Introduction to Abnormal Child and Adolescent Psychology. Robert Weis
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the therapist is required to break confidentiality to protect the child. For example, if during the course of therapy a 12-year-old girl admits to being maltreated by her stepfather, the psychologist would have a duty to inform the girl’s mother and the authorities to protect the child from further victimization.
Third, in exceptional circumstances, a judge can issue a court order requiring the therapist to disclose information provided in therapy. For example, a judge might order a psychologist to provide information about an adolescent client who has been arrested for serious criminal activity.
Fourth, therapists can disclose limited information about clients in order to obtain payment for services. For example, therapists often need to provide information about clients to insurance companies. This information typically includes the client’s name, demographic information, diagnosis, and a plan for treatment. Usually, insurance companies are the only parties who have access to this information.
Fifth, therapists can disclose limited information about clients to colleagues to obtain consultation or supervision. It is usually acceptable for psychologists to describe clients’ problems in general terms in order to gain advice or recommendations from other professionals. However, therapists only provide information to colleagues that is absolutely necessary for them to receive help, and they avoid using names and other identifying information.
Therapists also have a duty to protect children and adolescents from harm when they know youths are engaging in potentially dangerous behaviors. Frequently, ethical dilemmas arise when the therapist’s duty to protect children comes into conflict with the therapist’s responsibility to protect confidentiality. Consider Renae, a girl who is testing the limits of confidentiality.
When therapists face decisions about confidentiality, they must weigh two factors: (1) the frequency, intensity, and duration of the potentially harmful or maladaptive behavior and (2) the importance of maintaining the therapeutic process (Sullivan, Ramirez, Rae, Razo, & George, 2010). In general, therapists are more likely to break confidentiality as the risk of harm increases. For example, if Renae’s decision to have sex was made freely and if she was at low risk for pregnancy or illness, most therapists would respect her confidentiality. However, if we learned that Renae’s “boyfriend” was a 25-year-old man that she met online, we would need to take steps to protect her from harm. In any case, therapists place considerable importance on maintaining the therapeutic relationship. Would Renae ever trust her therapist (or any other therapist) if the therapist disclosed this information to Renae’s parents? What might the implications of disclosure be on Renae’s long-term mental health?
Case Study: Ethics with Children: Confidentiality
Risqué Renae
Renae is a 16-year-old high school sophomore who was participating in therapy for long-standing problems with depression. During one session, Renae tells her therapist that her parents are leaving for an overnight trip that weekend and she intends to have sex with her boyfriend while they are gone. She explains that this decision is “huge” because she has never had sex with anyone before.
Renae’s therapist asks questions about Renae’s sexual health and access to birth control. She also wants to know if Renae is experiencing any pressure to initiate a sexual relationship. Should Renae’s decision to have sex remain confidential, between Renae and her therapist, or do her parents have a right to know her plans?
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Case Study: Ethics with Children: Conflicts of Interest
Margaret’s Mournful Mother
Margaret was a 12-year-old girl who was referred to our clinic for oppositional and defiant behavior. Although Margaret was largely compliant at school, she would frequently disrespect her mother and throw tantrums to avoid responsibilities at home.
The therapist met with Margaret’s mother to gain additional information. During the course of the conversation, it became clear that Margaret’s mother was very depressed and was experiencing considerable marital problems with Margaret’s father. She said she was having a hard time caring for Margaret and performing her other responsibilities at home and work. She also admitted to thoughts of suicide.
The therapist believed that Margaret’s disruptive behavior was connected to her mother’s depressed mood. She offered to counsel Margaret’s mother individually, in addition to providing therapy for Margaret’s disruptive behavior. Was this a good decision?
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According to the Health Insurance Portability and Accountability Act (HIPAA), the right to confidentiality is held by children’s parents, not by children themselves. Consequently, parents have the right to the information their children disclose in therapy (Sikorski & Kuo, 2015). Therapists must balance parents’ rights with adolescents’ expectations for confidentiality. On one hand, parents have the right to know about the medical and psychological treatment for their children; on the other hand, adolescents are unlikely to fully participate in therapy if their thoughts and feelings are shared with parents without their permission.
Most psychologists raise the issue of confidentiality with parents and teens early in treatment. Here is one strategy:
Psychotherapy works best when adolescents have confidence in the privacy of their conversations. At the same time, parents want to feel confident about their adolescent’s well-being and safety. Since you (parents) were once teenagers, you certainly know that an adolescent may want to use therapy to talk about sex, alcohol, or other activities. Let’s discuss about how we can assure your child’s confidentiality so she can talk openly about what’s on her mind, and at the same time assure you (parents) about your adolescent’s safety. (Koocher & Daniel, 2012)
Conflicts of Interest
Usually, when parents seek treatment for their children, they have their children’s best interests at heart. Occasionally, however, ethical issues arise when it is unclear whether psychologists are providing services to children or to their parents. The Ethics Code indicates that psychologists must avoid such conflicts of interest—that is, instances in which the psychologist engages in relationships that impair her objectivity, competence, or effectiveness with her client.
Conflicts of interest can arise in child and adolescent therapy in several ways. One conflict occurs when a therapist is in a professional role with the child and then (inadvertently) enters into another role with the child’s parent. Consider the case of Margaret, a girl who presents a dilemma to her therapist related to a potential conflict of interest.
Although well intentioned, the therapist entered into a multiple relationship with Margaret and her mother. A multiple relationship occurs when a psychologist, who is in a professional role with a client, enters into another relationship with the same individual or a person closely associated with that individual. Multiple relationships are problematic when they impair the objectivity of services that psychologists provide (Campbell, Vasquez, Behnke, & Kinscherff, 2010). Would the therapist be able to effectively treat Margaret while also simultaneously providing services to her mother? Might it be better for the therapist to refer Margaret’s mother to another provider?
Conflicts of interest can also occur in situations of separation and divorce (Shumaker & Medoff, 2013). Imagine that Margaret’s family situation goes from bad to worse. Margaret’s father decides to divorce Margaret’s mother and seek custody of Margaret. Her father requests Margaret’s psychological records, which include information about her mother’s depressed mood and difficulty caring for Margaret. He intends on using this information to gain custody of his daughter.
The therapist now finds herself serving