Charli Wheeler
Capella University
Psychology Capstone PSYC-FPX4900
Ruhama Hazout
September 2023
Navigating Confidentiality and Duty to Warn in Counseling At-Risk Youth
School counselors face complex confidentiality dilemmas when counseling vulnerable students who disclose thoughts of self-harm. These situations highlight broader societal challenges around youth mental healthcare, including stigma, discrimination, balancing adolescent rights with parental oversight, and managing client expectations. This is exemplified in the case of 15-year-old Muslim American student Adara who confides suicidal thoughts to counselor Hannah. Adara expects absolute confidentiality but feels betrayed when Hannah informs her parents against her wishes. Adara’s faith likely contributes to her hesitance around mental health disclosure. Hannah aims to build trust with Adara but also has a duty to warn if harm seems imminent. Carefully weighing ethical obligations around confidentiality and self-determination empowers counselors to collaborate with youth clients while upholding their wellbeing.
In this case, professional standards point toward preserving client confidentiality and autonomy where possible, while allowing for breaches if essential to prevent harm. By thoughtfully analyzing options through an ethical lens, Hannah can make an appropriate determination despite competing duties. Her approach must balance respecting Adara’s rights with the need to intervene if danger is acute. Solutions to this dilemma have far-reaching impacts on addressing stigma and empowering youth mental healthcare.
Applied Ethical Principles and Standards
Several APA ethical standards and principles directly apply to Hannah’s dilemma and at times conflict. Standard 4.05 would recommend clearly discussing confidentiality limits before receiving Adara’s sensitive disclosures. However, the emergent nature of counseling may have prevented this. Regardless, not meeting Adara’s expectations represents an ethical pitfall.
Standard 4.02 allows Hannah to breach confidentiality without consent if Adara is at acute risk of harm. However, Hannah must thoroughly assess imminent danger and balance short and long-term impacts on rapport and trust before disclosing. Rashly violating confidentiality could damage the counseling relationship and Adara’s willingness to seek care.
Principle E supports preserving confidentiality out of respect for Adara’s autonomy, as long as she is not in immediate danger. However, Principle A prioritizes client welfare, so confidentiality may need to be overridden if Adara is actively suicidal and her safety cannot otherwise be ensured. Hannah bears heavy responsibility for discerning this threshold. Consultation may help determine appropriate disclosure.
Principle B underscores Hannah’s duty to warn if danger is clear, even if against Adara’s wishes. However, Principle D and Standard 3.04 also obligate Hannah to minimize harm from disclosure and enable ongoing care. This requires carefully balancing Adara’s rights against Hannah’s duty to protect.
Overall, Hannah faces a complex ethical dilemma with competing obligations to Adara’s welfare, safety, autonomy, and dignity. Determining which principles justify breaching confidentiality will require weighing both short and long-term impacts on trust, access to care, and adolescent empowerment. Thorough analysis and consultation are essential.
Alternative Solutions
Thoughtfully analyzing potential courses of action through an ethical lens empowers counselors like Hannah to make principled determinations despite competing obligations. By weighing the pros, cons, risks, and benefits of various alternatives, Hannah can choose an approach that aligns with Adara’s immediate safety and long-term growth.
Alternation Solution 1
Uphold absolute confidentiality by not disclosing any information to Adara’s parents without her consent.
Upholding absolute confidentiality by not informing Adara’s parents respects her autonomy in seeking mental health treatment as a minor and reinforces the privacy that builds trust (APA, 2017a). This demonstrates Hannah’s commitment to confidentiality expectations critical in counseling.
However, preserving complete confidentiality risks Adara’s immediate safety if she is actively suicidal and unable to maintain her own wellbeing. Hannah has an ethical duty to protect vulnerable clients from harm when possible (APA, 2017b). If her disclosures reveal imminent danger, Hannah is obligated to intervene through disclosure.
Not properly discussing limits beforehand could irreparably damage Adara’s trust if Hannah must later disclose against her wishes, violating transparency principles (APA, 2017a). Hannah could also bear moral and legal responsibility if harm resulted from non-disclosure.
However if acute risk is unclear, upholding confidentiality may encourage deeper disclosure over time as trust builds. This approach prioritizes long-term counseling rapport but risks short-term safety. Hannah must weigh these competing ethical obligations to both respect autonomy and prevent harm (APA, 2017b).
