Emma M. Sterrett, M.A., and Jacqueline E. Donnelly, M.A.
The prevalence of mental disorders among adolescents appears to be around 15-20% (Roberts, Roberts, & Xing, 2007; SAMHSA, 2008). Children and adolescents seek treatment for various concerns including mood disorders, psychosis, non-suicidal self-injury (NSSI), eating disorders, substance abuse and dysfunctional family patterns, among other presenting problems. As a result of the prevalence of mental health disorders among adolescents, there is a clear need for psychologists to be aware of and focus on ethical treatment practices involved specifically in the treatment of adolescents (Koocher, 2003).
A brief consideration of the nature of adolescence and the influence of culture and ethnicity will inform our discussion of ethical issues in the treatment of adolescents. Adolescence is a period of development in which individuals are beginning to seek more autonomy, are experiencing rapid cognitive development (Cummings, Davies, & Campbell, 2000), and during which issues of trust and loyalty are particularly salient (Martin et. al., 2006). Furthermore, it is important to consider cultural issues when working with adolescents, especially if a family’s cultural background subscribes to a view of adolescence that differs from mainstream America. For example, many ethnic and minority groups, including African-Americans, Latinos, Asian Americans, Native Americans, Jewish Americans, and Italian Americans, place a stronger emphasis on maintaining close relationships among family members throughout the life span than many Anglo-Saxon American families (Hines, Preto, McGoldrick, Almeida, & Weltman, 1999). While an exhaustive review of this literature is beyond the scope of this article, psychologists who treat ethnically or culturally diverse adolescents and their families are encouraged to educate themselves regarding the role of culture in families’ views of adolescence (suggested resources include The Expanded Family Life Cycle: Individual Family and Social Perspectives (Carter & McGoldrick, 1999), Psychotherapy research with ethnic minorities: Empirical, ethical and conceptual issues (Nagayama Hall, 2001), Black Families in Therapy: Understanding the African American Experience (Boyd-Franklin, 2006), and Counseling Latinos and La Familia (Santiago-Rivera & Arredondo, 2002).
In considering the ethical context of treating adolescents, it is important to remember that unlike therapy with adults, therapy with adolescents almost always includes the involvement of parents or guardians (the term parents will be used in this article). The involvement of parents creates ethical challenges, two of which will be discussed in this article: 1) determining the goals of therapy and 2) managing issues of confidentiality. A third challenge is the process of maintaining in both the adolescent and parent(s) maximum levels of trust in the psychologist, and this issue will be considered within the context of each of the two goals. Sensitive and well-informed management of the first two of these ethical challenges is central to the development and maintenance of trust in the psychologist.
Effective treatment of an adolescent client requires the determination of appropriate treatment goals. It is frequently difficult to integrate the divergent or contradictory pieces of information and perspectives provided by parents and teens. For example, the parents of an adolescent girl perceive that the clothes she wears are too tight, and worry that she is sending the wrong message to the peers and adults in her life. Her perspective is that all the girls at her school wear their clothes the way she does. Ethical Standard 2.01b of the APA Code of Conduct states that “where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age… is essential for implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals.” In addition, Principle A of the Code of Conduct, Beneficence and Nonmaleficence, states that “Psychologists strive to benefit those with whom they work and take care to do no harm” (APA, 2002). Taken together, this ethical standard and general principle remind us that psychologists who work with adolescents must be able to assess the relevance and contextual significance of information from adolescents and their parents in a responsible and developmentally appropriate manner. Psychologists must assess the accuracy of each side of the story while acknowledging the legitimacy of each stance based on each individual’s role in the family. For example, the psychologist might weigh the extent to which wearing clothes in a style that is contrary to parents’ wishes is within the bounds of typical adolescent behavior, while also noting that it is appropriate for parents to be concerned about factors that may impinge on the well-being of their children. This approach would assist the psychologist in the process of helping the adolescent and parents to either find common ground or agree to differ and would aid in improving rapport and trust in the psychologist.
