Dear "Ethics Rounds,"
I am a psychologist with a child and adolescent psychotherapy practice. I have been treating a very intelligent and capable 14-year-old girl for about three months. She was originally referred for treatment of depression in the context of the onset of school failure; previously she had succeeded academically and socially at school. After two months of therapy, she has disclosed an almost daily pattern of marijuana use and reliance upon some occasional shoplifting to support her use. I have shifted my therapy to focus upon her marijuana use, its triggers and relapse prevention. She has days of abstinence but continues to struggle. Last week I suggested that we inform her caregivers about this issue, particularly since she had asked for some ideas about how to better support abstinence. She absolutely refused any such suggestion. She claimed that "confidentiality" prevented my disclosing this information and, quite to my surprise, claimed that as a "substance abuse treatment" she was entitled to prevent any discussion of the content of her treatment.
Is she right?
Dr. D, MassachusettsDr. D appears to feel at the mercy of a substance abusing 14-year-old. This is not good.
The practice of clinical psychology is enormously challenging. As clinicians, we must keep in mind the complexity of both psychic and social realities, since both contexts-psychological and social-have a profound impact upon our work. Fortunately, our clinical training teaches us to remain mindful of multiple perspectives simultaneously. Those trained in family and group therapy, for example, must keep in mind that every member of a family or group has a unique set of values and concerns and that successful therapy depends on being able to respect and see the value and legitimacy, as well as the shortcomings, of each. Psychologists engaged in couples work, mindful that each person in the couple brings to treatment both health and neurosis, will use each partner's healthy and neurotic aspects in a productive therapy. Individual therapists are mindful of the complexity of their clients' psychic lives, both the elements and forces within their clients' psyches that have yet to be reconciled or integrated with one another, and those from without that impinge upon their clients' experiences. Whatever our modality and theoretical orientation, psychologists are trained to hold onto and keep present before them multiple perspectives, values, concerns and challenges. Success in our work depends on our ability to do so.
On a societal level, we are mindful that our clinical work takes place in a larger context, with laws and regulations. Legal considerations will affect whether our clients have the ability to consent to treatment, whether a communication triggers a mandated report or a duty to protect a third person, and how we respond to a demand to disclose confidential information when we receive a subpoena or a court order. A question then arises: What is a helpful way to think about the relationship between the clinical and the societal/legal perspectives, both of which are central to how we structure and conduct our treatments? Let us think through this question in relation to Dr. D's letter from the vantage of our expertise as psychologists.
I would encourage Dr. D to focus first on clinical considerations and let the legal questions follow from her clinical assessment. To begin with her clinical thinking does not in any manner diminish the importance of Dr. D's understanding and acting consistently with the relevant law. Rather, given that Dr. D's strength is as a clinical psychologist, her perspective as a clinician must be front and center in her determination of how to proceed. At the present time, Dr. D is at risk of getting this equation backward and of evaluating the relationship between the legal and clinical perspectives in a manner that may place the treatment and possibly her client at risk. As an example, it would be possible for Dr. D and her client to end up in a struggle that focuses obsessively on whether Dr. D may legally disclose this information, a struggle that could significantly distract from Dr. D's ability to conduct a competent and helpful treatment.
I would ask Dr. D about the process of informed consent and what was said about confidentiality at the outset of the treatment. While Dr. D's letter does not provide information about those initial discussions, it will be important to understand what her client and her client's caregivers were given to understand about how confidentiality would work in the treatment and whether any questions or concerns were voiced at that point or after. Second, I would want to understand the client's relationship to her caregivers, what role her caregivers currently have in the treatment, the client's fantasies about how her caregivers would react to this information, and whether Dr. D has any data that would be consistent or inconsistent with her client's fantasies. Third, I would want to explore with Dr. D why she believes the client is providing her such detailed and potentially incriminating information, and how these disclosures fit into Dr. D's sense of the client's relationship to her substance abuse. Fourth, I would ask Dr. D whether she believes that she can conduct this treatment in a competent fashion without her client having additional help and support from available adults or, posed in a slightly different way, how long the treatment in its current form could continue until Dr. D would be able to answer that question. A better understanding of these issues-and psychologists who work with teenagers and substance abuse would certainly suggest additional considerations-will provide the clinical foundation from which Dr. D will move forward.
Once Dr. D assesses what is in her client's best clinical interests, she will place that clinical determination in the context of her jurisdiction's laws and regulations. Part of this process may well involve consulting with an attorney, who can inform Dr. D about her jurisdiction's age of consent, laws and regulations that govern substance abuse treatment, and mandatory abuse and neglect reporting laws. A challenge for Dr. D will then be to synthesize the clinical and legal perspectives in a manner that adheres to the law and best serves her client.
The range of possible outcomes is broad and any outcome will call for considerable clinical skill. At one end of the spectrum, Dr. D may practice in a jurisdiction that gives her discretion whether to disclose her client's information, in which case Dr. D will make a determination about what is best for the treatment. At the other end of the spectrum, Dr. D may discover that her client has the prerogative to keep this information confidential. Note that in either case, for purely clinical reasons, legal considerations aside, Dr. D may feel that the client should decide for herself whether to accept Dr. D's assessment of the need for additional help or seek treatment from another psychologist. Helping her client work through that decision will require a great deal of clinical skill and tact on Dr. D's part.
In the process of coming to an appropriate clinical and legal course of action, Dr. D will hold onto multiple perspectives, as her training in psychology has taught her. I would encourage Dr. D to begin this process with her clinical thinking. Starting with her background, training and expertise as a psychologist will allow Dr. D to move forward from her strengths and will place her back in charge of the treatment, an outcome that both she and her client are likely to welcome.
Send questions, comments or suggestions regarding "Ethics Rounds"–or submit vignettes (without identifying information) for column discussion–via e-mail. "Ethics Rounds" welcomes your involvement and will confer with authors before publishing letters to discuss style and any confidentiality concerns.
Previous "Ethics Rounds" columns can be found at www.apa.org/ethics, in the "From the Director" section.