Confidentiality Considerations and Rapport Building Strategies with Children and Adolescents

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Confidentiality Considerations and Rapport Building
Strategies with Children & Adolescents
Lisa Vroman Stokes, PhD & Sarah Frantz, LMSW CAADC
October 3, 2018

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“How it feels to do family therapy”.Me.Me, https://me.me/i/how-it-feels-to-do-family-therapy-since-its-social-10679932. Accessed 19 Sept. 2018

4. Objectives
• Identify relevant state laws regarding confidentiality for
children/adolescents participating in outpatient psychotherapy
• Identify developmentally appropriate language to communicate
confidentiality to children/adolescents and their families
• Identify strategies for engaging children/adolescents in therapy
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Differences Between Psychotherapy with Minors and Adults

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“Very few children come to therapy on their own volition
(Leve, 1995). They are brought to treatment, usually by
their caregivers, due to problems they may or may not
admit having. Moreover, clinical experience suggests that
most frequently children are referred to therapy because
their psychological difficulties create problems for some
system (e.g., family, school).”
Friedberg & McClure (2002)Friedberg & McClure (2002), pp. 7
Differences Between Psychotherapy with Minors and Adults

7. Differences Between Psychotherapy with Minors and Adults
• Few children come to therapy of their own choosing
• Little choice about when therapy ends
• Function within systems (e.g., school, home)
• Rapid changes in cognitive, physical, emotional, and
social development
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Friedberg & McClure (2002); Koocher (2003)

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Confidentiality Considerations

9. Confidentiality
• Confidentiality is a central, unique distinction from adult
psychotherapy related to:
(a) State and federal laws regarding minor rights to autonomous health
care decisions
(b) Laws related to obligations of minors’ legal guardians
(c) Developmental challenges of children/adolescents’ ability to
understand their rights and nature of treatment
• Strive to balance protection of the minor’s welfare and their
development of privacy and autonomy.
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Fisher (2017); Ford Sori & Hecker (2015)

10. Common Therapy Session Structures
• Young children (3-6): Often have family sessions
• Middle childhood (7-12): Half and half
• Adolescents (13+): Parent involvement as needed, occasional
family session
• Note that heavy family involvement often tapers off with age
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11. APA Ethics Code
Ethical Standard 3.10: Informed Consent
(a) When psychologists conduct research or provide assessment, therapy,
counseling, or consulting services … they obtain the informed consent of the
individual or individuals using language that is reasonably understandable to
that person or persons except when conducting such activities without
consent is mandated by law....
(b) For persons who are legally incapable of giving informed consent,
psychologists nevertheless (1) provide an appropriate explanation, (2) seek
the individual’s assent, (3) consider such persons’ preferences and best
interests, and (4) obtain appropriate permission from a legally authorized
person….
*Ethics Code of the National Association of Social Workers details similar ethical guidelines
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APA (2002); NASW (2017)

12. APA Ethics Code
Ethical Standard 4.02: Discussing Limits of Confidentiality
(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.
(b) Unless it is not feasible or is contraindicated, the discussion of confidentiality
occurs at the outset of the relationship and thereafter as new circumstances
warrant.
*Ethics Code of the National Association of Social Workers details similar ethical guidelines
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APA (2002); NASW (2017)

13. Limits of Confidentiality
Informed consent must include explanation of limits of
confidentiality, including:
• a) Compliance with reporting laws, such as mandated child
abuse/neglect, to protect the patient from harm (suicide), and to
protect the public from harm (duty-to-warn laws).
• b) Guardian access to records in the case of therapy involving minors
or individuals with impaired consent capacities.
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APA (2002); NASW (2017)

