In California, where I practice law, therapists are required by statute to obtain the informed consent of parents in order to provide treatment to minors for mental health disorders. While exceptions are written into the law, they are narrow and generally involve situations where, for example, the family environment is abusive or severely neglectful.

Although there is very little guidance in the California law, it seems to me that the intent behind the statute is to require full disclosure to parents of the nature of the diagnosis, the proposed treatment, evidence supporting the treatment models under consideration, and other relevant facts that are necessary for the parents to make an informed decision. If the therapist is aware of facts that are relevant to the decision concerning the kind of treatment to be provided, and does not disclose those facts to the parents, then arguably any consent given was not informed.

While of course some families are abusive or neglectful, I think the burden of persuasion should be on any therapist who would choose to exclude families from treatment. In the case of anorexia nervosa, for example, there is no evidence that one-hour per week sessions of individual therapy are as effective as family-based refeeding around the clock, every day. Furthermore, I think any therapist should be extremely reluctant to recommend that family based treatment not be used. After all, how is a therapist to really know whether the family will be an effective support system? Unless family-based therapy is tried, there’s no reliable way for the therapist to know in advance. I suspect some therapists try to determine whether involvement of the family would be helpful based solely on how the patient describes his or her family relationships. But that approach assumes that the anorexic patient is able to objectively and accurately describe the relatinships within the family and fails to account for the disorted thinking that characterizes the illness. It also presumes that the therapist is free of distorted thinking and is able to make an objective decision. Given abuses that have occurred in the past when mentally ill patients have been isolated from their loved ones, I think that involving families is, except in rare cases, not only the more effective therapeutic model but also the approach most likely to safeguard the rights and the interests of the patient.

Thanks for your thoughtful response. You raise a good point about states differing as to whether the parents or adolescents are the holders of confidential information. I agree completely that not all families are willing or able to engage in therapy or support their adolescent, and this is a very unfortunate reality. It sounds as though you and I may work with very different types of families, though. The vast majority of the adolescent patients I treat have dedicated parents who are ready, willing, and able to support them through treatment. Of course, I deal with a self-selecting population: my adolescent patients come to me because their parents are very concerned about them and want to do whatever it takes to help them recover. It is the parents who search for an appropriate therapist, find me, call me, and initiate the treatment process. Many, if not most, of these parents have mental illnesses of their own, as most mental illnesses have a strong genetic component, but in my experience this does not prevent parents from playing an active and positive role in their child’s treatment.

In regards to your question about how I address confidentiality with adolescents and their parents – I spell out the issue of confidentiality and its limits in a detailed Parental Consent for Adolescent Treatment form as well as an Adolescent Assent for Treatment form that parents and adolescent patients sign prior to the initial evaluation. I discuss the issue of confidentiality with adolescents and their parents at the start of treatment and as often as necessary throughout the course of treatment. I make it clear to adolescents that there are certain issues that will remain private between the two of us and other issues that I need to tell their parents about, and I explain why it is important to tell their parents about certain issues (generally it is so their parents can help them with these issues). The issue of what to disclose to parents and what not to disclose is not black and white – in many cases it depends largely on the nature of the adolescent’s illness and my clinical judgment depending on my knowledge of the particular adolescent and parent in question. In my experience, most adolescents understand this policy, and most parents are very grateful for it.

I definitely agree that when the adolescent’s natural support system is that adolescent’s family, it makes sense to try and include the family in ways that will be beneficial to helping the young person recover and avoid relapse. However, for many young people, such as the adolescents I represent, their family is not functioning as a support system and in many cases, the family dynamic has so broken down that these families are not able to support the young person. In these cases it is unfair to immediately require that these young people engage with families who are incapable and often unwilling to provide the necessary support.

While I agree that families should be engaged and educated and involved when a family member (regardless of the family member’s age) has a mental illness, I also think there is an assumption that all adolescents have available families who are able to step up and take on a significant role. And this is sadly just not true. I don’t want to cut families out of the picture nor would I suggest that a family must be “perfect” to be empowered to help an adolescent struggling with a mental illness. But I think it is a misconception to assume that the family is always the adolescent’s “natural environment.”

I do commend you for outreaching to parents and providing them with empirical up-to-date information about their child’s condition because I think so often parents are denied this information.

I wonder however, how you approach the issue of talking with parent with your adolescent patients. Is this something you discuss with them up front? Do you explain what information will be kept confidential and what you propose to share with the parents? Do you discuss the reasons why it might be beneficial to share this information with parents?

Thanks again for you work and for this thoughtful post on the topic.

1.) Developmentally, adolescents need to separate from their parents and establish their own identity
2.) Therapy works best when the adolescent has complete trust in the therapist and knows the therapist is “on their side”
3.) The therapeutic relationship is of utmost importance, and sharing info with parents undermines the therapist’s relationship with the adolescent
4.) The child’s problems are, at least partially, a result of “helicopter parenting,” overprotectiveness, parental pathology, neglect, enmeshment, or other disturbed patterns of of family interaction
5.) Parents are at best unnecessary and at worst counterproductive in the treatment of their adolescent children
6.) Adolescents need to be empowered to “own” their recovery

These points are generally based on abstract theory, not empirical fact or rational analysis of what really works. I disagree entirely with points 3 and 5. Point 4 may have some merit in certain cases (parents who are abusive, neglectful, or addicted inflict great harm on their children and can interfere with the process of recovery) but this is relatively rare among the patients I treat. I agree with points 1, 2, and 6 in the abstract, but I would argue that my approach ultimately demonstrates that I AM on the patients side (NOT the side of their illness) and ultimately, after successful treatment, leads to a healthy, developmentally appropriate separation from parents, an establishment of an individual identity, and an ability to “own” one’s recovery.

I would like to share this with every clinician out there, see who agrees, and then for those who do not ask “why?”