Ethics Consult: Trying to Do The Right Thing

Dear Ethics Consult,

My teenage client told me that she had unprotected sex. Do I tell the parents? She doesn’t have a good relationship with her parents, and I fear telling them will irreparably damage our rapport.

—Trying to do the right thing

Dear Trying,

I’m going to give you a very long answer to a relatively short and simple question, and that answer is “it depends,” even though I know that’s unsatisfying. Whenever one of my law and ethics students uses “it depends” as an answer, even when they’re right, I ask them to take the next step: It depends on what? So I’ll do my best to do the same here.

Let’s split this question into three components, each of which has importance and deserves its own attention: Your legal obligations, your ethical obligations, and the morality involved.

Doing the right thing legally

Does the law obligate you to tell the parents? Probably not—but that’s with some important caveats, starting with the fact that I’m not a lawyer. If you’re wondering about your obligations in your state, you would be wise to use the legal resources available to you through your professional liability insurance or your professional association.

If your client is age 18 or older and consented for treatment on their own, then you of course have no obligation to tell the parents anything. Indeed, you likely couldn’t tell the parents anything about their teenager’s care even if you wanted to, unless the client had signed a release of information allowing you to do so. But I suspect the client is younger here, so let’s assume for now that the client is under 18.

In most states, if a parent or guardian provided consent for the minor’s treatment, that parent or guardian has a right to access records of their child’s care. But, even that right may come with some limitations. In California, for example, if you believe that such a release of records to the parents would damage your relationship with the minor, you can refuse. 

In some states, teenage clients can consent on their own to treatment. Generally speaking, if a client consents on their own for mental health care, parents don’t have an automatic right to records of that treatment. However, state rules on this can vary, so make sure to check what the regulations are in your own state.

There’s also the question of whether this information would even go into your records. Is it specifically relevant to your treatment to note the minor telling you they had unprotected sex? Or might it make more sense clinically to record their behavior as “risk-taking behavior”? It’s worth considering where this behavior fits into the clinical picture, as that might impact how you document it—and thus what information might be shared if the client file is viewed by anyone else.

Notably, even if the parents could request records, and even if you’ve made specific note of the client’s behavior in those records, that’s not the same thing as you having an obligation to proactively inform the parents about the child’s behavior.

One other legal note: Depending on the age of the minor, the age of their partner, and relevant state laws, even consensual sexual activity may be considered child abuse. In such instances, you may have a legal obligation to report the activity to a local child protective service agency. Of course, that’s different from an obligation to inform the parents, but if the child protective service agency launches an investigation, parents may be made aware of the activity as part of that investigation.

Doing the right thing ethically

So, those are a few of the legal considerations. Your ethical obligations will depend in part on who, exactly, you consider your client to be. Is it only the teenager, or their family as well? If you’re working with the whole family, then hopefully you have some form of “secrets policy” that directly addresses what kinds of information will be shared with the parents from individual discussions with their children. (For readers without such a policy, it may be a good idea to create one.)

Even if you’re working individually with the teenager, such a policy is still quite often a good idea. It can aid everyone’s confidence and comfort with the therapy process if they know, in advance, what information is expected to remain private versus what information the therapist may share with parents.

When ethics codes require you to inform clients at the beginning of treatment about exceptions to confidentiality, they typically don’t limit that obligation to the confidentiality exceptions prescribed by law. They want clients to be informed of any and all exceptions to confidentiality that are likely to impact their care. When you’re working with a minor under consent provided by their parents, it’s sensible that everyone involved should have a clear understanding of what gets shared out, and what doesn’t.

So, it’s worth considering, what does the teenager expect here? Do they have reason to believe that you’ll tell the parents about their activity? If so, they may have told you about it precisely because they want their parents to know—but don’t want to be the one to tell them. And similarly, have any expectations been set with the parents? Do they have reason to believe you will tell them about their teenager’s sexual activity? 

Some therapists who work regularly with adolescents develop very specific policies here. For example, they may seek agreement from both parents and teens that the therapist needs to be a trusted adult that the teen can talk to about issues of sexual development and behavior, drinking, and other forms of risk-taking that are common in adolescence, without fear that the therapist will immediately report back to the parents about it. 

At the same time, in the interest of protecting the teen’s safety, both parents and teens agree that the therapist has the right to use their discretion in determining when parents need to be informed so that they can assist in reducing danger. For example, if an adolescent becomes suicidal, or starts stockpiling weapons, it makes sense for the therapist to inform parents, even if the teen’s behavior hasn’t yet risen to a level where the therapist would otherwise be legally obligated to break confidentiality.