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Confidentiality Complexities
• Confidentiality is complex in childhood/adolescence!
• A parent who consents on their child’s behalf generally has the right
to know the content of the child's treatment.
• In some circumstances, you may decide that it is appropriate to
respect adolescent’s wishes to keep their privacy.
• Support child in considering risks/benefits of sharing private
information with parents.
• And there may be circumstances in which you determine that
sharing information would be helpful.
• Best to tell the adolescent what information will be shared and when.
• Best to include adolescent in the conversation.
Fisher (2017); Koocher (2003); Koocher (2008)

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Caveats to Confidentiality…
Considerations
• Emancipated minors
• A minor 14 years or older may request up to 12 outpatient
sessions or 4 months of outpatient counseling without
parental consent.
• Minors consenting to substance abuse treatment
• Minors seeking birth control
• Minors consenting to maintain life and preserve health of their
child or fetus
The Network for Public Health Law retrieved from:
https://www.michigan.gov/documents/mdch/Michigan_Minor_Consent_Laws_for_Sexual_Health_292774_7.pdf

16. Discussing Confidentiality with Families
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17. Communication Overview
• Communicate circumstances under which the minor’s
confidentiality would be broken.
• Communicate importance of protecting minor’s privacy, even
from parents, as appropriate.
• Adjust your language to the developmental level of the minor
and their family.
• Allow sufficient time to address family questions/concerns.
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18. Example Language
To help identify what the family may have (or have not)
discussed with their child prior to intake appointment:
“What do you know about why you are coming in to see me
today? What have you and your [parent/guardian] talked
about?”
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19. Example Language, cont.
To help establish rapport and address stigma of therapy:
“We aren’t going to do anything in here that hurts! You won’t get
any shots. We’re only going to talk today and any other time
you come in to see me.”
“You’re not in trouble. We will talk a little about some things that
might not be going well at home or at school but that doesn’t
mean you are a bad kid. And you won’t get in trouble for talking
in here honestly. We’ll make sure to spend time talking about
things that are going well too.”
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Example Language, cont.
To address confidentiality and what will and will not be kept
confidential:
“Everything that we talk about in here will stay confidential (or
private). I will not be sharing anything we talk about with
anyone else (siblings, teachers, etc.) unless you
(parent/guardian) give me written permission to do so. There
are a few exceptions to this. If I have reason to be concerned
that you may hurt yourself or someone else, I will need to
make sure we share that with your parents to make sure we
do everything we can to keep you safe (cont.)

21. Also, if I have any reasons to suspect abuse or neglect, I need to
share that with the appropriate people. Lastly, we also have an
electronic health record system, which means that your other
Spectrum doctors can see the notes that I write after our
appointments and vice versa. I make sure to keep my notes
brief to protect your privacy as much as I can. We should also
be sure to talk about any concerns you might have about
specific types of risky behavior as a family before we move
forward. What questions do you have for me about that?”
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Example Language, cont.

22. Example Language, cont.
“When I’m working with teens, I have found that is very important
they have a safe place to talk without worrying that I am going
to share everything they say with their parents. Therapy works
best when (patient) knows that he can be honest with me. I will
not tell you everything we talk about one-on-one. That said, if I
have any safety concerns (e.g., suicidal ideation, suspected
abuse), I will of course share that with you. Patient, I can’t keep
those secrets from your parents. Instead, I have found that it is
best to give you general updates about how we are doing in
therapy to keep you in the loop. What questions do you have
for me about that?”
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23. To address tension between child and parent and/or address
apparent resistance to treatment:
“I can see that this is really hard to talk about and understand that
you both see this situation differently. Both of your perspectives
are important. I don’t think either of you is to blame here and it
is my hope that over time we can work through this as a team.
These concerns have been going on for a long time and it’s
going to take us a little while to make some progress. I do think
it is possible.”
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Example Language, cont.

24. When possible, meet with teen individually to further establish
rapport and provide teen a safe place to open up:
“Is there anything you really agreed with mom about, or anything
you did not agree with mom about? Parents and teens often
see things differently and it’s OK if that’s true for you. I would
really appreciate the chance to hear what you think is going
on.”
“My goal is not to ‘fix you’ but instead to learn if there are ways I
might be able to support you.”
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Example Language, cont.