The difficulty in resolving conflicting therapeutic goals between parents and adolescents is indeed a common one, and it is not always resolved successfully. One study found that in only a third of the sample did therapists (including licensed clinical social workers, licensed professional counselors, psychologists, and psychiatrists), adolescents, and parents agree on a goal of therapy (Garland et. al., 2004). While the number one goal, as rated by therapists, was to reduce adolescent clients’ anger and aggression, followed by increasing adolescents’ expression of feelings and then improving family relationships, there was a significant difference in consensus in goals among different dyads. Adolescents and therapists were more likely than parents to endorse a desire to change the environment whereas psychologists and parents were more likely than adolescents to want to change the adolescent. For example, the parents of an adolescent want her to break up with her boyfriend who is of a different race whereas the daughter wishes to continue the relationship and is striving for more independence from her parents. One useful strategy is to encourage parents to prescribe certain areas within which the adolescent is allowed to express her individuality, for example, choice of hairstyle or friends (assuming that the parents don’t deem those friends to be bad influences), while maintaining clear structure and guidelines about expected behavior (Robin & Foster, 1989). The psychologist can then work with the adolescent in terms of how to make the best decisions within the boundaries set by the parents.
The second common ethical dilemma in psychotherapy with adolescents is how to handle confidentiality. In an investigation into the factors pediatric psychologists utilized in order to make a decision about whether to disclose adolescent risk-taking behavior to parents, Sullivan, Ramirez, Rae, Razo & George (2002) found that two factors emerged which together accounted for roughly 40% of the item variance. The first factor, Maintaining the Therapeutic Process, is comprised of the following items: the negative effects of reporting on the family, not disrupting the process of therapy, potential for the risk-taking behavior to stop without telling parents, and likelihood treatment will continue after disclosing information. The apparent seriousness of the risk-taking behavior, protecting the adolescent, and the frequency, intensity, and duration of the risk-taking behavior coalesced into the second factor which they termed Negative Nature of the Behavior. These two factors largely capture the push and pull of such a situation. When does a therapist prioritize the therapeutic alliance, and when is a behavior negative enough to lead the psychologist to inform the parents?
Parents almost always have the legal right to information about their adolescent, but frequently allow some privacy in order to promote a therapeutic alliance between the adolescent and psychologist, and to facilitate the therapeutic process. It is important for there to be a shared understanding that the adolescent’s communications to the psychologist are not legally protected, although the parents may agree to respect the adolescent’s privacy in a manner that is consistent with the psychologist’s clinical judgment.
In order to avoid conflicts and damage to the therapeutic alliance, communication regarding the transfer of information is vital. The APA Ethics Code (2002) provides clear guidance on establishing the limits of confidentiality and describing the use of information provided by clients at the outset of therapy, and in case of changing circumstances in Standards 4.02a and 4.05b. Standard 4.02a states: “(a) Psychologists discuss with persons (including, to the extent feasible, persons who are legally incapable of giving informed consent and their legal representatives)…(1) the relevant limits of confidentiality and (2) the foreseeable uses of the information generated through their psychological activities.” In addition, Standard 4.05b states that “(b) Psychologists disclose confidential information without the consent of the individual only as mandated by law or for a valid purpose such as to… (3) protect the client/patient, psychologist or others from harm” (APA, 2002). These standards combined mandate that adolescent clients and their parents understand what information will be held in confidence and under what circumstances it will be disclosed; namely, when the psychologist determines that doing so will work to protect the adolescent from possible harm.
By establishing a clear standard for disclosing information to parents up front, before an adolescent reveals risky behavior, the adolescent is afforded self-determination and can make an informed decision as to whether or not to reveal potentially risky behaviors to the psychologist. This is an integral step in the process of informed consent by which the psychologist acts to establish trust with both the parents and adolescent. It is also critical to the forging of an honest and respectful therapeutic alliance with the adolescent early in the relationship. As recently summarized by Fisher (2008) regarding psychologists who inform parents when an adolescent is engaging in dangerous behavior: “Although such a disclosure can create clinical complications, it creates no ethical dilemma unless the psychologist failed to inform minor and parents about that policy at the onset of the relationship” (p. 4).
The basic question then is how might we as psychologists best adhere to ethical standards in the treatment of adolescents?
Before a disclosure is necessary:
- Discuss limits of confidentiality with the adolescent and his/her parents during the initial meeting, as a part of providing informed consent, including concrete examples of reasons you would disclose information to the parents.
