Counselling Dilemma: Confidentiality Issues with a Teenager
You work as a counsellor for an organisation that offers counselling services to the general public. The free service is aimed at community members who cannot afford counselling services otherwise. You start counselling a young man who made an appointment with the service when he saw the advertisement in the local community newspaper.
In your initial session you learn that he is 16 years old and sought counselling on his own without the knowledge of his parents. He tells you confidentiality is very important to him and he doesn’t want his parents to know he is in counselling. He tells you that he is afraid his parents might ridicule him for this if they find out since they have ridiculed him about other things in the past. He says he struggles with motivation, getting out of bed in the morning and has low self-esteem. He also says he doesn’t even feel like seeing his friends anymore. He wants to address these issues with you in counselling.
What do you do in this case? What are the ethical issues you need to consider?
There are several issues here that you may need to explore. When it comes to the ethical provisions of the law you need to explore at what age and situation does a child / young adult require parental intervention? For example, in some states a child can leave home on their own accord without parental consent at the age of 15. Although the age of 18 is used to differentiate a child from an adult, there are also some significant ?grey areas? that blur this distinction for those aged under 18. It would be important to find out about state laws pertaining to this and also the guidelines of your counselling services. If in doubt you can also check with your governing body (e.g. ACA) and child welfare.
Ethical consideration s for the client also need to be reviewed. It is important to register that the main issue here is that your young client is reaching out to gain help. If you as a counsellor do not feel well equipped to deal with issues at this age group or your organisation does not provide counselling for those under 18 without parental consent, it would be important to consider some good referral options. There are often free services provided to young people that specialise in areas of youth counselling including face-to-face, online and telephone counselling services that are confidential.
Also there may be some other avenues for your client to use with school counsellors, church or youth groups he is already involved in. Importantly though, it is essential to ensure that the client would want to use another service before you head him on his way and it may be best to help him book appointments whilst he is there. This visit to you may be the only call for help he has instigated thus far so your response will be significant as to how confident he is in his decision to seek help.
His presenting issues of struggling to get out of bed, low self-esteem and not finding joy in his usual activities (such as seeing friends) are potential symptoms with indicating depression. It would be essential to explore with him whether he has had or is having thoughts of self harm and to ask about his current mental state (e.g. his perspectives of life and his abilities to cope).
It may be due to his general low depressive feelings he is experiencing that he feels that approaching his parents would be met by a negative response; however this should be explored more for potential emotional and physical abuse before you begin to discuss options of him speaking to his parents about his mental health. Other support persons he has in his life can also be explored, and if he feels there is nobody it would be important to provide him with a 24/7 counselling service that he can call on (e.g. Kidshelp line, lifeline, suicide hotline) before he leaves his appointment.
I have called this boy Ben. Whatever the age group, it is my responsibility to balance Ben?s right to autonomy with my obligation to do him only good, avoid harming him, keeping my promises to him, and to do him justice.
Legal obligations: Ben is a minor and while there are no clear legal guidelines as to counselling minors, both Ben and I are more vulnerable because of this. Depending on the State, the attitude of the Law regarding ?the rights of minors?, varies. What is my organisation?s policy regarding counseling minors?
What protection do they offer me, should Ben later claim that some aspect of the counselling was inappropriate? Is there is a private area outside in the garden, for example ? where we could be seen but not heard? This would be an ideal place for Ben and I to talk.
Explaining the reason for this will help him understand the implications of protecting both our rights. To close myself behind closed doors with Ben is to leave me without a reasonable defence were there to be a complaint from Ben, his parents, or anyone else.
Follow normal procedure of contract, emphasising the limits of confidentiality, and the consequences regarding exceptional circumstances. It is important that Ben understand that counselling is not about my colluding with his secrets, but about my respecting his experiences. Should I come to believe that he is a danger to himself, or to another, or as demanded by a court of law, I am obliged to break confidentiality. I will advise him of my intention to do so, in advance, if at all possible.
Early on, as soon as Ben discloses his presenting concerns , I let him know that while he is free to make the decisions about his own life, counselling includes referring people to other services if that might be helpful (like to a doctor). Ben?s developmental work (according to Erikson?s model) at this stage is in ?Identity vs Role confusion? where he will be experimenting with differentiation. We might talk about how to go about applying for his own Medicare Card so that if he wanted to access a Doctor, he could do so independently.
His isolation is a significant factor and it is important to allow Ben to tell and explore his own story, and to give him plenty of feedback. It takes courage and intention for a 16 year old male to come to counselling. He is a minor, caught in that social phenomena called ?adolescence?, where he is neither fully child nor fully adult. He is in a stage of ?becoming?. I want Ben?s experience in utilizing community resources to be a positive one.
Ben?s cognitive capacity at this stage will be, most likely, superior to his moral capacity (i.e. ability to understand the consequences of his choices). I need to be very concrete and realistic in any information I give him, double check we have understood each other at all times, and assist him visualising consequences.
At the end of the first session I will give Ben a range of supplementary resources (eg Kids Line), fully document the session, and access supervision as soon as possible.
I think it helps also to truely imagine myself on the spot in counselling when considering a case scenario … so what is the priority (what can I make sure I accomplish) in the session to meet my obligations and client needs?
Two things stand out for me …
The client has mentioned thoughts and feelings that suggest depression … it is important to ask Ben if he also thinks about ‘killing himself’. This is a hard thing to ask, however with practice it can become as comfortable as asking other information gathering questions. Softening the question (for our own comfort!) by asking about self harm or ‘checking out’ or other variations may not be interpreted by the client as killing themselves. It is also important to keep this question in the same context as other questions … ie phrased as a question without changing your body language or voice, and as a natural response to someone sharing feelings of lack of motivation and low self-esteem. This will be the best time and method of learning about the clients thoughts on suicide, without inadvertently communicating any personal thoughts about the topic.
As an example I once asked a client this question and they replied ‘yes, all the time’ and following on from this they revealed that they had not told anyone else, not even their doctor or psychologist! So I think the way in which the question is asked is very important. If the client says ‘Yes’, then proper response and procedure for that issue would take precedence in this case I would think.
The next priority as I see it is Policy regarding the age of clients accepted by the program/project. ‘Free’ counselling services exist due to funding from specific agencies, and this arrangement puts very particular accountabilities onto the individual counsellor to other stakeholders other than the client. Clarifying this at the first session is important because if a referral is required, the client’s interests are best served by having that arranged and agreed to immediately, before any therapeutic relationship is established with the counsellor who is unable to continue providing support. Then leaving the client the added difficulty of having to re-establish confidence in repeating shared information with a new person.
So address safety for the client, and then clarify eligibility for the service with proper referral if necessary. If I could get that done in the first session I think I would have provided this client with the best support I could in an hour.