Clinical Psychologist
When Family Members Tell on Each Other:
Dilemmas and Solutions in Adolescent-Family Therapy
Mark Dadds, Leanne Geppert, Emma Kefer, and Kristina Vaka
Griffith University
&
South Brisbane Child and Youth Mental Health Service
Clinical and ethical problems associated with therapists’ knowledge (or lack of knowledge) of
family secrets have long been discussed in the family therapy literature (e.g., Brown-Smith, 1998) and has
been the subject of some empirical research (e.g., Vangelisti & Caughlin, 1997). Most of this literature
deals with the use of secrets to maintain power relationships and balance within distressed family systems,
and how the secret can be “outed” and thus resolved in ways that benefits the family system and its
members. In contrast, little attention has been paid to a related and common problem with information
sharing in the child and family therapy field. This concerns the opposite, i.e., when information about
family members is passed on without the knowledge or approval of the subject of the information. For
example, parents often tell therapists things about their children in private. The goals of such information
sharing may be many and varied, having both positive and negative intentions and consequences. This
paper deals with negative aspects of such sharing and the dilemmas it can create for therapists.
In 1999, the authors were involved in a professional supervision group dealing with complex
child and family therapy cases seen within a large teaching hospital servicing a low SES inner city area.
Struck by the amount of time we were all spending dealing with confidentiality issues, and the difficulty
with which some of the disclosure problems had been managed, we decided to take a more structured
approach to the problem. A literature review revealed little of help so it was decided to make a start by
analysing our own problematic cases. The aim was to look for commonalities and solutions that may help
us and other clinicians take a more knowing approach in the future. In this paper, we present several
clinical examples of information sharing that created serious management and ethical problems for
therapists. Some solutions are suggested and finally, a general framework is developed and presented for
thinking about and managing these common scenarios.
The Case of Lisa
Lisa, 13 years of age, was referred by her mother for problems of withdrawal
and depression in the home, and mild conflict with the stepfather. Antecedents included
the death of her father 18 months earlier after a protracted cancer-related illness, family
conflict with her older brother resulting in him leaving home, and the mother’s new
relationship resulting in the formation of a new stepfamily. She was well adjusted at
school, however, and assessment revealed only mild depression and conflict with the
stepfather, both of which resolved quickly after some individual and family counseling
sessions.
Six months after the initial presentation, however, the mother re-contacted and
requested a session for her daughter, worried that she has become withdrawn again. At
the first session, the stepfather and the daughter presented alone. Before the session had
formally commenced, the stepfather passed a letter from the mother to the therapist and
asked that the daughter not be informed about it. The therapist assessed the daughter,
finding no evidence of depression or other problems, and continued positive adjustment
at school. The therapist also noted an increased distance between the teenager and
himself but it was very subtle and difficult to identify specific behavioural
manifestations over and above a hunch she was not as open as usual.
In contrast to the daughter’s presentation however, the mother’s letter reported
extreme concerns with the daughter’s behaviour at home including: obsession with
morbid themes and pictures of death, especially “witch” themes including casting of
black spells and so on, withdrawal into her room, and posting a sign on her door saying
“Hell is nothing, life is worse”. The letter reported that the school psychologist was also
concerned about her morbid behaviour, but insisted that the rather exclusive private
school not be contacted in order to avoid any possible stigmatisation.
The therapist is clearly in a very difficult situation. The daughter has denied all
problems and generally appeared convincingly healthy and happy to the therapist.
However, the mother’s note clearly raises worrying issues about withdrawal,
depression, and suicide risk. The mother’s denial of permission to contact the school
precludes the possibility of obtaining collaborative information from this important
source of information. Further, the therapist is unable to disclose the information at
hand due to the invocation of confidentiality about the letter. Even if the therapist was
able to raise these issues openly with the daughter, this would potentially compromise
his relationship with the daughter as she would quite rightly see him as being an agent
of the mother in assessing the daughter.
Both practically and ethically, the therapist cannot override the mother’s wishes
for confidentiality unless the daughter was judged to be in acute risk. Thus, the solution
in this case is to schedule a session with the mother (and stepfather) and educate them
about the difficulties associated with the process created by the confidential sharing of
information. The aim would be to assess the need for, and perhaps set up, a session with
both mother and daughter to openly work through the former’s concerns.
