Expanding the Domain Privacy, Secrecy, and Confidentiality

Over the last ten years we have seen an increasing acceptance of the general idea of working with parents of child patients. What remains as an area of controversy is the question of whether and how much therapists should work concurrently with the parents of adolescent patients. Questions cluster around the issue of confidentiality and lead to the even larger issue of conceptualizing the developmental goals of the phase of adolescence.

Let us start with a clinical vignette: Jake was a high school senior preparing to leave for a prestigious university, his father's alma mater. He was in turmoil, determined to leave but clearly unready to do so. His parents took it for granted that Jake would follow in the family tradition and wanted treatment to help him “pull himself together and get on with his life.” As the work proceeded, it became apparent to Jake and me that removal of the obstacles to his further development would require much more than self-control and immediate effort. When Jake and I met together with his parents to discuss this, his parents expressed concern and support, but at home they told Jake they were profoundly disappointed in him and expected him to try harder.

Jake was hurt and angry, but he shifted his rage to his girlfriend, whom he had encouraged to go out with another boy, and to me. He raged for weeks, broke up with his girlfriend, and began hinting at thoughts of killing himself. I noted this and asked Jake whether he was planning to kill himself, perhaps, to punish his girlfriend and me. Jake said he had been thinking about using one of his father's guns to blow