If, however, it is clear that the patient cannot give any guarantee that he can keep safe, or there are factors that would indicate that he is at risk, then the parent will have to be told in order to plan for safe care.
Each situation needs to be worked out individually, and each has its own ethical confidentiality issues, especially in such cases as self-harm, abuse, or eating disorders. The child's safety is paramount. If the therapist can keep the child safer by not telling parents, that may be the right decision. Often, talking to the patient, working out the script to be used with parents, and talking with the parents while the patient is present will maintain trust and keep the parent-therapist dialogue open. Discussion with a colleague and recording each conversation is important; discussion with medical insurance providers might be necessary as appropriate.
The following case vignettes provide examples of difficulties that can be encountered with parents of child and adolescent patients.Case vignette 1
Mrs H was very angry with the mental health team because the behavior of her daughter Jane (aged 6 years) continued to cause her problems. Mrs H received a lot of parenting advice and support. Jane also had problems at school and Mrs H was angry with the school, as well. Mrs H had a background of parental abuse, had been depressed, was in a difficult, violent relationship, and had fallen out with all the health professionals she had seen in the past. She felt blamed. She often missed appointments or stormed out. We always tried to arrange appointments to suit her. We offered her appointments on her own and with her child. She wanted the child to be "made better." We reviewed the situation and asked for a second opinion at a regional clinic. This clinic admitted the daughter and diagnosed her behavior in the autism spectrum. The mother changed her therapeutic team and felt vindicated, although she still finds her daughter to be hard work.
This case illustrates that when dealing with an angry parent, it is sometimes necessary to stop, take another look at the problem, and try to understand why the parent is angry. A reevaluation may be required to confirm that the initial assessment was correct.
When a family is proving difficult to work with, it can be helpful for therapists to work in pairs. This allows one therapist to monitor the conversation while preventing the other from becoming drawn into an argument or a hostile exchange. It is often useful to have a witness to these interviews, and in this case, it might be helpful to encourage the mother to have a support person also. Two therapists make it possible to have both "good" and "bad" persons present, if that is important to the therapy. It would be especially helpful with angry parents if both a male and a female therapist were available.
A reflective team might be helpful if the situation were at an impasse. Staff members would be available to talk to the family before the session, thus enabling therapists to work out the issues. With the family's consent, members of this team could either be behind a screen or, if necessary, in the room and available for advice throughout the session. Finally, it is important for medicolegal purposes to document all communication.Case vignette 2
Mrs D presented with her son Peter (aged 6 years) who had problems with controlling his temper and was extremely oppositional. She had had a very difficult pregnancy and long labor, followed by a caesarean section because of fetal distress. She had postnatal depression following the birth of this child and had had to spend some time in the hospital. Her husband looked after the child while she was in the hospital because she was too ill to have the baby with her. She admitted to the therapist that she had never bonded with Peter and blamed him for her illness. She found it very hard to even cuddle or comfort him as a baby. Although this had improved somewhat, she still had a very different relationship with him than with her 2 younger children.