How technology is reshaping the therapeutic alliance in modern therapy
Therapist confidentiality gives clients the safety and freedom to explore their most vulnerable parts without fear that their information will be shared outside of their therapy session.
Confidentiality might seem straightforward at first glance, but therapist confidentiality with minors can become increasingly nuanced as federal and state laws regarding confidentiality offer different guidance depending on the case.
In the National Association of Social Workers (NASW) Code of Ethics, the NASW states that “social workers should protect the confidentiality of all information obtained in the course of service, except for compelling professional reasons.”
The American Psychological Association (APA) agrees with the NASW in its own Ethical Principles of Psychologists and Code of Conduct, guiding their members to “take reasonable precautions to protect confidential information.”
It is our duty as counselors to consider confidentiality in counseling minors from many angles, including ethical and legal issues, as well as best practices to serve our clients.
Do parents have access to child mental health records?
In most cases, guardians must provide informed consent for behavioral health treatment, which includes an understanding of potential benefits and potential consequences of therapy.
Some guardians may request access to their child’s mental health records in the name of giving informed consent to treat a minor.
According to federal law and the U.S. Department of Health and Human Services, parents can generally access their child's medical records, but not psychotherapy notes that are kept separate from the record.
However, some states, such as California, have laws like Family Code 6924 that allow minors who are 12 years or older to consent to outpatient mental health treatment without parental or guardian consent.
Family Code 6924 was originally created as an emergency measure to protect youth in crisis. The consent standard for Family Code 6924 proved to be a burden for minors with state-funded insurance. Effective July 1, 2024, Assembly Bill 665 removed restrictions regarding proof of ongoing crises to benefit more youth in California.
Also in California, Senate Bill (SB) 543 includes adolescent confidentiality laws to cover the gap between crisis work and preventative outpatient treatment, creating a confusing structure for clinicians in California to follow. The laws sometimes seemed to overlap and diverge on the same topic.
Thankfully, SB 543 and Family Code 6924 are now viewed as complementary and “mental health services must be made available to all young people based on the same consent standard” in California, according to the National Center for Youth Law. When a youth consents to their own treatment under these laws, they must provide written authorization for parents to access their medical records.
If a specific state law is not in place regarding parents’ access to children’s mental health records, like it is in California, clinicians are allowed to provide parents with access to their child’s mental health records but are encouraged to protect the specifics of the treatment discussions under federal law.
Are counselors mandated reporters?
There may come a time to break confidentiality in counseling minors. A common question among adolescent clients is: Can a therapist tell your parents if…?
Yes, in some situations. Depending on your state's laws, you may need to involve parents, and in other cases you must report to child protective services or other authorities.
An important exception to therapist confidentiality with minors occurs when practitioners suspect abuse or neglect, which triggers mandated reporting, or when a client poses imminent danger to themselves or others, where duty-to-protect rules vary by state. Knowing when to break confidentiality in counseling minors allows clinicians to protect the client while maintaining legal compliance.
When reporting to your local authorities, it is best practice to inform the client and their family of a pending report. Some families will continue to seek treatment after a report is made, so take care to inform the family before an investigation to protect the therapeutic relationship from a potential rupture.
The exception to informing family members of a potential investigation is if you believe there is imminent danger to the client or any other vulnerable person due to the investigation. If this is the case, inform the authorities of these concerns when making the report.
Although counselors are widely considered mandated reporters, the specifics of these requirements vary by state. Ensure you are aware of your state’s reporting process before working with minors and provide clients with a full understanding of the limits of therapist confidentiality at the beginning of treatment.
What are the ethical considerations for maintaining confidentiality with minors?
The therapeutic relationship requires a level of trust that must be protected for the client to see progress toward their goals. Establishing therapist confidentiality with minors fosters the environment necessary for progress. Therapists must carefully evaluate when to break confidentiality in counseling minors to protect client welfare without causing unnecessary trust ruptures.
Unfortunately, I have seen firsthand how a relationship between a child and their therapist can shift as they realize that a therapist can tell their parents information that the client had thought was private.
Sharing information with family and guardians should be handled with the utmost care and consideration for the client’s personal wishes.
If a parent requests information, you can provide topics covered or an overview of treatment without sharing vulnerable information about the client.
Additionally, if parents have concerns about their child’s therapy, you can address these issues in family sessions with all parties present to maintain confidentiality with minors while providing holistic care to the family system.
How can you protect confidentiality with minors in a clinical setting?
When working with a minor and their guardians, set and agree to boundaries as soon as possible. Create an expected structure around therapist confidentiality with minors from the beginning of the relationship and reevaluate regularly. Clearly defining therapist confidentiality with minors during the client intake process prevents future misunderstandings with caregivers.
Inform both parents and the minor that you are a mandated reporter and the specifics of your duty to report in your state.
Scheduling regular family meetings, as mentioned above, can allow children to communicate safely with caregivers with your support.
Family meetings will keep the parents informed while giving the client space to learn new communication strategies.
How do minors and informed consent work?
Addressing minors and informed consent in outpatient counseling requires frequent reflection on professional ethics.
Clear and strong boundaries protect the therapeutic relationship from potential rupture and our clients from undue emotional damage in our care. Collectively, counselors’ various codes of ethics hold client confidentiality in high regard, regardless of any nuances introduced by counseling minors.
It is important to stay up to date with federal and state laws that may impact your practice. Knowing specific laws in your state, such as SB 543 and Family Code 6924 adolescent confidentiality laws in California, will guide your practice and assist you in creating appropriate boundaries around confidentiality.
When providing counseling to minors, ensure that the client knows their rights and potential limitations of patient-doctor confidentiality with minors, including your duty to report potential abuse or neglect.
Be honest with your clients by sharing that there are times when a therapist can tell their parents something. There are times when a therapist might even tell the authorities if there is a safety concern.
Knowing your own personal and professional boundaries and clearly stating them at the beginning of a relationship, as well as reevaluating as the relationship evolves, is the best place to start if you are questioning when to break confidentiality in counseling minors.
Establishing clear policies on therapist confidentiality with minors ensures a safe therapeutic space, which is essential when deciding when to break confidentiality in counseling minors.
Sources
American Psychological Association. (2016). Ethical principles of psychologists and code of conduct.
California Legislative Information. (n.d.). Family Code section 6924.
California Legislative Information. (n.d.). Health and Safety Code section 124260.
National Association of Social Workers. (2021). Social workers' ethical responsibilities to clients.
National Center for Youth Law. (n.d.). Minor consent for mental health care: Implementing Assembly Bill 665.
U.S. Department of Health and Human Services. (2022). Does the HIPAA Privacy Rule allow parents the right to see their children's medical records?
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