- Include a statement about limits of confidentiality on the consent form.
- Revisit limits of confidentiality periodically during therapy to ensure the adolescent client understands and remembers what has been said.
If an adolescent chooses to share information that the psychologist determines to be significant risk of harm, the decision to disclose this information to the parents will not be a complete surprise to the adolescent, due to previous conversations. When discussing a necessary disclosure to parents with an adolescent, a necessarily difficult situation can be navigated with less injury to the therapeutic alliance by assuming as collaborative a stance as possible. Examples of how to proceed, which are adapted from suggestions by Taylor and Adelman (1989):
After a disclosure is necessary:
- Maintain a tone of concern for the adolescent.
- Explain to the adolescent why a disclosure to the parents needs to be made.
- Discuss possible consequences to the adolescent that may result from the disclosure, allowing the adolescent’s input.
- Determine ways to disclose the information that will minimize negative outcomes for the adolescent, such as by suggesting that he/she be the one to tell the parents, or that he/she be present when the information is disclosed.
Informing parents in the case of potential harm to an adolescent is generally the most ethical action for psychologists to take, but what constitutes sufficient risk of harm to warrant disclosing information? In responding to this question, Sullivan et al. (2002) suggest that psychologists who work with adolescents cultivate knowledge regarding normative risk taking behaviors in adolescents, and normative levels of intensity, frequency, and duration in those behaviors by consulting empirical data. This is consistent with Standard 2.04 of the APA Ethics Code (2002) regarding bases for scientific and professional judgments which states: “Psychologists’ work is based on established scientific and professional knowledge of the discipline”. For example, despite strong reactions to any adolescent marijuana use by many parents, large national studies reveal that approximately half of all adolescents have used marijuana at least once in their lives by 12th grade (Johnston, O’Malley, Bachman & Schulenberg, 2006).
An example of a helpful resource for learning more about normative levels of drug abuse in adolescents in the U.S. is the Monitoring the Future study sponsored by the National Institute on Drug Abuse (NIDA). A sample of results from 2006 follows:
Prevalence of Use by the 12th Grade in a Large, Nationally Representative Sample in 2006
|Any use of marijuana||42.3%|
|Any use of “Ecstasy”||6.5%|
|Any use of alcohol||72.7%|
|Drinking until drunk||56.4%|
|Any use of cigarettes||47.1%|
In addition, in community samples of older adolescents, the prevalence of non-suicidal self-injury has been estimated at 13-46% (Lloyd, Richardson, Perrine, Dierker & Kelley, 2007; Ross & Heath, 2002), and, in younger adolescents, 56% (Hilt, Cha & Nolen-Hoeksema, 2008). In terms of sexual behavior, the Centers for Disease Control (CDC) produced a report on the prevalence of sexual intercourse in teenagers (Abama, Martinez, Mosher & Dawson, 2004) which reported that in a large nationally representative sample in 2002, 30% of females aged 15 to 17, and 31% of males of the same age reported ever having sexual intercourse. In that sample of 15 – 17 year olds, 17% of males and 14% of females had 4 or more sexual partners in their lifetimes. In adolescents aged 15 to 16 years, 24% did not use any method of birth control during their first sexual experience. Perhaps even more importantly, a number of studies have linked behavior problems, psychopathology and drug and alcohol abuse with sexual risk taking in adolescents (e.g. Capaldi, Stoolmiller, Clark & Owen, 2002; Ramrakha, Caspi, Dickson, Moffitt, & Paul, 2000; Tubman, Gil, Wagner & Artigues, 2003), increasing the chances that a teenager seen in therapy may also be engaging in risky sexual behavior. Large, nationally representative samples are very general, and it is certainly true that specific communities are likely to have different norms. However, data from these samples can be a reference point, especially for psychologists who may be less familiar with normative levels of potentially risky behaviors in adolescents of similar social group, socioeconomic level, race and ethnicity within their geographic community as the client they are treating.