This approach was taken with some success in that the mother’s anxiety about
the daughter was reduced and their otherwise positive relationship continued. However,
a negative outcome remained that was unable to be rectified. The therapist’s hunch that
the daughter had distanced herself was correct. She had in part known about the letter
and reinterpreted the therapist’s role, from that time on, as an agent of the mother; no
longer her personal confidante. Attempts to redress this perception were not fully
successful. The negative corollary of this is that the potential of the therapist to
contribute positively to any future problems involving the daughter is greatly reduced.
This case illustrates two points, one obvious and one more difficult. The first is
that healthy systems (family, therapeutic) require information to be shared in open
ways. While children should not be privy to all aspects of family life, it is clearly healthy
for them to be informed about actions (such as contacting therapists) that directly affect
them. The second point is that there may be clear advantages of specifying this
expectation as a ground rule from the outset in child and family therapy. As in the
above, attempts to redress the situation once information has been passed on in a
non-open way may be ineffective compared to preventing such a scenario from
occurring in the first place. The setting up of ground rules about this is rare in our
experience. Most therapists will set up ground rules for confidentiality, i.e., that
information a teenager provides will not be passed on by the therapist unless there is
risk involved. However, rarely do therapists set up ground rules about passing on
information to the therapist with the expectation that the therapist will act on the
information but keep it a secret at the same time.
The Case of Natalie
Natalie, a 16 year old girl, was referred by her psychiatrist for individual therapy
for a Major Depressive Disorder. She presented with depressed mood, withdrawal from
social activities, family relationship difficulties, weight gain, anhedonia, and school
refusal. Precipitants included moving from Perth to Brisbane 18 months earlier with her
father and her mother joining them four months after this time; a loss of peer support;
and mother having a major falling accident resulting in facial injury. Treatment
involved weekly individual therapy for Natalie, monthly joint sessions with Natalie and
her parents, monthly psychiatric reviews, and liaison with Natalie’s school. From the
onset of therapy confidentiality issues were discussed and the need for Natalie to have a
confidential outlet to express her emotions was understood and encouraged by all
family members.
After 10 months of treatment significant shifts were noted in Natalie’s
depression; she had formed friendships with her peers and she was attending school on
a full-time basis. Natalie and her parents reported that she was coping well and
treatment was reduced to monthly individual sessions for Natalie.
At the next appointment her mother spoke to the receptionist and slipped her a
note asking if she could speak with the therapist first. The mother said that this was very
important and asked if this request could be kept secret from Natalie. The therapist,
concerned about the urgency of the mother’s request, asked her to enter the therapy
room. Natalie’s mother then burst into tears and reported that she was not coping with
Natalie’s behaviour, in particular how long it takes her to get ready in the morning and
the subsequent arguments resulting from this. The mother described how her daughter
spends hours on her appearance, resulting in mother being late for appointments. The
mother asked the therapist if she could raise these issues with Natalie in order to bring
about some change. Upon leaving the therapy room, Natalie’s mother asked the
therapist not to tell Natalie why she had spent time with the therapist. She also feared
Natalie discovering how tearful and upset she had become and said she would hide in
the clinic bathroom while the therapist brought Natalie into the room for her session.
When Natalie entered the room for her session she immediately asked the therapist
where her mother was and what she had spoken about.
This situation presents the therapist with a number of dilemmas. Firstly the
therapist is faced with the issue of being asked to protect the privacy of the mother while
also trying to maintain Natalie’s trust. If the therapist confirms that Natalie’s mother is
distressed she will break the trust of the mother; if the therapist does not answer
Natalie’s queries about her mother she risks becoming entwined in the family pattern of
secrecy and subsequently risks losing Natalie’s confidence and trust. A second
therapeutic dilemma involves the mother’s request for the therapist to subtly raise the
issue of Natalie’s grooming with her, without acknowledging that her mother had
revealed this information. A third therapeutic dilemma involves how to handle future
“urgent” consultations required by Natalie’s mother.
The following interventions were made to address these therapeutic dilemmas.
The therapist spoke in session with Natalie’s mother about the difficulty of keeping her
distress a secret and also of trying to address Natalie’s organisation skills without
acknowledging that her mother had raised this as a concern. It was agreed that Natalie’s
mother would go home and discuss with Natalie that she had had some concerns that
she had wanted to discuss with the therapist. Natalie’s mother did this and also
encouraged Natalie to raise these issues herself in individual therapy, which she
subsequently did. Second, a joint session was held between Natalie and her mother
where they both voiced their concerns over the grooming behaviour. It emerged that this
behaviour was far more bothersome for Natalie’s mother than it was for Natalie herself.
