentiality” (399). Only one exception to the frequency idea. therapists determined they should report HIV positive teens who engaged in infrequent, unprotected sex.
2. Maintaining the therapeutic process. Counselors fear that once confidentiality has been breached, clients will no longer trust them and will not disclose important information in subsequent sessions. Further, they fear that should the teen terminate treatment, the family and the teen will be less likely to avail themselves to another counselor for fear of the same. So, you can see that this factor leads to the temptation to keep quiet about something that maybe should be revealed to the parents for the life/health of the teen. It is possible to maintain the therapeutic process (no guarantees) by supporting the teen in telling his/her parents instead of telling on them.
In some ways, this study deserves a “well, duh…” response. Of course this is our tension. How can I protect the teen vs. How can I keep working with the teen?
What do you think of operating under the ethic of, “Well, I would want to know if it were my kid.” I would suggest that it isn’t a good ethic. Compelling but not necessarily the most helpful in that it raises the parents’ desire to know over the child’s right(?) to privacy. Further it doesn’t help us determine the cutting point. I might want to know if my kid thinks I’m a jerk. Another therapist might want to know if their kid has smoked dope. Another might want to know only if the child has a pattern of smoking dope.
Sullivan, JR et al (2002). Factors contributing to breaking confidentiality with adolescent clients: A survey of pediatric psychologists. Professional Psychology: Research and Practice, 33, 396-401.