Alternation Solution 2
Seek partial consent from Adara to disclose concerns about risk to her parents while keeping session details private.
Seeking Adara’s partial consent to share limited risk concerns with her parents aims to balance respecting confidentiality (APA, 2017a) with Hannah’s duty to warn if danger seems imminent (APA, 2017b).
Gaining Adara’s explicit agreement to disclose could empower her voice rather than Hannah deciding unilaterally. Collaborating demonstrates transparency and upholds consent principles (APA, 2017a). This may help Adara feel involved rather than betrayed.
However, Adara may still perceive any breach, even with permission, as damaging trust and violating her expectations of absolute confidentiality as a minor. Consent could be coerced if refusing seems impossible.
Parents informed of risks may demand full session details, further violating confidentiality against Adara’s wishes (APA, 2017b). This could irreparably undermine counseling rapport if Adara feels Hannah revealed more than agreed upon.
Partially empowering if implemented sensitively, but still risks eroding trust without thoughtful navigation of consent and disclosure processes. Aims to balance obligations through compromise but requires careful collaboration.
Alternative Solution 3
Support Adara in seeking counseling with a licensed therapist without parental consent.
Enabling Adara to independently pursue counseling respects her autonomy in seeking mental health treatment (APA, 2017a). Research indicates many states allow minors ages 14-17 to consent to outpatient therapy (Dalton et al., 2018). Seeing a therapist confidentially could empower disclosure without parental oversight.
An external professional may have more expertise than Hannah to assess imminent risk (APA, 2017b). This could relieve Hannah’s burden regarding disclosure decisions as a school counselor.
However, Hannah likely still has an initial duty to warn if risk seems acute based on their sessions. Adara’s parents reacting negatively if undisclosed therapy revealed could damage family relationships.
Logistical barriers without parental support could significantly hinder Adara’s ability to access consistent mental health care, limiting the potential benefits of therapy (Dalton et al., 2018). For example, obtaining transportation to regular appointments could prove challenging without parents able to provide rides. Insurance coverage and payment for sessions may also be obstacles if Adara’s parents are not involved to handle the financial aspects. Having to coordinate these logistics independently may disrupt the consistency needed for therapy to be effective for Adara. Since parental participation can greatly facilitate practical access to care, pursuing counseling without their support risks undermining the approach’s benefits.
This approach aims to uphold privacy and self-determination but has risks if implemented insensitive to context. An outside provider may be better positioned to discern risk and need for disclosure if danger is unclear.
Alternative Option 4
Hannah could discuss with Adara the option of disclosing some concerns to a trusted adult family member rather than to her parents directly.
Another potential compromise is Hannah discussing with Adara the option of disclosing some concerns to a trusted adult that Adara herself selects, rather than disclosing directly to her parents (Woolley, 2009). Allowing Adara to choose someone she feels comfortable with gives her some power in determining who will be involved. This adult would not act in loco parentis but could provide additional support, transportation to therapy, and possibly funding for counseling.
A supportive trusted adult that Adara selects may be able to facilitate access to care while allowing her some independence and privacy in treatment. Research shows that supportive non-parental adults can serve as key protective factors and sources of guidance for adolescents (Eisenberg et al., 2019).
However, Adara may still perceive any disclosure to a trusted adult as a breach of confidentiality that damages the counseling relationship. She may not have a trusted adult she feels comfortable enough disclosing sensitive issues to. Furthermore, her parents could possibly eventually find out about the counseling indirectly through the adult, which risks causing family conflict.
Involving a trusted non-guardian adult that Adara chooses herself aims to address logistical barriers to accessing care while avoiding risks of unilateral parental disclosure against her wishes. It could enable her to access counseling with some privacy maintained. But thoughtful collaboration with Adara would be essential to implement this sensitively without damaging the counseling rapport.
Recommended Course of Action
The recommended course of action is for Hannah to thoughtfully collaborate with Adara to identify a trusted adult family member who could be brought in as an additional source of support and guidance. Rather than unilateral parental disclosure, empowering Adara to help choose a relative confidant demonstrates meaningful respect for her preferences and autonomy as a developing youth seeking mental health care. This upholds Principle E: Respect for People’s Rights and Dignity of the APA Ethical Standards (APA, 2017a) by prioritizing self-determination through a collaborative process and providing a support system.
