mostly not self-referred, therapy with children and adolescents requires a partner- ship which is unlike that of a therapist and an adult patient.
Work with children involves an understanding of developmental issues, the varied nature of presentation of disorders, appropriate management strategies and ethical principles. Thus a practitioner has to integrate the needs of the child, the family’s objectives in treatment and the developmental level of the child. One must also keep the sociocultural context that the child is reared in mind while providing care to the child. Their relatively higher dependence and lower autonomy present complex ethical challenges in clinical care (Belitz and Bailey2009).
The responsibility to uphold ethical standards and incorporate ethical principles into practice lies with the psychotherapist. Because of this responsibility, identi- fying ethical issues as and when they arise and understanding how one’s personal values and beliefs may affect the therapeutic relationship, are paramount to main- taining professionalism and ethics in psychotherapy (Roberts et al.2002).
When a child is taken up for therapy, it is the therapist’s obligation to create and protect the integrity of the psychotherapeutic space. Boundaries, privacy, confi- dentiality and autonomy are components of this space (Ascherman and Rubin2008).
that the therapist always remains a ‘blank screen’ because he is inevitably a participant/observer in the therapeutic dyad (Sullivan1940).
Children and adolescents tend to think and communicate in concrete terms.
Communication at a personal level, which inevitably involves some self-disclosure, is more effective. Children and adolescents are less able to understand that the therapist is playing a role; governed by certain rules (Gaines1995). They experi- ence the relationship as real, and the therapist’s expressions or lack of expressions as his or her true feelings. In this context, a conversation without some therapist self-disclosure feels cold and rejecting (Gaines2003). Tactful and carefully planned therapist self-disclosure can be a natural part of therapeutic interaction and help in fostering engagement with the child.
3.1.2 Respect for Autonomy
Adults are defined as individuals competent to make decisions for themselves and those for whom they are designated as having primary custodial responsibility.
Consequently, only they can give consent for treatment of the children under their care (Macbeth 2002). Children, by legal definition, are perceived as lacking the necessary competence to give consent, but they have the psychological capacities to voice assent or dissent (United Nations Convention on the Rights of the Child1989).
In clinical scenarios where safety is the prime consideration, the therapist may need to override the child’s right to autonomy. In other situations, where safety of the child is not the issue, the therapist must consider the age, degree of emotional development and cognitive maturation of the child while weighing the degree of respect to be paid to the young client’s autonomous decision-making capacity (Sondheimer and Rey2012).
For example, a depressed adolescent who has not been going to school for a few months, sitting at home the entire day watching TV and playing video games, and who does not see the need or the point of therapy, would need to be motivated to engage in therapy. In contrast, a 17-year-old person with severe specific learning disability who has been brought for therapy, as his parents need the therapist to
‘motivate’ him to study while he has made an informed decision to pursue voca- tional training, may not require professional services.
Usually, when parents want treatment for a child and the child assents, treatment proceeds smoothly but often the child and the parent do not see eye to eye on the issue of need for psychiatric evaluation or therapy. Most parents make decisions that they believe are in the best interest of their child. In the Indian setting, some parents believe that the child need not have a say in decisions regarding their own treatment as they are not mature enough to weigh the pros and cons and make an appropriate choice. This is the case especially when the child expresses dissent about a particular treatment that is recommended by the treating team and consented by the parent.
3 Ethics in Child Psychotherapy: A Practitioner’s Perspective 39
To facilitate collaborative relationships with minors and their guardians, and to enhance patient autonomy, it is the duty of the culturally aware mental health professional to engage in a discussion with the parents. They may be helped to understand that even though the legal need for child’s consent is absent, it is important to include the child in making decisions about his/her treatment. This is especially important in psychotherapy as it conveys respect. The therapeutic alli- ance between the child and the therapist is strengthened when the child feels that his opinion has been given consideration rather than experiencing treatment/therapy as being imposed by others.