Natalie and her mother constructed a behavioural contract specifying length of time
allowed in the bathroom and family rules about leaving for appointments and events on
time. Third, Natalie’s mother was referred to another therapist for supportive therapy
relating to her difficulty coping with Natalie’s behaviour. It was agreed that no further
individual sessions for Natalie’s mother would be held with Natalie’s therapist. The
monthly joint sessions with Natalie and her parents would continue to allow time for all
family members to share views and information.
The Case of Jenny
Jenny, a 14 year old girl, was referred at the age of 12 for assessment and
treatment of an acute psychotic episode (visual and olfactory hallucinations, paranoid
delusions, and disorganised speech and behaviour) with a strong affective component.
With vigorous medical and psychological treatments, the psychotic illness has
significantly resolved and Jenny was able to attend a mainstream school part-time after
12 months of absence. This was a time of both relief and anxiety for Jenny and the
family, given that successful reintegration was the first major step towards full
recovery.
Over the two years of treatment, Jenny participated in weekly individual
psychological therapy, her parents and two younger siblings participated in fortnightly
supportive therapy, and the whole family attended monthly information sessions. A
strong rapport was developed between the family and the treating team over time and
clear therapeutic boundaries were formed and maintained, particularly surrounding
Jenny’s individual therapy, which more recently focussed on mood management,
mainstream school reintegration and self-esteem development.
Two weeks after the school reintegration began, Jenny’s mother contacted the
individual therapist and requested an urgent appointment without Jenny. Jenny’s
mother used this session to inform the therapist of a confidential conversation between
Jenny and herself that week, in which Jenny disclosed experiencing severe stress with
the return to school and frequent bullying by classmates (school refusal became evident
the day after the conversation between Jenny and her mother). However, Jenny asked
her mother to keep this information private and not to inform her mental health support
people or school staff. At the end of the session with the individual therapist, Jenny’s
mother requested that this appointment not be discussed with Jenny and that “the
problem” be corrected without Jenny knowing that the mother had disclosed her
“secret”. One day after this urgent appointment, the mother wrote a letter to the therapist
which pointed out further difficulties Jenny was having with school, and also the
mothers’ mood problems, suicidal ideation and sense of helplessness. The letter
contained extensive information about the mother’s guilt at having to break her promise
about sharing the information with mental health staff.
This situation presents both the therapist and the parent with a dilemma. The
therapist is aware of a critical situation that may evolve into significant relapse, given
that stress and self-perceived failure were two clearly identified illness risk factors for
Jenny. As long as mental health staff and school staff are unaware of the difficulties (or
unable to act on them in order to keep the “secret”), action plans are unable to be
developed and implemented with Jenny herself. The mother is also presented with a
dilemma - she is aware of the risk factors but also her promise to keep the “secret”. In
contrast to Jenny, Jenny’s mother feels unable to manage the situation within the family
and would like support from mental health staff.
The individual therapist responded to the dilemma in a number of ways. First,
the mother was encouraged to go home and discuss her own concerns about Jenny’s
situation, and revisit the issue of involving (as a first step) the individual therapist in the
problem-solving phase. In addition to this, the ground rules for “secret” sharing were
discussed with the mother, and it was agreed that if the mother was unable to keep the
“secret”, she would speak with her daughter before informing the therapist. Second, the
mother was asked to gain Jenny’s permission to also discuss this issue (and any similar
issues in the future) with the father. This would provide support for the mother, who
could share her concerns validly and it would strengthen the family’s ability to manage
the situation internally.
The final strategy was implemented as part of the original support plan put in
place for Jenny, which encompassed weekly telephone calls by the individual therapist
to the school for feedback about Jenny’s progress. Upon doing this, the therapist was
informed that Jenny had not attended school for two days. A special therapy session was
arranged with Jenny to discuss the feedback from the school, and the information was
presented to the therapist by Jenny from her own perspective.
The Case of Amy
Amy, 14 years, was referred to a community clinic after being presented by her
mother at a local hospital with symptoms of depression, self-harming behaviour
(cutting) and suicide ideation. The family context included long term parent-child
conflict, maternal depression and suicide attempts, and a recent unsuccessful attempt by
Amy to live with her father interstate. Amy’s attendance at the clinic was a condition of
her returning to school where she had become increasingly noncompliant, disruptive
and aggressive towards her peers.
Treatment was contracted to be weekly individual appointments with Amy and
less frequent, but regular individual appointments for mother with her own therapist.
