Dr. Starr is in the private practice of psychiatry in Washington, D. C., and is a member of the Mental Health Commission. Her article questions the value of confidentiality as it applies to the adolescent-therapist relationship. She examines the effect that  secrets  have on family life

Starr, Dorothy A.

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The Linacre QuarterlyVolume 41 | Number 3 Article 10August 1974Primum Non NocereDorothy A. StarrFollow this and additional works at: https://epublications.marquette.edu/lnqRecommended CitationStarr, Dorothy A. (1974) "Primum Non Nocere," The Linacre Quarterly: Vol. 41 : No. 3 , Article 10.Available at: https://epublications.marquette.edu/lnq/vol41/iss3/10Primum Non Nocere Dorothy A. Starr, M.D. Confidentiality where adoles-cents are concerned is a two edged sword poised on a thread over the head of any outside Other who wants to live dangerously. There are two aspects of the problem; one is confidentiality from the Dr. Starr is in the private prac-tice of psychiatry in Washington , D. C., and is a member of the Mental Health Commission. Her article questions the value of con-fidentialit y as it applies to the adolescent-therapist relationship. She examines the effect that "secrets" have on family life. parents about the whole relation-ship and the 'other includes them in, for better or for worse, more or less. My particular concern is the confidentiality between adoles-cents and unselected Others with-out parental knowledge, without parental approval, without any due process to set aside the ex-isting guardianship rights and often in defiance of known par-200 ental objections, opmIOns or re-ligious convictions. For our pur-poses, we are excluding those spe-cial relationships, such as the con-fessional and analytic psycho-therapy, in which parents, know-ing that they will not be advised as to what transpires, freely con-sent to and voluntarily promote in order to achieve long range goals. Unfortunately, analysts have sometimes not been entirely successful in making these ground rules clear to the parents. Many physicians have learned this when parents react to their exclusion with anger, vehement criticism of psychiatry in general, and threats to treat the bills as that doctor treats their inquiries. Considering the rapid prolifera-tion of publicly and privately supported programs to provide a variety of services to individuals under the age of 18, on their own recognizance, without the knowl-edge, much less the consent, of a parent or guardian, and without judicial review, there is a dearth of validation of the need, desir-Linacre Quarterly ability and long range effects of such intervention in the parent-child relationship. These meas-ures are an intrusion into one of the basic functions of the family - the protection and education of its children - and go signifi-cantly beyond the older laws reg-ulating child labor and school at-tendance. The older laws were publicly mandated and publicly enforced - in fact told the par-ent what he had to do, not the child what he could or should do, and involved no element of con-fidentiality. It is interesting that these changes come not thirty years after the end of the Hitler holacaust and a full decade be-fore 1984. The rationale for waiving par-ental knowledge or consent is that the adolescent is alleged to be unable and/ or unwilling to in-volve the parent or guardian, and the need for free access to the services outweighs any other con-siderations. Implied in this is the presumption that the services to be rendered, and the secrecy sur-rounding them, will be in the best interests of the individual con-cerned. All of these premises are worthy of examination. First, to define our subject, adolescents are individuals in the stage of development from the be-ginning of puberty to the attain-ment of legal majority. Unfortu -nately, the beginning age varies and the end is a subject of legal controversy. Coming of age varies from one jurisdiction and purpose to another. To be more specific, I will use the term adolescents to August, 1974 mean individuals who I)ave passed their twelfth birthday and/ or manifested obvious physical signs of puberty, have not attained a locally recognized legal status of emancipated minor, or their 18th birthday. In today's world, 18, 19 and 20 year-olds are not routinely self sufficient adults. Many are still financially dependent, many are emotionally dependent. But the range of maturity is a con-tinuum and the legal status am-biguous, so I have excluded them. Privileged Communication Defining confidentiality is rem-iniscent of Humpty Dumpty's comment to Alice: " When I use a word it means just what I choose it to mean - neither more nor less." The legal definition of priv-ileged communication is one be-tween parties to a confidential relationship such that the re-cipient can not be legally com-pelled to disclose it in court proceedings. The law spells out the parties and specifies the re-lationships in this privilege. Law-yers advise that this has become so watered down in practice that specific measures are needed to delineate a special psychothera-pist-patient privilege. To my knowledge, no one has addressed the question of who has the au-thority to waive privilege for an unemancipated minor in a confi-dential relationship from which the parents have been excluded. Customary usage has required parental permission for release of medical information on a child patient - a quandary if in fact the parent is ignorant of the ex-201 istence as well as the content of such information. Confidentiality per se is the quality of being confidential, pri-vate or secret; not for disclosure to unauthorized/ outside persons; not for publication. The Hippo-cratic Oath binds physicians to hold confidential that which they learn in the course of their medi-cal practice but it does not put it under the seal of the confessional. Physicians have interpreted the confidentiality with