In addition, objective measures are available to assist psychologists in assessing the frequency and severity of risky behaviors in which a particular adolescent client is engaging. For example, the Self-Injurious Thoughts and Behaviors Interview (SITBI, Nock, Holmberg, Photos, & Michel, 2007), Functional Assessment of Self-Mutilation (FASM, Lloyd, Kelly, & Hope, 1997), Suicidal Ideation Questionnaire (SIQ, Reynolds, 1988), and the Beck Scale for Suicide Ideation (BSI, Beck, Steer, & Ranieri, 1998) are measures that assess various aspects of self-harm and suicidal ideation. The MacAndrew Alcoholism Scale, (MacAndrew, 1965), and two scales of the Minnesota Multi-Phasic Personality Inventory-Adolescent Version, Third Edition (MMPI-A), the Alcohol/Drug Problem Proneness scale (PRO, Weed, Butcher, & Williams, 1994) and the Alcohol/Drug Problem Acknowledgement scale (ACK, Weed, Butcher, & Williams, 1994) are measures of assessing adolescent substance use. The Youth Risk Behavior Survey (Brener, Kann, McManus, Kinchen, Sundberg, & Ross, 2002) is a measure of several domains of risky youth externalizing behaviors, such as risky sexual practices and substance abuse. The Eating Attitudes Test, (EAT, Garner & Garfinkel, 1979), the SCOFF eating disorders test (Morgan, Reid, & Lacey, 1999), and the Multidimensional Body Self-Relations Questionnaire (MBSRQ, Brown, Cash, & Mikulka, 1990; Cash, 2000) are measures of disordered eating attitudes behaviors and body image. However, when using standardized tools with minority populations, it is always important to determine the extent to which the assessments have been normed for use within those groups.
By making a thorough assessment of the adolescent’s emotional status and behavior and comparing it to an empirically and statistically informed knowledge base, the clinician can determine if the adolescent’s behavior falls within the limits of normative adolescent behavior. This normative perspective is imperative to the adequate determination of risk and the process of considering whether an adolescent’s parents should be notified of the psychologist’s concerns. Ultimately, the threshold for disclosure is an individual one for each psychologist, with each psychologist determining the amount of risky behavior to tolerate in adolescent clients and in consultation with the parents. However, it is necessary that the decision-making process in such instances be communicated as clearly as possible from the very beginning of the therapeutic relationship to both the parents and the adolescent client.
In working with adolescents in clinical settings, a number of ethical standards, particularly those regarding communication and competence, provide guidance regarding the commonly encountered dilemmas of setting therapeutic goals and whether to reveal information an adolescent has disclosed about risky behaviors to his/her parents. Psychologists must attempt to continually balance the demanding tasks of maintaining the therapeutic alliance with the adolescent, setting goals that are appropriate, and communicating potentially harmful adolescent behaviors to parents. Furthermore, psychologists must provide a service that is satisfactory to parents, who are often paying for these services, and, in addition, generally have a legal right to access clinical information. If these tasks are accomplished, psychologists can form and maintain an enriching therapeutic relationship with adolescent clients, one in which adolescents are provided a safe context in which to address and practice the skills and developmental tasks that lead to becoming healthy adults.
Two vignettes are provided in order to suggest some ways in which the effective management of ethical challenges can facilitate treatment:
The Petersons are a middle-class Caucasian family who bring in their 13-year-old son, Brandon, for therapy. They report that Brandon has become very weird lately. He has been wearing all-black and, when he is home, stays in his room listening to loud rock music. What is most alarming is that after school he recently pierced his eyebrow with a needle. They are concerned that this is the beginning of a pattern of self-mutilation. They insist that you begin Dialectical Behavior Therapy (which they read about on the Internet) with Brandon immediately, to prevent any future self-injurious behaviors.
As with all psychotherapy, treatment begins with the informed consent process. This would include a discussion of the limits to confidentiality. The psychologist communicates clearly that Brandon is the client, and therefore the focus of treatment will be on Brandon and his psychological well-being. In addition, the psychologist, Brandon, and his parents come to an agreement regarding the circumstances in which the psychologist would inform the parents of concerns about Brandon’s safety or well-being. For example, they might agree that if Brandon does engage in more traditional self-injury (such as cutting or burning himself) and the parents are not aware, that the psychologist would inform his parents.