Amy attended regularly at the clinic as she stated that she wanted to continue at school
and that the appointments were convenient for her as she could miss certain classes each
week. Mother did not regularly attend appointments.
Amy was slow to establish rapport with the therapist and her ability to use the
therapy constructively was limited initially. During a week where her mother had not
attended her own therapy appointment, mother sent a fax to Amy’s therapist prior to
Amy’s appointment time containing copies of journal writings and diary entries which
mother had found when she was searching Amy’s room. Mother believed the content
showed evidence of a multiple personality disorder and requested the therapist read the
material prior to the appointment, and address the mother’s concerns with Amy without
telling Amy where the information had come from or that her mother had sent it to the
clinic.
Clearly this places the therapist and the therapeutic relationship in a very
difficult situation. Amy had slowly begun to establish a collaborative relationship with
the therapist and was beginning to openly discuss her family, emotional and behaviour
difficulties. The faxed information was obviously related to these difficulties, however,
was much more personal than Amy had been willing to disclose at that point. In
addition, the mother had stated that she had acquired the writings secretly and was
requesting that the content of the writings be addressed in a secretive way.
Management of this intrusion on individual therapy was more based on clinical
judgement rather than any formal ethical guidelines. There are no guidelines in the APS
Code of Ethics for parental intrusion on an adolescents therapy. It was judged that the
building of the therapeutic relationship and need for the relationship between the
adolescent and therapist to be collaborative was of primary importance for the success
of therapy, and the long-term psychological functioning of the adolescent. As such, the
immediate discussion of concerns the mother had introduced prematurely into therapy
did not occur. The intrusion into the therapy was addressed directly with the mother, at
a family systems level.
An individual appointment with her own therapist was arranged for mother.
The information, the manner in which the information had been provided and the role of
both mother’s and Amy’s individual therapy/therapist were discussed. It was clarified
that concerns the mother had could be discussed with her own therapist either by
appointment, phone or fax and it was made clear that any faxed material would not be
read by Amy’s therapist unless this was provided by Amy. Where the mother and her
therapist agreed that her concerns needed to be addressed directly with Amy it was
agreed that a family review appointment would be scheduled at which mother, Amy and
both therapists would attend. Mother was also encouraged and assisted to communicate
with Amy in a more open, non-reactive way. In this instance this response provided
containment for the mother’s anxiety and for a short time enabled her to address her
concerns regarding the daughter’s mental health, and her difficulty parenting Amy to be
addressed.
As therapy continued and Amy became more independent from her mother a
more serious intrusion on the therapy occurred. Mother provided a parent of another
child at Amy’s school the therapists name and phone number so that the parent could
ring and discuss their concerns regarding Amy’s behaviour. It was planned that this
would be addressed at both a family and individual level. Although it was made clear to
the parent that they needed to discuss their concerns with Amy’s mother and the school,
and Amy’s mother attended an appointment at which the breach of confidentiality, and
the implications of this for Amy were discussed, this incident was never discussed with
Amy as she did not attend any further appointments. It appears that when Amy was told
of the phone call (by her peer at school), she became suspicious of the role that the
therapist now performed between herself, her mother, other adults, and school and no
longer trusted in the confidential nature of the relationship or that the therapy was to
assist her.
This case illustrates a number of points. The first concerns the definition of who
is the client. If Amy is the client, confidentiality is confined to her both within and
without therapy appointments. If the family (mother – adolescent) has been contracted
as the client, then confidentiality is within the family system. In this case the therapy
was negotiated to be concurrent individual therapy for mother and daughter; however,
the mother did not engage with her therapist and continued to intrude into the
daughter’s therapy. Confidentiality of the adolescent’s therapy is compromised, mother
has not been able to use her own therapy, and her attempts to communicate with Amy’s
therapist have been undertaken in a secretive, collusive manner which undermine
Amy’s therapy.
The second point - how should intrusions on an adolescent’s therapy be
managed. This is of particular importance due to the developmental stage where
adolescents and parents are dealing with individuation issues. Ideally the boundaries of
confidentiality and the therapeutic relationship could be discussed with all vested
parties prior to the commencement of therapy so that intrusions could be avoided.
However it is very rare that this can successfully occur. At best, when they occur
intrusions would be managed in an open, constructive way with all parties present. The
reality appears to be that even this can not often occur successfully as in many cases
neither parents or the children have the interpersonal or communication skills necessary
and have not adequately dealt with their own interpersonal and/or mental health
difficulties so that it can occur.
