Confidentiality, Alchemy, and Adolescence
Mar 6, 2023- Client confidentiality is one of the most important ethical boundaries in psychotherapy and other provisions of medical, behavioral, and academic services. Maintaining a gold standard of confidentiality with adolescent clients can be especially challenging as most teenagers are still under the care and supervision of their parents. It makes sense that providers may struggle with this dilemma.
However, probably the number one complaint I hear from my adolescent clients against other service providers, especially those between the ages of 13–17yrs old, is that of breaches in confidentiality. I hear of these breaches in my personal conversations with friends and family. I have had adolescent clients reach out to me in despair and outrage when they’ve not been allowed to speak privately with their medical providers or when their prescribing doctors have divulged information to parents without their patients’ permission. I have heard too many stories regarding school counselors calling parents after conversations with students when the students believed the discussion was to be kept confidential. Adult clients will share how therapists, school counselors, and pediatricians broke confidentiality when my clients were adolescents. The damage to the rapport and the lack of safety for the adolescent can be distressing enough that some clients are still telling their stories a decade or two later.
Breaches of confidentiality for anyone of any age is a violation. However, because of the essential nature of Adolescence, breaking confidentiality is, I believe, damaging at a different level and for reasons unique to this stage of development.
Therapy as an alchemical container
My training as a psychotherapist was steeped in the traditions of imaginal, archetypal, and Jungian psychologies. One of the earliest seminars in my graduate program, taught by Sukey Fontelieu, was memorable enough to stay in my mind over 20 years later. She introduced to our cohort the concept of the therapeutic relationship as an alchemical vessel in which powerful transformations happen. When working with psychoactive material, the vessel must be strong, tempered, and able to contain volatile energies of all sorts, textures, intensities, and temperatures.
I teach my clients that this vessel within which we do our work is made strong by the following:
the therapist who continues to work on her own psychoactive material
an agreed upon exchange of energy — the skill and training of the therapist and the monetary fee from the client (Another seminar helped me understand that money is simply energy. The word has its roots in the Roman goddess Juno Moneta, protectress of funds)
the boundary of time for the session
the boundary of relationships — no dual relationships
and the boundary of confidentiality.
To break confidentiality—to let the secrets, mysteries, shadow material, and that which lies in the innermost sanctum of the client’s psyche leak out of the vessel—is to essentially break the therapeutic container. There is now no safe space for the client and therapist/physician to sit with, explore, and come into relationship with the psychoactive material and do the transformative work that is the essence of healing. For the adolescent, this means that there is no longer a safe space to continue engaging in the intense and tumultuous process of adolescing and becoming.
The essential nature of Adolescence
I continue to circumambulate a clear description of the essential nature of Adolescence; it is difficult to pin down, an inherent quality of Adolescence. For brevity’s sake, I turn to my go-to manual on Adolescence, Richard Frankel’s book The Adolescent Psyche. Dr. Mary Watkins writes in the Foreword:
“Frankel asserts that much of what we witness with adolescents are their attempts—often desperate—at self-initiation; efforts to shatter their innocence through wounding; efforts to build their capacity to endure losses through the navigation of betrayals, separations, and symbolic deaths; efforts to express the purity of their idealistic visions of the possible.”
The adolescent service provider who is bound by professional ethics of confidentiality must be able to hold all of this. They must be able to sit with stories of kids dancing on the edges of chasms and precipices, standing at the top of slippery slopes prepared or already halfway down, or hovering at the threshold of dark places, if not already fully committed to an Underworld journey. Mind altering substances; risk taking behaviors of all kinds; teasing Death both in fun and in earnest; decisions about sex, love, relationships, betrayals, and boundary violations; exploring morality through immoral acts; trying on different personas, beliefs, religions, and passions; and the list goes on. Toss in whatever traumas and other goings-on in their lives, and it’s a wild ride sometimes.
The alchemical vessel of adolescent therapy must be well-tempered for it to be most effective for these processes of adolescing. The adolescent service provider is challenged to assess what they are mandated to report, what they feel should be reported but is not mandated, and what information is most therapeutic to keep in confidence—whether they are mandated to report or not.
Tips for navigating confidentiality with adolescent clients in psychotherapy
Know your professional Code of Ethics and your state’s administrative and legal codes regarding confidentiality and privilege for youth.
Have specific language in your Informed Consent/Disclosure Form regarding privileged and confidential information for your adolescent clients. Explain the parameters of confidentiality for the child who is under the age for confidential and privileged information and for the child who is of age and how you navigate this.
Have a clear, forthright conversation with your client and the parents/guardians during the intake regarding confidentiality. For clients of privileged age, I let parents and kids know what I may not divulge to parents without explicit permission from the adolescent client. Parents and kids are often surprised by what I may and may not tell parents depending on the age of the child, including: sexual activity, birth control, drug use, illegal activities, STDs, prenatal care, abortion, etc. (These will all depend on the age of the child, your professional ethics, and the laws of your governing bodies.)
After this conversation, have the client sign a Release of Information (ROI) form permitting you to speak to their parents regarding scheduling and payment, at the very least. Without this ROI, legally, you cannot communicate with the parent about anything.
On my ROI, I always have an option available if the client agrees, which states that any other information to be discussed with parents is first discussed with the client. I make a note of this in the progress notes and then clarify with the client exactly what I will be saying and what I won’t be saying. This holds true if the ROI is for other parties as well.
If the young person reports anything that is of concern that you, as the clinician, feels should be shared with the parent, yet is within the client’s right to maintain confidentiality, then the therapy can focus on when, how, and with what support the child can have the conversation with the parents or caregivers. In my experience, eventually the issue is always brought to parents in a way that is therapeutic and beneficial for the client.
Always aim for transparency with your client. Keep the alchemical vessel well-tempered.
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