judgement and discretion, they have decided when and what to tell relatives and when circumstances warrant-ed release of some or all medical information to another physician without a formal authorization; always with judicious concern for the well being of the individual concerned. Physicians have also recognized and respected the right of an adult patient to keep secret from anyone even the existence of the consultation (s) but custom, until recently, precluded even en-tering into a doctor-patient rela-tionship with a child without par-ental authorization. Dealing with adolescents in secret tends to transfer the privi-lege to the recipient, to waive or not as the recipient sees fit be-cause adolescents are not inde-pendent adults, able to assume full responsibility, pay their own way, act unilaterally on their own decisions. In these confidential relationships with an unknown Other, not a chosen agent of the parent, we have an outsider as-suming guardianship, authority and discretion to a greater or 202 lesser extent, without judicial process, in secret, at his own dis-cretion, with or without legisla-tive sanction and with or without any defined professional qualifi-cations or license. Parental consent is still rou-tinely sought for such momentous decisions as "Mary may/ may not have milk at lunch." The school that requires a parental permis-sion slip to transfer from Spanish to French requires nothing for a counselor to embark on a quasi-therapy program. Failing grades and undone homework are re-ferred to parents, emotional prob-lems to the guidance counselor. A dental examination requires ap-proval, a pelvic examination does not. The emergency treatment of a severely injured unidentified adolescent requires the convening of a court of proper jurisdiction, the harboring of a runaway child is at the discretion of the child. Suturing a small laceration re-quires the parental presence, in-sertion of an IUD is none of the parent's business. These are end-less and surely there are incon-sistencies in this state of affairs. Implicit in the rationale and justification is first the premise that the adolescent is unable or unwilling to involve the parents. Adolescents themselves say so, frequently. "My mother would kill me if she knew. " "My father would beat me up, again. " "I'll kill myself if you tell them." "They don 't care what I do, they hate me." "They treat me like a baby. They never let me do any-thing." "I'm on my own, I ran Linacre Quarterly away from home." These state-ments are not significantly al-tered if prefaced by a bland request for the services. The sit-uation is not significantly altered if a bland request for services is followed by a psuedo sophisticat-ed explanation such as "I've abandoned out-dated middle-class morality." "This is not their decision but mine to make." " I'm mature for my age and need pri-vacy to find myself." Conflict Between Generations All of the above, no matter how expressed, reflects the essence of the adolescent problem, the con-flict between the generations. The major work of this period is eman-cipation from parental control and delineation of one's own ego with control of instinctual impulses and sublimation and postponement of gratification. Indulgence and immediate grati-fication belong in the nursery. The very fact that the adolescent is unable or unwilling to work through a resolution of the con-flicts with the parents is the prob-lem. The need for secrecy is the problem and a pacifier; pablum when the individual needs help cracking the tough nuts. Secrecy thus evades the issue, is in the nature of yielding to threats and appeasing demands and as such tends to foster regression rather than maturation. If of course these statements abo~t abusive,' unfeeling, uncar-ing parents are taken literally , the recipient would be well ad-vised to consider reporting this case of child abuse. Under the August, 1974 impact of the recent federal legis-lation this will soon be reportable by anyone having knowledge . The other question is the effect of secrets in the family system. Extensive work with families re-ported by such widely respected family therapists as Ackerman, Bowen, and others, does not sup-port the thesis that secrets are helpful or desirable in families but rather the reverse. Secrets further impede communications and ag-gravate problems. In my own work I have never been success-ful ~hen I erroneously got into the role of confidante to one or the other of the spouses or the adolescent. As to the adolescent's contention that he is unable or unwilling to divulge this matter except in strict confidence, few of them even pause when I inter-ject a disclaimer before they go on to spill the super secrets. In fact , the profuse documentation of all these secrets, in and on copy books endless notes carelessly left i~ pants pockets, the numer-ous clues discarded in waste bas-kets and other secure repositories, leave me quite dubious of the allegation tha t adolescents want their parents in the dark. If in fact the purpose of the acting out is t~ precipitate interaction with the parents, the secrecy only forces the adolescent to move on to something more conspicuous. The evidence on which legisla-tion is promulgated is to be found in legislative hearings. Being resi-dent in the District of Columbia, our town council is the congress 203 of the United States and I have reviewed a number of committee reports and congressional hear-ings. The evidence consists large-ly of lengthy statements by the advocates of the program, such as directors of runaway houses, population control enthusiasts, program planners, some qualified child psychiatrists, less often op-ponents (unless there is organized opposition), and often quite mov-ing anecdotal accounts of a few individual case histories validat-ing the need for legislation. Since all elected officials are in favor of child services, there is a tendency to confuse the worth of children and the worth of the