A woman telephones her marriage therapist and says she "has to unload" about something that she has not revealed in therapy. "First," says the therapist, "you have to realize that once you share this information with me, it will have to be shared with your husband." The woman changes her mind and hangs up. ::
The father of a teen-age girl in therapy is upset and confused: "I care for my daughter very much. But her therapist won't tell me what she's saying in there. And I'm the one paying the bill." It is a constant struggle, psychiatrists say: striking a balance between a patient's right to privacy and the need of family members to understand and help.
In individual adult therapy, confidentiality is a relatively simple concept. There must be total trust between patient and therapist for the therapy to succeed, and nothing leaves the therapy room. But it becomes much more complicated when a child, adolescent, married couple or family is treated.
"Parents and married couples considering therapy need to ask the prospective therapist how confidentiality is treated," says Dr. Larry Silver, former acting director of the National Institute of Mental Health, who now privately treats children and adolescents and their families. "And if they don't like the way the therapist handles it, they should keep searching."
Silver's methods are standard for most accredited child and adolescent psychiatrists. Depending on the patient's age and understanding, the doctor's language may vary, but the message is clear: "Whatever we talk about in this room will stay in the room, unless it is something dangerous to you or to someone else. Then I will have to tell your parents, but I will let you know first that I am telling them."
The term "dangerous" refers to life-threatening issues, such as suicide, homicide, running away or criminal offenses.
When it comes to setting up rules for revealing any information outside the description of "dangerous," therapists differ. For example, a therapist may not necessarily let the parents know that their child has said she was sexually promiscuous or that she was cheating in school. "Such issues as these," explains Silver, "require a judgment call, and I have to ask myself, what will telling the parents do with the therapeutic alliance?"
Most child/adolescent therapists talk to the parents only in general terms. Dr. Jerry Wiener, chairman of the department of psychiatry at George Washington University Hospital, says that he might tell the parents if their child is "depressed" or suggest how to "give a hug" rather than "criticism," but there is no detailing of what the child has been saying to bring Wiener to that diagnosis and suggestion.
Wiener says he may also suggest to the young patient, "I think it's very important for you to say these things with your parents here. Why don't we get together?"
At first, parents may protest that they want to hear more, says Silver, "especially at the start of therapy." But in time they adjust and prefer it that way. One Bethesda mother whose 6-year-old was treated for school phobia said she was actually relieved not to know what her daughter was saying and doing during the sessions, which included play therapy. "I didn't want to know the specifics," this mother said. "I don't think I could have handled all the guilt of thinking I had raised her wrong."
Such parental apprehension is common, but it has nothing to do with the doctor's decision to "not tell." "The first and foremost consideration is solely keeping the trust of the patient," says Silver.
"The young patient needs to feel free to talk about anything without fear that he or she will be judged by the parents.
"When adults are in therapy, they are often dealing with people in the past," says Silver. "Imagine how a child feels, who is talking about mommy or daddy, and mommy is sitting in the waiting room? Mommy is the one who takes the child home and feeds her."
A child/adolescent therapist can choose to not see the parents at all or see them and divulge little or nothing. If this is the case, it is a practice usually agreed on before therapy begins. Wiener, who is also the president of the American Academy of Child and Adolescent Psychiatry, believes this type of therapy "shuts the parents out."
It is "an overly rigid application of the confidentiality rule," Wiener says, and "it can be used as a weapon by the child: 'I'll tell everything to Dr. X and you'll never hear about it.' "
One discipline that has no rigid confidentiality rule whatsoever is marriage therapy. Because most states do not have marriage or sex therapy licensing laws, anyone can hang out a shingle to help hurting couples. The risk of an ill-trained therapist breaking or mishandling confidence can be devastating to the already troubled marriage.
It is typical for qualified marriage therapists to meet separately with a husband or wife, especially in the beginning of the treatment, says Dr. Steven J. Wolin, a Washington family and marriage counselor. "But I would be very suspicious of someone seeing the husband and wife individually over time and calling it marital therapy. This is confusing a broker's role for a therapist's role. It is the marriage, not the husband or the wife, that is the patient," and that means joint sessions must be held.
When Wolin does do individual work with a married couple, he says "it is usually dealing with something from childhood, nothing to do with the marriage.I recognize that I might be told things, but sooner or later those secrets come out as the therapy progresses. When a patient does tell me something, I let them know they have to tell their spouse. It is very hard."
Dr. H. Vincent Kelly, a Bethesda family systems therapist and clinical associate professor at Georgetown University, says, "When a patient in marriage therapy comes to me privately wanting to reveal something that is bothering them -- often this is having another relationship -- I give them three choices: You can tell it to your spouse on your own; wait for the session and you initiate it; or if it is too painful, I will initiate it."
Confidentiality does a complete turn-around when couples decide to enter family therapy. Rich Simon, editor of The Family Therapy Networker magazine and a Washington family therapist, says that "family therapists are distrustful of their having confidentiality or secret understandings with family members in the therapy. If a family member wants to speak to the therapist privately, this may perpetuate some sort of collusion. So the patient is told well ahead of time that the therapist may share any secret with the family if necessary."
In some family therapies the sharing of confidences could include children, grandparents, uncles and aunts. Family therapists are "aiming for the spread of communication rather than the barriers," says Kelly. "And one of the problems with the way families work is the secrecy."
Kelly gives the example of a mother and father who came in with their 18-year-old son. "They were concerned about drugs and suicidal tendencies. Initially all three were seen together, then the parents, then the child.
"It was understood, whatever they gave to me was mine," says Kelly. "I would try to use it in a therapeutic way. I wouldn't deliver messages from one to the next. But I would decide how to use it in the therapy. I may even decide not to say anything. That is to be understood as an option."
But if necessary, doctors like Kelly who are trained in family therapy "will get to specifics" with the family unit. "Our basis," says Kelly, "is to break the logjams of communication that have built up in the family."
Barbara Mathias is a free-lance writer in Washington.