Why it is (usually) Okay to Not Know What is Going on in Your Teenager’s Therapy
It is an inherently human trait to be curious about what goes on behind closed doors. This desire is multiplied by the thousands when it is your own child, especially when your child is going through a challenging time and seeing a mental health professional. However, one of the first conversations that I often have with the parents of my older adolescent patients is that, well- I may not be talking to them much after this initial conversation. Parents often may not know exactly what is going on in their teenager's therapy-- and this is typically a good thing. Below, I have listed several reasons why holding this boundary is so important.
The containment that confidentiality provides
Confidentiality is the cornerstone of any effective therapeutic relationship. Simply put, it means that what you say to your therapist cannot be repeated to anyone else- with a few exceptions (see below). The importance of confidentiality in therapy cannot be overstated, and this is even more true for teenagers who are navigating a constantly changing social landscape. Every adolescent (but really, every person) has a thousand thoughts going in their head at once. These thoughts ask many questions: Am I saying the wrong thing? What will they think about what I am saying? Is this feeling stupid? Am I stupid? What am I even doing? These evaluative thoughts are defenses, protecting the individual from saying something that may cause uncomfortable feelings or social stress.
These defenses act as obstacles, getting in the way of deep-held emotions being expressed. But, it is often these emotions that need to be expressed and understood in order for therapy to be successful. The structure of therapy is therefore meant to be as containing as possible, so that the defenses feel that they can rest for a little while. Containing refers to several factors: therapy is at a predictable time on a predictable day; therapy lasts for a prescribed amount of time; and most importantly, what is said between the patient and therapist stays in that room, at least for the time being.
Desiring confidentiality within therapy does not mean that your teenager does not trust you. Think of the person who you know and trust the most- your spouse, your best friend, or even your own parent. How would it feel to have them sit in on a therapy session? Even if you tepidly agreed to such an arrangement, you may spend more time mulling over your words than you would if you were alone (I know I certainly would!). This is a natural reaction to being around other people, but it makes therapy so much less effective. So, even for teenagers who trust their parents immensely, it is counterproductive to therapy for the parents to be overly involved.
2. Building rapport
Study after study has confirmed that one of the most important factors to the success of therapy is the development of a healthy rapport. Though it has a fancy name, rapport simply refers to having a positive therapist-client relationship.
If a teenager has a healthy rapport with their therapist, not only will they feel contained and me more willing to open up, they will also be more comfortable with being challenged. For me, part of having a healthy rapport with my teenage clients is making sure that I fully understand their world, from their point of view. Your sister is the favorite child? Got it, good to know (as I side note, I have never worked with a self-identified "favorite child", furthering my belief that much of that perception might be in the eye of the beholder). Your teacher is incredibly unfair for assigning you a lab to do over the weekend? That does sound really frustrating, tell me more. When developing rapport, I am not too concerned with the objective truth, because ultimately therapy is not a fact-finding mission. It is about emotions, and anyone who has ever experienced an emotion knows that feelings rarely follow a logical path.
Of course, that does not mean that therapy never seeks to challenge established viewpoints-- quite the opposite. But especially for adolescents, their whole world is often comprised of adults telling them that how they are thinking is wrong. As a therapist, I strive to not just be another adult giving advice. Through looking a teenager's world nonjudgmentally, this establishes the trust that is required for teenagers to have their viewpoints challenged in a way that sticks, because they feel completely understood and listened to. And all of us, adults included, are more likely to take challenging from someone whom we feel knows us as completely as possible.
So, how does all of this go back to confidentiality? As I mentioned, teenagers are used to adults telling them what to do, or telling them that the way they view their world is incorrect. If teenagers knew that their parents had any window into the therapeutic room, they may throw up defenses before the conversation even begins. Confidentiality allows the true worldview to come out, untethered to anyone else’s real or perceived judgement.
3. Fostering independence and learning healthy boundaries
I often talk about how teenagers exist in a confusing, ever-changing landscape of time. Their responsibilities and expectations are rapidly increasing both at school and at home; relationships may be becoming deeper; and questions about what the future holds constantly loom. Yet at the same time, they are still a kid, likely living under their family's roof, and taking directions from parents and teachers. Because of these constantly shifting expectations, this time is a critical period to set the foundation for how teenagers in the future will look at their own personal responsibility, both for themselves and within relationships.
By communicating primarily with the teenager within therapy, I am implicitly communicating to them that they are responsible enough to make some decisions on their own, and I am encouraging them to be their own best advocate. These are skills that they will need to use more and more as they get older, and therapy is a safe place to test out those bounds. By clearly laying out the boundaries of our own relationship, and boundaries of confidentiality with parents, I am communicating to them that it is okay to have boundaries with the ones that you love.
When parents need to be looped in
Of course, as with any general rule in psychology, there are a host of exceptions. I covered in my previous blog post how families often need to be involved during active OCD cases, as otherwise families may be inadvertently providing reassurance and thus supporting compulsions. Oftentimes, kids want me to communicate to their parents- in the name of allyship, I often describe myself as a "child parent translator" who is able to communicate challenging insights to parents in a way that their kids may not be able to (and vice versa). If there are active safety concerns- i.e., the therapist believes that the adolescent might be a risk to themselves or others -then parents should absolutely be looped in (and at that point, the therapist is ethically bound to break confidentiality). It is important to note that every therapist may define the line of "risk to themselves" differently. While some risk factors, like an active suicidal plan, are clear-cut, others are a bit more gray. It is thus very important for the therapist to inform both the patient and their parents about exactly what they define as falling into that category, so everyone is on the same page.
Regardless, it is imperative that when confidentiality has to be broken, that it is never a surprise to the teenager. If I feel the need to speak to parents, I always review what I am going to say with the patient first, to reinforce the allyship. Because ultimately, therapy being a safe and independent place does not mean that all dark secrets go to die there- but it does mean that there are never any surprises. Because, just as it is a human trait to be curious about what goes on behind closed doors, it is also an inherently human trait to want to be in control of where your most vulnerable thoughts go. And whether we are fourteen or forty five, we are all ultimately human.