25. Establishing Rapport
25 “Office space boss im gonna need you to follow all these rules mkay.” Meme Generator, https://memegenerator.net/instance/64220938/office-
space-boss-im-gonna-need-you-to-follow-all-these-rules-mkay. Accessed 19 Sept. 2018

26. Rapport
• Rapport describes the bond/connection between the therapist
and the minor. Can be tricky to establish given confidentiality
complexities with this population.
• Therapeutic engagement is typically reciprocal but this this
approach may not work with children/teens.
• Engagement is not a “one-time event” it is a process.
• Important to demonstrate flexibility and willingness to meet
needs of multiple family members.
• Avoid placing blame on family members
• Emphasize “team approach” to treatment
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Bolton Oetzel & Scherer (2003); Karver & Caporino (2010); Leach (2005)

27. • Increase client engagement, strengthen therapeutic alliance
• Build trust, minimize defensiveness
• Promote client’s willingness to take responsibility and make
changes
• Improve client outcomes and satisfaction with treatment
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Benefits of Rapport Building
E.g., Bolton Oetzel & Scherer (2003); Leach (2005)

28. Establishing Rapport
• Child development is a function of the match between their
environment and their personality.
• Remember, behavior is not random. Children/teens engage in
behavior for a reason!
• It is our role as therapists to generate hypotheses about the
reasons for behaviors displayed in the office.
• If a child is uncooperative in session, consider how their
environment(s), relationships with caregivers, and history may be
influencing their behavior.
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Bolton Oetzel & Scherer (2003)

29. Addressing ‘Teen’ Behavior
• Assess how the child/teen feels about therapy early on. Reflect on body
language, tone of voice, eye contact, etc.
• Teens’ experience interacting with other adults creates a template of how to
interact/what to expect with you.
• Most experience some form of anxiety about therapy, which can manifest
many ways:
• Seek connection with therapist
• Manipulation of therapist
• Dismissive and distancing from therapist
• Stay present, be assertive but avoid confrontation or directive approaches
• Validate what you can
• Be careful not to validate/reinforce the maladaptive behavior but can validate
the reasons for the behavior.
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Bolton Oetzel & Scherer (2003)

30. Establishing Rapport
• Make a positive impression by being positive/hopeful, express
confidence in therapy, emphasize teen’s/family’s strengths.
• Teens respond favorably to therapists who are:
• Candid (or “being real”)
• Sincere and honest
• Warm and respectful
• Flexible/open-minded but firm
• Interactive and engaging
• Willing to offer choices
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Bolton Oetzel & Scherer (2003); Leach (2005)

31. You Can Lead a Horse to Water…
• Adolescents ‘forced’ to participate in therapy likely will not
participate. Mandated treatment often reduces participation and
collaboration.
• Offer choices when possible:
• To participate in therapy or not
• Therapist
• Interventions
• Content discussed
• Teen reluctance maybe reflective of dysfunction in family system.
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E.g., Bolton Oetzel & Scherer (2003)

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• It’s OK to take time at the beginning to get to know the child/teen
better (e.g., extracurricular activities, friends).
• Ask questions about child/teen’s interests.
• “What kinds of things do you and your friends like to do together?”
• “Tell me about your favorite things to do when you’re not at school”
• Use handouts to develop conversation.
• Stick with “getting to know you” handouts initially
• Allow child/teen to ask questions. Some self-disclosure is ok!
• Children/teens are more likely to connect if they are able to ask
questions to get to know the therapist
• Be brief, only share when/what is appropriate for rapport building
Strategies to Build Rapport
Karver & Caporino (2010)

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Getting to Know You Activity
“Getting to know you worksheets.” Work Sheeto. http://www.worksheeto.com/post_printable-getting-to-know-you-
worksheets_300139/. Accessed 20 Sept. 2018