For some behaviors, such as recreational drug use, unprotected sex, or non-suicidal self-injury, it can be difficult for therapists to know whether disclosure to the parents is necessary or beneficial, and that seems to be where you are. You’re certainly not alone there. Some therapists aim to get specific agreement, even getting granular on these kinds of behaviors, with teens and their parents at the beginning of therapy. 

Others simply set a broad policy, and ask clients and parents to agree to that policy. Still others take a clinical-judgment approach, which allows the therapist the freedom to make decisions about what to share after considering the full context of any such behavior, but may leave clients confused about just how much they can safely tell you while keeping things confidential from their parents.

If your client and their parents have been informed of what information gets shared and what doesn’t, then your decision-making becomes much simpler—you abide by what you’ve already established. In the absence of such an agreement, there are great arguments to make in both directions. Either option, sharing with the parents, or not, can be justified as the best one. So how do you make the choice?

A few years ago, my colleague Dr. Dana Stone and I wrote an article about using scaling to assist ethical decision-making in situations like this. I think that’s a useful approach. And it also leaves room for active consideration of the morals and values involved—for you and the family both.

Doing the right thing morally

Here, of course, is where things get the most difficult. Perhaps you haven’t established clear ground rules with your client or their parents for what gets shared and what doesn’t. And now you’re in a complex situation where you want to preserve your relationships with all involved—but what they want from you may differ. The teen may prefer privacy, while their parents may want to know what their child is doing, especially around sex.

Before deciding what to do, consider your own values, and how they may impact your natural tendencies. If you had an open and supportive relationship with your parents, you may have felt comfortable telling them about your own early sexual experiences. You may default to a position that the parents should know about the client’s behavior, because they hopefully would respond well to the information. On the other hand, if your relationship with your parents was more strained, or if you experienced more shame around sexual activity, then you may be inclined to keep your teen client’s behavior private. 

I mention this because we have an ethical responsibility that is directly tied to our own morals and values—the responsibility to not impose those morals and values on our clients. To the degree possible, it often makes sense to look at situations like this through the client’s moral lens rather than our own.

Does the client experience their behavior as something bad or shameful? Do they believe that they have a right to privacy related to what they tell you? On the other hand, do the client’s cultural background and values suggest an expectation that adults will share information about them, even when the teen might be embarrassed?

You’ve noted that this teenager doesn’t have a good relationship with their parents. That’s common among teenagers working to establish their own identity, and doesn’t necessarily mean the parents aren’t good or trustworthy. Many parents, if they knew their teen had engaged in unprotected sex, would do exactly what we would want them to do: Discuss it with the teen without punishing or shaming them, and instead focus on reducing risk and helping the teen make positive choices. 

I wonder what your own experience of the teen’s parents has been, and how that may impact your thinking on this question. It’s tempting, out of loyalty to a teen client, to side with them and against their parents. Sometimes that’s a good and useful strategy. Other times, doing so shuts out some potentially powerful allies in the teen’s healing process.

Finding a place to land

Clearly there is a lot here to consider. For me, if I hadn’t put any policies on teen privacy in writing with the client or their parents, it would be tempting to reflexively assure the client that their privacy is safe with me, in the interest of protecting the therapeutic relationship. And, to be honest, after going through the considerations above, that still is likely where I personally would land.

At the same time, it’s possible that their privacy shouldn’t be safe with me, either because I could have set a different expectation with the teen and their parents, or because their morals and values suggest that the parents should be informed. In those instances, it may be possible to protect that relationship while also making sure the parents are informed—by talking with the teenager about when and how they will tell their parents about their activity.

In this specific instance, if the law allows you keep the information private, and if you hadn’t set an expectation with the teen or their parents that such information would be shared, and if the behavior isn’t part of a larger picture of risk-taking that leaves you worried for the teen’s safety, and if it can be justified as consistent with the client’s values, then I’d support you in choosing not to tell the parents. While that’s a lot of “ifs,” they’re all worth considering, and in many cases, you can check off each one of them.

I would also encourage you to consider having a clear and specific policy around such things for the teens you’ll work with in the future. It’s tough as a therapist working with minors to be in a position where you feel torn between competing interests. You can save yourself that strain in the future by knowing that, at the start of treatment, you were clear with everyone involved about what parents get to know—and then you stuck to it. 

Good luck,
Ben

Disclaimer: This article is for informational purposes only, and should not be considered legal or ethical advice. For specific guidance for your situation, consult with an attorney or your professional liability insurer.