Following the informed consent process, the psychologist thoroughly assesses the problems presented by Brandon and his family. The psychologist conducts a detailed interview with both Brandon and his family in which the psychologist gathers information regarding the function of the piercing for Brandon, whether he has considered any additional alterations to his body and how Brandon feels in general about self-harm or self-mutilation. If there is concern, after this interview, that Brandon is indeed engaging in self-mutilation he could be administered a FASM or a SITBI. The therapist also interviews Brandon regarding his preferences for dark clothing and rock music to determine whether his tastes are signs that he may be a part of an adolescent culture, such as goth or emo. This information is helpful, only in so much that it may signal an interest in morbid or depressive subjects which perhaps could be related to depression or self-injury. However, in addition, the psychologist also strongly considers the extent to which Brandon’s behaviors and interests may fall within normative adolescent development. Specifically, it is very common and even adaptive for adolescents to cultivate their own individual preferences and tastes in dress and music, because it can serve as steps in the progression towards the adolescent becoming more independent, cognitively and behaviorally. Once this assessment is completed, the psychologist develops treatment goals in collaboration with Brandon and his parents. Education of the parents regarding normative adolescent behaviors may well be a critical component of developing a consensus about treatment goals.
The Perez’s are a working-class Mexican-American family who bring in their 14-year-old daughter, Jessica, for treatment. During the intake, Mr. and Mrs. Perez state with intense emotion that Jessica has been smoking and drinking and overall “is not the Jessica they once knew.” Her parents state that they know Jessica is lying and they are furious. They want you to convince Jessica that drinking and smoking are bad and that she should spend more time with her family. At the first session, Jessica tells you that her parents are “totally over-reacting.” She states that her parents have always been over-protective and that they are “freaking out” now that she’s finally starting to make friends at her new high school and is spending more time away from the family. She confides that she attended a party recently where most of her friends were drinking, and that she drank “a couple of beers.” She also says that her mother had found a pack of cigarettes in her book bag and confronted her. She lied and said they were a friend’s. Jessica says she started smoking cigarettes two months ago, but that she only does so at parties and with friends after school. She argues that she knows other teens who not only drink and smoke much more frequently than she does, but who also abuse drugs. She wants you to convince her parents that her behavior is normal, and that they should give her some space to be a “regular teenager” like her friends.
It would be important for the psychologist to be familiar with Latino, or more specifically Mexican-American, views of family and adolescence, while maintaining an open stance towards the meaning of these concepts within this particular family. As with the previous vignette, the psychologist is encouraged to begin the initial session by informing Jessica and her parents that Jessica is the client. In addition, the psychologist is also encouraged to discuss with Jessica and her parents the situations in which the psychologist might decide to inform her parents of problematic behavior. In determining goals for treatment, the psychologist is encouraged to have an open dialogue with the family regarding their views of adolescence as compared to the mainstream American view, as well as the parents’ goals for therapy compared to Jessica’s goals for therapy. In this case, one goal for therapy (that may not be a stated goal for Jessica or her parents) would be for the family to create a common understanding of what the transition to adolescence will look like in their family, given the likelihood of varying perspectives and cultural influences. For example, the family may decide that Jessica will still be expected to participate in family activities and responsibilities, but at the same time, that she will be allowed to spend time with peers, within the boundaries set up by the family. If deemed significant, the psychologist would assess Jessica’s use of substances through clinical interviewing, or perhaps by using measures such as the MMPI-A subscale, the PRO or the ACK. These instruments would be particularly helpful as the MMPI-A is one of the most widely-used personality measures with Latinos and a recently published book is completely devoted to the use of the MMPI-A with Latinos (Butcher, Cabiya, & Lucio, & Garrido, 2007). Once these steps are completed, the psychologist can set more specific goals with the family, which, depending on the results from the assessment, could include, in addition to forming a shared family definition of adolescence, Jessica’s increased adherence to family rules, improved positive peer relations, and increased self-awareness.
Jacqueline E. Donnelly, M.A. is a clinical psychology doctoral student at Duke University.
Emma M. Sterrett, M.A. is a clinical psychology doctoral student at the University of North Carolina at Chapel Hill.
Acknowledgments: We thank Erica H. Wise, Ph.D. for her editorial assistance on this article and the one on which it is based (Donnelly & Sterrett, 2007) which was previously published in The North Carolina Psychologist.
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