Dear Therapist:

When I asked my fifteen-year-old daughter’s therapist questions about what was being addressed in therapy and why we needed to continue, she was evasive, making it clear that it wasn’t my place to know and there was no reason for me to be involved. I was quite baffled and rattled. It just didn’t make sense to me at all that I was not being included as an important team member. But I put aside my troubled feelings in deference to professional opinion. But as the situation got much worse, I had to face the fact that my initial profound skepticism turned out to be well-grounded.

I later spoke to a number of other professionals who adamantly insisted that the only way to help a teen is by involving parents. For example, a psychologist we spoke with was surprised about our experience, being that when she works with teens, a very important part of her job is explaining things to parents. Also, she said, she needs to hear from parents to know what is really going on with the child and she would never agree to work with a teen alone. Another psychologist says that parents are the child’s support and therefore unless the parents are totally crazy, she would always include them. A social worker explained that if the teen is uncomfortable involving parents, an important treatment goal would be to foster a more open, trusting relationship. He says the only way he would use “attachment theory” with teens is to build stronger attachment to parents. It seems that at times therapists undermine the family resulting in chaotic and sometimes catastrophic outcomes. All this when better therapy would have put all the pieces back in the right place, resulting in closer stronger families, with more supportive parents and a more respectful child. And as my daughter later said of her own experience, you can’t help a child if you don’t include the parents. She was also so relieved that there were no longer “secrets.”

I am hoping you can comment on the importance of the above and help parents make better choices when choosing help for their child, as well as exert influence in the therapy world as to the importance of teamwork. I know there is a “fine line” since “confidentiality is the bedrock of therapy”. Apparently, there are many mental health professionals who know how to navigate the fine line and still include parents to ensure much better, healthier outcomes. Perhaps those of you who know how to incorporate parents effectively can share what such a treatment plan would look like.

Response:

You described your daughter’s therapist’s response as “evasive.” Your sense was that she was making it clear that there was no reason for you to be involved in your daughter’s therapy process. Although there may be a reason that information is not being shared with you, being evasive is generally not appropriate.

The following will include edited excerpts from one of my previous columns.

As with most things, arguments can be made for both sides. Also as with most things, in your situation it largely depends on the particular circumstances. Although I would generally agree with most of what you wrote, there are many factors that are unclear. For instance, I don’t know what the reason is that the therapist doesn’t want to share with you. I don’t know if there’s a particular reason that she decided to be evasive rather than being open with you about the reasons for her decision not to include you, or if she was simply flustered at the time. I don’t know whether the therapist expects to share with you at some point in the future, and is trying to work with your daughter to help her become a part of that process. (If this is the case, she may deem it necessary to build a strong enough rapport with your daughter prior to speaking with you so as not to lose her trust.)

Generally speaking, there are a few reasons that a therapist might not speak with a client’s parents (or to anyone else for that matter) without consent from the client. With regard to sharing information, there can be legal, ethical, and therapeutic consequences. These areas can combine in interesting and interrelated ways.      

Ethically, one could argue that it is not appropriate to share private information with someone else, unless the benefit outweighs the risk. From a legal perspective, health care information is highly confidential, and can only be released under very specific circumstances (for instance, the clear sense that the person will cause imminent harm to self or others). There are times when ethics appear to point in one direction, while legality points in another.

Ethics and legality aside, an essential and fundamental reason for confidentiality is the efficacy of the therapy process. Without the assurance of privacy, clients are less likely to be open and honest about their feelings and needs. Additionally, without a sense of mutual respect and a connection between the client and therapist, the therapeutic relationship is likely to suffer. When we have a sense that our therapist is warm, understanding, empathic, genuine, and supportive, this can go a long way toward development of a strong therapeutic relationship.

Generally speaking, the most significant factor leading to successful treatment is the therapeutic relationship. This has been shown in multiple studies and meta-studies, and is true for a variety of reasons. The therapeutic relationship has been shown to be the most significant indicator of successful treatment regardless of the particular therapeutic modality. In order for your daughter to properly gain from therapy, she needs to feel comfortable with the therapist as well as with the therapy process.

I don’t know to what degree your daughter discusses her therapy sessions with you. I assume that you know when her sessions occur. Perhaps she shares some basic information with you; perhaps she doesn’t feel comfortable discussing it at all. It is likely that the more uncomfortable she is, the more important confidentiality is to the therapeutic alliance—and therefore to the therapy process.

I don’t know whether your daughter’s therapist is willing to obtain information from you without disclosing much. This depends on a few factors. If you want to convey information with your daughter’s knowledge, I imagine that the therapist would discuss this with her and, if agreed to, would schedule a session or a phone call with you.

Family members sometimes want to impart information but do not want the client to know. If you want to discuss things without your daughter’s knowledge, this can add a problematic wrinkle to the situation. If the therapist were to withhold from your daughter the fact that she spoke with you, this could lead to challenges. If your daughter were to discover that this conversation occurred, it could cause irreparable harm to the therapeutic relationship. Even if she were not to find out, the therapist would always need to be cognizant of what she could and could not say—and how to present certain ideas. This would undoubtedly affect the therapist’s genuineness, one of the tenets of a good therapeutic relationship.

It is important to stay focused on the long-term goals of therapy, and to be careful not to get hung up on short-term goals. Of course, I don’t know what your daughter’s specific issues are, so I cannot speak to those. Using an example, however, if your daughter is depressed, it can be extremely difficult for you to see her hurting. You may feel that your input and involvement can help the therapist to better work with your daughter. Although this may be true—and doing so may actually do some good in the immediate term—if done so against your daughter’s will this can adversely impact the therapeutic relationship. It can cause your daughter to stop trusting her therapist—or even therapists in general. Thus, the short-term gain may be obtained at the cost of a significant long-term loss.

I don’t know how much of this relates to your specific situation. Perhaps in your daughter’s case, there is an immediate need that absolutely has to be addressed “at all costs.” Perhaps you have a clear sense that your daughter’s therapist is not addressing any of her problems. If this is the case, open and honest discussions with your daughter can help the both of you to air your concerns and to help one another to see the other’s perspective. Or you might be able to have a frank discussion with her therapist about her reasons for not wanting to disclose information.

If these are not possible, you need to approach the situation pragmatically. Ask yourself whether there is something that you can do to change the situation for the better. Is insisting that your daughter see a different therapist likely to do more harm than good or vice-versa? Even if this therapist is not being appropriate is some ways, identify what you can do and let go of what you cannot. Although this may be difficult, it can help you to better deal with a situation that is less than ideal.

-Yehuda Lieberman, LCSW

  psychotherapist in private practice

  Woodmere, NY

  adjunct professor at Touro College

  Graduate School of Social Work

  author of Self-Esteem: A Primer

  www.ylcsw.com / 516-218-4200

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