Numerous studies on the benefits of non-parental adult mentoring relationships provide empirical support. A relevant 2019 study by Fish and colleagues investigated connections between trusted adult supports and suicidal thoughts and behaviors among over 34,000 LGBTQ youth across the United States. The researchers found LGBTQ youth who reported having at least one trusted adult in their life showed significantly lower rates of past-year suicide attempts compared to those without such support (6.9% vs. 12.4%). Building relationships with accepting, compassionate adults who provide guidance and unconditional support correlated with reduced risk of suicidal ideation and attempts. The authors conclude non-parental adults can have pivotal impacts in fostering LGBTQ youth resilience (Fish et al., 2019).
Additionally, a 2016 study by Raposa and colleagues examined outcomes for at-risk youth enrolled in a school-based mentoring program paired with adult volunteer mentors. Over one year, mentored youth showed significant positive gains in academic attitudes and motivation compared to non-mentored peers. Through modeling, guidance, and supportive bonding, the mentors improved youth attitudes about school importance and engagement. The authors highlight the potential for one-on-one adult mentoring programs to greatly benefit at-risk youth’s psychosocial well-being (Raposa et al., 2016).
Together, these studies provide strong evidence that establishing a relationship with even one trusted, accepting, non-parental adult can act as a major protective factor for vulnerable youth like Adara. Collaboratively identifying a supportive relative mentor, Hannah can uphold ethics while empowering Adara’s autonomy and resilience.
If Hannah and Adara decide to identify and involve a trusted adult relative for support, it will be essential that Hannah thoughtfully facilitates the process to fully empower Adara. She should begin with an open conversation explaining her legal responsibility to disclose imminent risk to parents/guardians but also expressing her desire to explore alternatives that better respect Adara’s confidentiality and autonomy. Next, Hannah can invite Adara to brainstorm extended family members who are caring, open-minded and can be trusted to keep sensitive information private until Adara feels ready for wider disclosure.
Since Adara understands her own family dynamics best, Hannah should let Adara guide the selection of the most appropriate relative confidant. Before any disclosure occurs, Hannah can encourage Adara to first speak privately with the chosen relative to confirm they respond in a caring and supportive way when learning she is struggling with mental health challenges. If the relative reacts supportively, the three of them can then have a joint discussion where Adara shares her story, with Hannah only adding essential details related to the risk factors she has observed. Ongoing check-ins between Hannah and Adara will help assess whether the arrangement is truly benefiting Adara according to her own standards. Maintaining voluntary consent through each step of this collaborative process can strengthen Adara’s support system while keeping communication open and transparent in order to fully uphold her rights.
Research
The Functions and Longitudinal Outcomes of Adolescents’ Naturally Occurring Mentorships study by Miranda-Chan, Fruiht, Dubon, and Wray-Lake (2016) provides strong empirical support for involving a trusted non-parental adult to support Adara.
This large-scale longitudinal survey study analyzed national data from over 4,800 U.S. adolescents, surveyed initially at ages 12-18 and again 15 years later. Quantitative analysis assessed associations between having a natural mentor and outcomes related to wellbeing, relationships, education, employment, and crime. Qualitative analysis categorized mentoring functions based on coding mentor support descriptions.
Relevant quantitative results showed mentored individuals subsequently reported greater wellbeing in adulthood compared to non-mentored peers. The qualitative taxonomy demonstrated emotional support as a key protective capacity.
The longitudinal design was highly appropriate for evaluating mentors’ lasting impacts into adulthood. The large national sample increased generalizability, despite limitations like retrospective self-report.
These findings confirm that establishing an informal bond between Adara and a trusted relative could profoundly shape her wellbeing and growth. Collaboratively facilitating this relationship adheres to APA ethics of promoting autonomy and beneficence (APA, 2017). The extensive scope provides strong empirical grounding for involving a trusted adult to support Adara.
A second study, Development of Perceived Familial and Non-familial Support in Adolescence, a longitudinal study by Spitz, Winkler Metzke, and Steinhausen (2020), provides additional empirical support for involving a trusted non-parental adult in Adara’s mental healthcare.
This study analyzed survey data from 857 Swiss adolescents who were surveyed at ages 11, 13, and 18 about their perceived social support from various sources. The longitudinal design appropriately captured developmental shifts in youth social support. The large community-based sample increased generalizability.