3.1.3 Maintaining Confidentiality
Child mental health issues can be understood in the context of interactions between biological predisposition and environmental influences which include family, community and culture. Child psychotherapy cannot be carried out in vacuum without interaction with parents or guardians. Also, parents have the right to be informed about therapy and are entitled to regular updates about the child’s pro- gress. Therein lies the challenge of protecting the child’s privacy, maintaining confidentiality and keeping the parents involved in the process of therapy.
Consider the following vignette:
Case 3.1
Miss V is a 13-year-old girl with Anorexia Nervosa who has given her assent for cognitive behavior therapy. During one of the therapy sessions, she revealed that for the past 10 days, after every meal at home, she would go the bathroom and vomit. At school, she had not been eating at all. Her parents had no knowledge about the purging behaviour. She tells the therapist that this information must be kept confidential and must not be divulged to her parents at all.
Such a situation presents a veritable dilemma to the therapist as this information needs to be told to the parents, being a potentially life-threatening behaviour which needs monitoring. On the other hand, if it is told then it may result in the adolescent not trusting the therapist any longer. This challenge can be dealt with by ensuring that the following details are shared with the adolescent and the family when a recommendation for therapy is made.
1. Explanation about the rationale and structure, duration and frequency of therapy.
2. Confidentiality in the therapeutic space as well as the limits of confidentiality in a manner appropriate to the developmental level of the child. It is important to describe to the child, the scenarios in which one may need to override confiden- tiality and disclose information to the parents such as personal neglect, imminent
40 S. Bhaskaran and S.P. Seshadri
harm to self or others and high-risk behaviour. Examples of scenarios that mandate disclosure are instances of harm to the child/adolescent—abuse/neglect, suicidal ideation, plan or attempt. Instances of harm to others—homicidal intent or intent to hurt others—physically or emotionally such as bullying and sexual assault.
Instances of high-risk behaviour include; planning to run away from home, harmful use of substances, engaging in sexual activity with multiple partners, engaging in potentially harmful online interactions.
This helps the young person to make an independent decision about disclosing information to the therapist.
3. The child/adolescent should be informed about the frequency of sessions with parents and can be invited to discuss what he/she would like to be communi- cated in the sessions. The therapist must also offer to review with the child, the summary of the session with his/her parents after it occurs with due respect to the confidentiality of the parents.
In the above scenario, the issue of confidentiality and its limits could have been introduced in the beginning itself in the following manner:
Before we begin, I would like to discuss with you the“rules”of our meeting. These rules may not be new to you since you have seen therapists before but it’s important that we go over them. This is a private space where you can express your thoughts, feelings that you mayfind difficult to say in front of others. Although this is private and what you talk about will stay in this room, there are exceptions to this. First, if you were to tell me that you were in a danger of some kind, then I would have to tell your parents about that. Secondly, if you were to tell me that another person is in danger of some sort, then I would have to talk to some adults about it. I will do this only after telling you. We will be able to talk about who needs to know and how we should tell them. Does that make sense? Do you have any questions about what I just said?
When the child reveals regarding the purging behaviour in a subsequent session, the therapist discusses with her the serious consequences of low weight and vomiting and how this puts her in danger. A reference to the earlier discussion on confidentiality and its limits needs to be made. Considering the imminent harm to adolescent’s health, the need to inform the parents about this to ensure her safety is emphasized. Then the therapist and Miss V could discuss how and when they would tell her parents.
In our country, children live with parents until they get married or even after that in a joint family system. Many parents believe that they need to know everything that is going on in their child’s life and may feel offended when they do not know or feel upset that their child trusts the mental health professional more than them. They may feel responsible for the child’s problem and feel that they have a ‘right’ to know and expect the clinician to discuss confidential details discussed in therapy.
It is important for the mental health professional to discuss issues related to child’s need for privacy with the parents. They need to be helped to understand the difference between privacy and secrecy. The information shared in the therapeutic space is secret but its therapeutic purpose is to promote freedom in the space and not to hide for any covert purpose (Ascherman and Rubin2008). They also need to 3 Ethics in Child Psychotherapy: A Practitioner’s Perspective 41
be reassured that they will be met on a regular basis to keep them updated about the progress and that information suggesting imminent danger to the child or others will be told to them at once.