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      Consent

      Perhaps the best way to avoid ethical problems is to make sure that children and families know what they are agreeing to before they decide to participate in therapy. The Ethics Code requires psychologists to obtain consent from individuals before assessment, treatment, or research. The person must have the ability to understand the facts and consequences of participating in treatment. The person also must voluntarily agree to participate. Consent protects people’s right to self-determination (Nagy, 2011).

      Informed consent to therapy includes a number of components. First, individuals are entitled to a description of treatment, its anticipated risks and benefits, and an estimate of its duration and cost. Second, the psychologist must discuss alternative treatments that might be available and review the strengths and weaknesses of the recommended treatment approach. Third, psychologists must remind clients that participation is voluntary and that they are free to refuse treatment or withdraw from therapy at any time. Finally, psychologists should review the limits of confidentiality with their clients (APA, 2017a).

      Informed consent is especially important when treating children and adolescents. Children, unlike adults, rarely refer themselves to therapy. Instead, children and adolescents are usually referred to therapy by parents, teachers, other school personnel, pediatricians, or (sometimes) the juvenile court. Although these adults may want the child to participate in treatment, the child’s motivation might be low. Consider Rachel, a girl who refuses to participate in therapy.

      Children and adolescents, by virtue of their age and legal status as minors, are usually not capable of providing consent. Consent implies that individuals both understand and freely agree to participate. Young children may not fully appreciate the risks and benefits of participation in treatment. Older children and adolescents, like Rachel, may not freely agree to participate because they may feel pressured by others. Instead, proxy consent is obtained from parents or legal guardians. Then, psychologists obtain the assent of children and adolescents before providing services. To obtain assent, psychologists typically describe treatment using language that youths can understand, discuss goals for therapy that might be acceptable to the child or adolescent, and ask the youth for tentative permission to initiate treatment (Shumaker & Medoff, 2013). Although Rachel’s parents provide consent for therapy, a skillful therapist knows that obtaining Rachel’s assent is essential. Assent gives Rachel a voice in the initial stages of therapy and allows her to set goals (and parameters) for therapy that are important to her, not only to her parents and teachers (Knapp et al., 2015).

      In rare cases, children can receive treatment without parental consent (Hecker & Sori, 2010). For example, clinicians can provide therapy to children who are in a state of crisis (e.g., thinking about killing themselves). Similarly, clinicians can delay obtaining parental consent if youths seek treatment because of suspected abuse, neglect, or endangerment. Psychologists who work in clinics and schools may also provide short-term mental health services to youths who are pregnant or experience sexual health concerns (Jacob & Kleinheksel, 2012). Parental consent is delayed in these special cases to provide immediate care to children in need or to allow youths to access services they might avoid if parental consent was required (Gustafson & McNamara, 2010).

      Confidentiality

      Confidentiality refers to the expectation that information that clients provide during the course of treatment will not be disclosed to others. The expectation of confidentiality serves at least two purposes. First, it increases the likelihood that people in need of mental health services will seek treatment. Second, it allows clients to disclose information more freely and facilitates the therapeutic process (Koocher & Campbell, 2018).

      In most cases, confidentiality is an ethical and legal right of clients. Therapists who violate a client’s right to confidentiality may be sanctioned by professional organizations and held legally liable. Many psychologists consider protecting clients’ confidentiality the most important ethical standard (Sikorski & Kuo, 2015).

      Although clients have the right to expect confidentiality when discussing information with their therapists, clients should be aware that the information they disclose is not entirely private. There are certain limits of confidentiality that therapists must make known to clients, preferably during the first therapy session (DeMers & Siegel, 2018).

      First, if the client is an imminent danger to self or others, the therapist is required to break confidentiality to protect the welfare of the client or someone he or she threatens. For example, if an adolescent tells his therapist that he plans on killing himself after he leaves the therapy session, the therapist has a duty to warn the adolescent’s parents or guardians to protect the adolescent from self-harm. The psychologist’s duty to protect the health of the adolescent supersedes the adolescent’s right to confidentiality.

      Second,