Transparency and Confidentiality in Clinical Work, Part I

Part I: Managing Transparency and Confidentiality in Work with Children and Adolescents

In this newsletter we continue to take a microscopic view of the treatment process, its subtlety and intricacy. To date we have focused on the patient and his or her psychological needs. However, when looked at broadly, treatment is almost always multi-faceted, often involving contributions from several professionals and modalities. That the patient lives in a family and a social system introduces further complexity. Our effort at the Center for Collaborative Psychiatry, Psychology, and Medicine has focused on developing an integrated model for working on this level.

We now turn emphatically to the supporting systems for the patient’s life and the extent to which it is helpful for a clinician to openly collaborate with the people involved. The official designation for this topic is “therapeutic transparency.” We begin with adolescence.

There is hardly a child or adolescent treatment in which the therapist is not legitimately accountable to parents. In fact, when treating a child or even an adolescent sometimes work with parents is all that is required to achieve the desired result. The therapist meets with the patient, in these cases mainly for diagnostic purposes and to provide guidance for the parents, but not for treatment proper. In keeping with this thinking, our model for psychotherapy with children and adolescents allows for significant involvement between therapist and parents. Our viewpoint departs sharply from the tradition of minimizing parent contact in child and adolescent treatment or keeping them out of it altogether. In addition to collateral contact with parents, child and adolescent treatment frequently requires collateral work with teachers, tutors, nannies, and pediatricians.

A related consideration in these treatments is confidentiality, usually a barrier to transparency. Most adolescents and even children object to the therapist telling details of their discussions to parents. Their trust in the therapist is often contingent on whether they believe their privacy will be protected. Nonetheless for a therapist to not judiciously share information with parents may reflect poor judgment, impeding therapeutic progress. Further, deciding not to confide in parents, especially when the child’s or adolescent’s behavior is worrisome, almost always creates an ethical and even legal quandary for the therapist. Then, there is the opposite clinical dilemma, whether the therapist should share the details of his or her contact with the parents with the child or adolescent.

Ken provides a good illustration of these clinical issues. At age 16 Ken was failing all of his classes. His mother described him on the phone as, “surly and probably using drugs.” He had lost the right to use his cell phone and his computer had been removed from his room. His mother, an admirable critical care nurse, did little more than yell at him about doing his homework. His father, who drank too much and was mainly ineffectual, supported the mother. As a park ranger he owned and brandished his law enforcement equipment and skills, threatening mild violence toward Ken and his allegedly “no-good friends” if Ken remained in violation of family rules.

When I (Steve Frankel) saw Ken for the first time I wondered whether I had made a mistake taking him on as a potential psychotherapy patient. He greeted me in the waiting room with a grunt from underneath his hooded sweatshirt which at the time was pulled over his head. No question. I had a druggie on my hands.

Then Ken began to talk. Shockingly he was mild. His words were carefully chosen and remarkably sophisticated for a guy who looked like he was straight out of “the hood.” The next shock was when the copy of The Economist he was reading fell out of his sweatshirt.

So I asked him, “What the hell is this all about?” Wasn’t he the loser I had “heard only bad things about?” “What, Ken, is the real story?”

Ken was never very animated, just sparklingly intelligent. He mainly answered my questions, rarely initiating conversation. However, he was always cooperative. Ken’s response was that in compliance with his parents’ edicts he intended to pass all his courses next semester, a claim that proved baseless. He insisted that the real problem was that his parents wouldn’t let him have any of his vital possessions including his cell phone, and that they attempted to regulate and patrol him in like a prisoner of war.

“Okay, Ken, if you want a reprieve you will have to work closely with me. We will need to meet with your parents in a week or so, and again every so often thereafter. You will have to do your best to stop being so surly and actually try in school. You obviously are bright, if not in some ways brilliant, and we need to prove that to you and your parents. Hence the need for at least cognitive testing (in his language “intelligence testing”), since everyone seems to be convinced that you’re not very smart. How about it?” Note, that Ken was clear with me that he did not use drugs and had a surprising goal he felt was more important than school, to achieve the eagle rank in boy scouting, an organization with which his father was deeply involved. So, as is often the case with adolescents, I became an advocate for Ken with his parents and a source of advice for him as he started to straighten out his life. This role is typical in work with adolescents as they prove to themselves and the world that they are capable human beings.

With Ken, I was honest in my agreement that his parents were opaque to his virtues, mainly seeing and magnifying his failures. With Ken ‘s parents, I openly shared my experiences and impressions of Ken, calling them and leaving a message after every other session with him. Ken was aware I was making these calls. He gave his assent for me to make them. At times, however, I spoke to his parents about matters that might have troubled Ken had he known what I said to them. The information his parents provided became particularly important in our sessions as he failed to carry out on his promise to pass his classes. Presumably as a result of my openness and my judicious use of the information I gleaned, both Ken and his parents remained faithful to the work and both were satisfied.

The testing was done by Diane Engelman, Ph.D., one of our Center associates. It revealed that Ken was as bright as I thought, but with a few exceptions. His verbal intelligence was in the superior range while non-verbal measures found him relatively lacking. Executive functioning was also an area of deficiency for Ken, making it hard for him to create order in his life. These discoveries suggested that while Ken could master some intellectual concepts like a wizard, he had a much harder time grasping information about life and comprehending the relevance of and responding to peoples’ requirements for him. These discrepancies in Ken’s cognitive functioning were reinforced by his adolescent preference for action and immediate satisfaction.

Typically, and certainly characterizing my work with Ken, the therapist of an adolescent is in the paradoxical position of being the patient’s advocate, while at the same time maintaining an alliance with his or her parents. In part the therapist needs judiciously to engage in this balancing act since teenagers characteristically take risks that may put them in jeopardy. They are trying their new wings and have not yet developed adult-level judgment about life. A subtle example of this kind of behavior was Ken’s reckless disregard for his school-work. He never did his homework, was failing most of his classes, and, yet, believed with conviction that he would graduate with his classmates and get into a good college.

Discussion

What would you have done if you had been working with Ken? Would you have kept in regular touch with his parents as Steve did, at times sharing information with them that Ken might have wanted to remain private? Would you have been as open and supportive with him about his parents’ misapprehensions about his character? The dilemmas are many and relatively typical for psychotherapy with adolescents. In Ken’s case they also included his mostly age appropriate desire to remain anonymous and keep the friends about whom his parents objected, Ken’s need to find someone who could advocate for him against his parent’s misguided beliefs about his character, and his need to move on in school and life, at times in ways that conflicted with his parents expectations for him. — You’d need a whole squad of traffic cops to keep all these intersecting needs and limitations in mind and under control.

Returning to where we started, our topic is therapeutic transparency. In the next newsletter we will expand our reach to adults, exploring whether and when collaboration with other professionals and family is useful and appropriate in those treatments.

This is how we think about things. We advocate transparency in clinical work when it is possible and judicious. However, not everyone agrees with our ideas, making this a fertile topic for debate. We hope you will share your thoughts with us.