particular services. There is also a tendency to confuse the need to do some-thing with the need to do this. Read in their entirety, few of these documents would be sufficient basis for a professional prescrip-tion for a standard treatment. There is always an element of self-fulfilling prophesy. The more services are offered with guaran-tees of absolute confidence, the more adolescents are programed to the implicit assumption that parents must not know, and the more likely they withdraw from parent - adolescent communica-tion , and the more impaired the communications and so on round the circle. If there was some evidence that secrets were good for families , if there was some evidence that this served the adolescent well in achieving maturity, if all these confidential relationships with 204 outside adults promoted the ado-lescent process or simplified it, then child rearing should be left to the state experts. If we assume that secrecy or confidentiality is mandatory for the services to be used, and they are in themselves essential to the well being, growth and develop-ment of adolescents, then perhaps the end justifies the means which may only be indifferent. What are these so essential and construc-tive services? Access to free clinics, psychotherapy of various persuasions, contraception and abortion, treatment of venereal disease and drug reactions or complications, provision of food and shelter to runaways and in-formation about all these facilities and services. None of these is in-herently bad in a pluralistic so-ciety with honorable differences about those which are controver-sial. If we assume that these pro-grams and services are essential and beneficial, it seems reason-able to look for results. Significant Questions Has the steady increase in school counseling services de-creased quantitatively or qualita-tively the emotional problems and drop-outs, or increased the aca-demic performance or adjustment of the population? Have drug ed-ucation programs, hot lines, and crash pads reduced the percent-age of adolescents experimenting with drugs and alcohol, or re-duced the severity? Has the free and confidential provision of con-traception and abortion decreased unwanted pregnancies proportion-Linacre Quarterly ate to the increased number of sexually active adolescents? Is sexual activity, under fifteen, un-der eighteen, developmentally de-sirable? The answers are harder to come by than the questions. School counseling is difficult to evaluate. Psychiatrists see only the fail-ures, but there is no reported de-creased need for other services. Drug education programs are cur-rently suspected of being how-to-do-it courses. Sex education and birth control clinics must be credited with changing the ter-minology from "sexual acting-out" to "sexually active," and, I would add, deleting the use of the term "girl," as in "sexually active teen-age woman." Contraceptives are now pushed in adolescence as if this group had had the highest incidence of illegitimate pregancy. In fact , 1969 statistics indicated that the 15 to 19 year-old cohort had only half the incidence of pregnancy per thousand to that found in either the 20 to 24 year group or the 25 to 29 year group. Thanks to the post-war baby boom however, there were so many teenagers as to increase their percentage in the popula-tion. If early sexual intercourse is good in itself then it may be wise to provide these services and the encouragement. The major thrust of the rationale has been rather, that either adolescents are going to anyway, or want to begin sexual activity, and that the only problem is population control. This does not address itself to August, 1974 what is developmentally desir-able. If it can be documented that most, or many, adolescents would be benefited by having free access to any services without parental knowledge or approval and that it is beneficial to remove parental controls - then that problem should be faced and the parental role in adolescence clarified. I have not addressed the prob-lems of confidentiality involving the whole triangle, adolescent, parent and Other because of its ambiguity unless used in the sense of keeping private, not for disclosure to outsiders. If it means that the adolescent is deceived by the Other who promises secrecy, then relays information to the parent, it is simply dishonest and not likely to be sustained. If this works the other way and the par-ent confides in the Other who re-veals it to the adolescent, it is also likely to be a short lived re-lationship. When any two people exchange secrets about a third, it affects their relations with each other and with the third in ways not likely to increase trust and communication. With an adoles-cent in skillful therapy the vari-ous pitfalls may be avoided. The experienced therapist makes ex-plicit his ground rules to both adolescent and parent and is pre-pared to work through the com-plications. This is quite different from transferring some of the ground rules to a myriad of other situations. Some therapists are able to function as the repository for everyone's secrets in what 205 amounts to simultaneous therapy with two family members sepa-rately; this is generally regarded as technically difficult and usual-ly foolhardy. Acting out adoles-cents are rarely considered suit-able candidates for such classic therapy on an outpatient basis and the more problems the ado-lescent and the family have, the more likely they are to be in less experienced hands, where confi-dentiality really will be a two 206 edged sword. When this confiden-tiality is used to conceal from the parent that which he is known or likely to object to, the confidante deliberately or accidently has joined forces with the adolescent against the parent, and become a chum. Advocates of rebellion may be popular but the question should be, "Are they doing more harm than good?" Linacre Quarterly 

Primum Non Nocere

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