Daughter’s Therapist Doing More Harm Than Good?

Reader’s Question

My husband and I have been concerned about our daughter’s lack of progress in her counseling. She is 17 and in the past year and a half her grades haven fallen. We have noticed she is far more tense and angry than she used to be. In the eight and a half months she has been in counseling, her therapist has offered nothing of substance and really nothing more than vague generalizations and superficial observations that virtually anyone could offer. Don’t therapists have some professional responsibility to determine whether their services are effective?

Psychologist’s Reply

Whenever I see an adolescent in therapy, I always make sure that both the parent(s) and teenager understand from the onset how I handle communications about the teen’s treatment. Psychologists have an ethical and legal obligation to inform their clients about matters concerning confidentiality, record-keeping, fees, and other aspects of therapy before the therapy process begins. This initial process is known as “informed consent” and ensures that the client understands her rights as well as the potential risks and benefits of treatment prior to entering the therapeutic relationship. At the first session, the client signs a consent form detailing all of this information to ensure that she is well-aware of the emotional, financial, ethical, and legal aspects of therapy.

Since your daughter is under age 18, she is not legally considered an adult and, correspondingly, this makes informed consent procedures a bit more complicated. If you are in the US, you undoubtedly had to co-sign an informed consent form with your daughter as her legal guardian (your therapist would be breaching legal and ethical grounds if he did not have you do so). Your therapist should also have described the limits to confidentiality regarding your daughter’s treatment. The therapist should have explained how, legally, you may have the right to access treatment information about your teen, but the therapist has an ethical obligation to keep treatment records confidential in order to maintain the integrity of the therapeutic relationship. Psychologists and therapists generally ask parents to respect their adolescent’s privacy; only in situations where the teen may be a danger to herself or others (or informs the therapist that a child or vulnerable adult is being harmed) will confidentiality be breached.

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These considerations regarding confidentiality may explain why your therapist has not openly disclosed specific information about your daughter’s treatment. He may simply be protecting your daughter’s best interest by revealing only vague information about her therapy. However, it sounds like you have concerns regarding whether therapy is helping your daughter and you even suggest that your daughter’s mood, behavior, and school performance have actually worsened. You have every right to approach the therapist with these concerns and request his opinion about why your daughter seems more anxious and angry than when she initially started therapy. Sometimes psychological symptoms can worsen before they improve (e.g., processing difficult feelings or traumatic memories can worsen depression and irritability in the short-term). The therapist might feel that this is precisely what is occurring with your daughter. On the other hand, if he determines that your daughter is not improving with therapy, he has an ethical obligation to end treatment and attempt to refer your daughter to another therapist.

Although psychologists should routinely assess whether their services are beneficial, there is not yet any mutually agreed-upon means for determining client treatment outcome in private practice settings. Standardized outcome measures are not typically used and, instead, progress is usually determined by the therapist’s clinical judgment or per the client’s report. (Please refer to ‘ The Use of Outcome Measures by Psychologists in Clinical Practice‘ for an excellent article addressing this issue). This means that your daughter’s therapist probably is using clinical opinion as a basis for deciding whether she is improving or not. I advise speaking again with the therapist to clarify how he views your daughter’s progress. You may also wish to ask your daughter herself whether she feels she is benefiting from therapy. If your daughter feels she is not being helped, you may wish to find a different therapist who is better suited to treat her.