Overview and discussion
All of the above cases share the following aspects:
1) information was shared with the therapist without the open consent or knowledge of
the subject of the information;
2) in most cases, the aim of sharing the information was positive. That is, the parent
felt it was important to the welfare of the adolescent that the information was
provided to the therapist;
3) related to the previous point, in most instances the information was important. That
is, it concerned potential risks to the adolescent;
4) part of the motivation for parents wanting to the keep their role a secret was their
own anxiety about being able to deal with the scenario, and in not wanting to be seen
to betray the adolescent.
5) acting on the information put the therapist in a position of compromising their own
relationship with the adolescent, particularly by being seen as in partnership with
the parent.
The difficulty for the therapist in these situations is how to effectively act on the information without
compromising their relationship with the adolescent. In most instances this involved encouraging the
parent to discuss the issue openly with the adolescent, initially without the involvement of the therapist.
This appears to be the first solution of choice. However, this solution can raise difficult issues about the
parent’s willingness to do this and skills at achieving a favourable outcome. In some cases, the therapist is
left with no choice but to facilitate some sort of open information exchange, again posing a serious
challenge to the relationship with the adolescent as exemplified in the above cases.
Two solutions we found helpful were:
1) using the idea of “quarantining” the relationship with the adolescent prior to any
action in relation to the (inappropriately shared) information. That is, the
therapist talks to the adolescent about the implications of holding sessions with
other family members, or holding joint sessions. The therapist can judge the
extent to which the adolescent needs to be told about the specific reasons for the
session at this point, i.e., the inappropriate sharing of information. The aim is to
make explicit to the adolescent client that holding sessions with other family
members can sometimes make the client feel that the therapist has multiple and
competing alliances. The therapist makes it clear that such sessions, if
necessary, need to be structured in a way that the adolescent feels comfortable
with and that will not compromise their relationship. Thus, the adolescent is
reassured that their wellbeing, and thus, the therapeutic relationship is the top
priority, and is given some decision making power in designing the scheduling
and structure of these sessions.
2) Specific parent or family sessions are then scheduled with the consent and
involvement of the adolescent;
3) In the subsequent parent or family sessions, family members are encouraged to
develop a solution to the problem of secrets and information sharing with the
therapist taking a “not-knowing” and facilitative rather than leading role. That
is, the therapist is seen to seek advice from the family about how he/she should
deal with passed on information. This approach de-emphasises the family
having a problem and needing to fix things up and instead, places the family in
the role of expert and help giver. Such roles have been shown to reduce conflict
and communication problems in families, whereas feeling pressured and
blamed by therapists can lead to increases in conflict and disturbed
communication (Terkelson, 1983). This session(s) might be done with the
parent and then adolescent alone, with the goal of moving to an open-shared
session.
While we have not discussed the issue here, such cases as the above can be made
all the more complex when a therapeutic team is used rather than a single therapist.
In such cases, information may be passed on to one therapist but not others. A
common example we came across was where the parent and the adolescent had been
assigned separate therapists and the parent’s therapist was being made privy to
important information about the adolescent or vice verse. In these situations, one
therapist may have clinically important data that should be passed on but not have
permission to do so. Further, even if permission is at hand, the difficulties in
disclosure and its threat to the relationship is as discussed above. Our approach to
these dilemmas followed the same principles as above, i.e., that is, a gradual move
toward openness while quarantining the relationship with the adolescent, except
that in these cases the systemic issues are complicated by the inclusion of the
therapeutic teams. In a sense, the information sharing issues often show parallel
processes within and between the family and the therapeutic team systems.
Despite the above attempts, we clearly have not been able to suggest any
definitive or broadly applicable solutions to these dilemmas. Further, their
complexity places them beyond the useful application of any formal and structured
ethical guidelines. Hopefully, this discussion may provoke some further work in
this area and alert therapists to the need to set up some working guidelines that can
be communicated to families as a preventative strategy at the outset of therapeutic
contracts with adolescents and their families.
References
Brown-Smith, N. (1998). Family secrets. Journal of Family Issues, 19, 20-42.
Terkelson, K.G. (1983). Schizophrenia and the family II: Adverse effects of family
therapy. Family Process, 22, 191-200.
Vangelista, A.L., & Caughlin, J.P. (1997). Revealing family secrets: The influence
of topic, function, and relationships. Journal of Social and Personal
Relationships, 14, 679-705.