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Strategies to Build Rapport
• Use of play in session.
• Ex: Jenga, Uno, Skipbo, throwing a ball back and forth, drawing
• Allow child/teen to choose activity
• Determine whether activity is directive or indirective (i.e., create therapeutic
rules or allow free talk)
• Use feelings identification or highs/lows of the week to start conversation.
• “Tell me three feelings you had this week. What situations lead to those
feelings?”
• “What was a positive experience you had this week? What was a more
challenging situation you had?”
• Ask teens open-ended questions. Listen, paraphrase, and reflect back what you
heard. Teens who feel understood are more likely to participate.
E.g., Hudak (2000); Leach (2005)

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‘How Are You Feeling Today?’ Poster

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Recommendations and Resources

37. Recommendations
• Familiarize yourself with relevant laws
• Study developmental theories and gain practical experience
• Discuss limits of confidentiality at start of treatment
• Consider needs of child and family, and include all relevant
family members in goal setting
• Seek consultation from knowledgeable peers
• Consult with legal experts as needed
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Koocher (2003)

38. Resources
Agencies:
• Spectrum Health Risk Management team
• Many state associations offer legal aid to members (e.g., Michigan
Psychological Association)
Readings:
• Ethical principles of psychologists and code of conduct (Published by APA in
2002)
• Code of Ethics of the National Association of Social Workers (Published by
NASW in 2017)
• Decoding the Ethics Code: A Practical Guide for Psychologists (Published by
Fisher in 2017)
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“kermit the frog any questions” Meme Creator, :
https://www.bing.com/images/search?view=detailV2&ccid=IopewFNF&id=E600B39AE34C3335C0301E5B0B8E1FF61C11EAC7&thid=OIP.Iope
wFNF7Vdz78NwwZJ0gwAAAA&mediaurl=https%3a%2f%2fwww.memecreator.org%2fstatic%2fimages%2fmemes%2f4799515.jpg&exph=400&
expw=400&q=kermit+the+frog+any+questions&simid=608034760289879735&selectedIndex=0&adlt=STRICT&ajaxhist=0. Accessed 19 Sept.
2018

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References
American Psychological Association. (2002). Ethical principles of psychologists and code of conduct.
American Psychologist, 57, 1060-1073.
Bolton Oetzel, K., & Scherer D.G. (2003). Therapeutic engagement with adolescents in
psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 40(3), 215-225.
Fisher, C.B. (2017). Decoding the ethics code: A practical guide for psychologists. Thousand Oaks,
CA: SAGE Publications, Inc.
Ford Sori, C., & Hecker, L.L. (2015). Ethical and legal considerations when counselling children and
families. Australian & New Zealand Journal of Family Therapy, 36, 450-464.
Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy with children and
adolescents: The nuts and bolts. New York, NY: The Guilford Press.
Hudak, D. (2000). The therapeutic use of ball play psychotherapy with children. International Journal
of Play Therapy, 9(1), 1-10.
Jungbluth, N.J., & Shirk, S.R. (2009). Therapist strategies for building involvement in cognitive-
behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77(6),
1179-1184.

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References
Karver, M.S., & Caporino, K. (2010). The use of empirically supported strategies for building a
therapeutic relationship with an adolescent with oppositional-defiant disorder. Cognitive and
Behavioral Practice, 17, 222-232.
Koocher, G.P. (2003). Ethical issues in psychotherapy with adolescents. Journal of Clinical
Psychology, 59(11), 1247-1256.
Koocher, G.P. (2008). Ethical challenges in mental health services to children and families. Journal of
Clinical Psychology, 64(5), 601-612.
Leach, W.J. (2005). Rapport: A key to treatment success. Complementary Therapies in Clinical
Practice, 11, 262-265.
National Association of Social Workers. (2017). Code of ethics of the National Association of Social
Workers.