Relevant findings showed consultation of parents and grandparents for support declined over time but remained very satisfying sources. This suggests family remains integral while peer roles expand in adolescence.
This large Swiss study confirms that family remains integral to perceived support while peer roles expand in adolescence. It highlights the ongoing value of collaborative family involvement in youth mental healthcare while respecting adolescent autonomy needs through privacy and consent. Incorporating a trusted relative as an additional support can adhere to these developmental support priorities.
Together with the previous study, this rigorous longitudinal research provides empirical grounding for our chosen approach of involving a trusted adult family member to support Adara while avoiding risks of parental disclosure.
Conclusion
Navigating confidentiality duties while respecting adolescent autonomy poses complex dilemmas for counselors like Hannah. However, solutions exist to uphold ethics and prevent harm through collaboration. As McGrath et al. (2016) found, unilaterally breaching youth confidentiality often damages therapeutic alliances critical for positive change. However, by partnering with adolescent clients, counselors can earn informed consent for disclosure when essential for safety.
Specifically, this case reveals an ideal resolution is identifying a trusted adult family member who can provide support if a crisis arises. Hannah involving Adara in choosing an adult confidant respects her preferences and voice, upholding Principle E of the APA ethics code on respect for autonomy. With Adara’s consent, this relative can be brought in to facilitate access to care while avoiding the risks of parental disclosure without her collaboration. This compromise integrates Adara’s insights to customize an ethical, empowering solution supported by research evidence on the benefits of natural mentors.
Training and policies must equip school counselors to integrate this collaborative practice. By transparently balancing duties, rights, and risks while inviting adolescent input, counselors like Hannah can build trusting relationships fundamental for youth mental health. This collaborative disclosure model should become the standard. Progress requires implementing developmentally appropriate, empowerment-focused approaches to transform how the profession handles confidentiality with teens. In navigating complex confidentiality dilemmas with youth, collaborative disclosure represents the ideal ethical solution.
References
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code
American Psychological Association. (2017). Multicultural guidelines: An ecological approach to context, identity, and intersectionality. https://www.apa.org/about/policy/multicultural-guidelines.pdf
Dahlquist, L.M., Dawson, A.E., Estrada, A.U., Ehrenreich-May, J., & Campo, J.V. (2018). Youth preferences for disclosure and information management in psychotherapy. Journal of Child and Family Studies, 27(10), 3656-3668. https://doi.org/10.1007/s10826-018-1186-7
Fish, J. N., McInroy, L. B., Paceley, M. S., Williams, N. D., Henderson, S., Levine, D. S., & Edsall, R. N. (2020). “I’m Kinda Stuck at Home With Unsupportive Parents Right Now”: LGBTQ Youths’ Experiences With COVID-19 and the Importance of Online Support. Journal of Adolescent Health, 67(3), 450–452. https://doi.org/10.1016/j.jadohealth.2020.06.002
Harries, S., Elam, M., Hauer, U., & Mellinger, C. (2015). Clinical ethical conflicts regarding confidentiality in adolescent psychotherapy. International Journal of Adolescent Medicine and Health, 31(3). https://doi.org/10.1515/ijamh-2015-0059
McGrath, P., Cappelli, M., Wiseman, D., Khalil, N., & Allan, B. (2016). Confidentiality and privacy in adolescent psychotherapy. The Canadian Journal of Psychiatry, 61(1), 32–42. https://doi.org/10.1177/0706743715621453
Miranda-Chan, T., Fruiht, V., Dubon, V., & Wray-Lake, L. (2016). The functions and longitudinal outcomes of adolescents’ naturally occurring mentorships. American Journal of Community Psychology, 57(1-2), 47–59. https://doi.org/10.1002/ajcp.12031
Raposa, E. B., Dietz, N., & Rhodes, J. E. (2017). Trends in volunteering in the United States: 2002–2015. Nonprofit and Voluntary Sector Quarterly, 46(3), 487–504. https://doi.org/10.1177/0899764016681971
Spitz, E., Winkler Metzke, C., & Steinhausen, H. C. (2020). Development of perceived familial and non-familial support in adolescence; Findings from a community-based longitudinal study. Child and Adolescent Psychiatry and Mental Health, 14(1). https://doi.org/10.1186/s13034-020-00327-8