A Circle of Safety: Adult Collaboration in Adolescent Treatment

adult collaboration

When a teenager requests more privacy, withdraws from her parents, and demands more freedom, we get it.   After all, the primary developmental tasks of the adolescent years are separation and individuation. Most responsible adults will respect the adolescent’s burgeoning need for autonomy (within reason, of course), grant her the privacy she requests, and give her the independence she craves, provided that she demonstrates the ability to handle these privileges in a responsible manner.

Helping a teenager navigate the turbulent waters of adolescence is not easy, but we do the best we can by communicating clear expectations and setting reasonable limits. We constantly strive to balance privacy with safety, freedom with responsibility, autonomy with connectedness.  Want to drive a car?  Well, you’d better get a job to help pay for gas. Caught texting and driving?  You can say goodbye to your phone for a week, and you’re not driving the car for a month.  Want to spend all weekend out with your friends?  Great, but you’d better be home for family dinner on Sunday.

When an adolescent has a mental illness, issues of privacy, autonomy, and responsibility become even more complex. It is the therapist’s responsibility to negotiate these issues with sensitivity to the needs and desires of the adolescent patient as well as the rights and responsibilities of the parent, while remaining ever mindful of the ultimate goal of achieving an excellent clinical outcome.

There are many therapists who share very little information with the parents of their adolescent patients. After all, they argue, it is important for the teenager to separate from her family and establish an independent identity.  These therapists believe that they are respecting the patient’s burgeoning sense of identity and enhancing her personal responsibility by excluding her parents from treatment.  They also believe that they are nurturing the therapeutic relationship by refusing to disclose all but the most essential information to an adolescent’s parents.

I have observed that many therapists who work this way believe that the parents are somehow guilty of causing or contributing to their child’s disorder.  The belief in parental culpability may be overt or it may be subtle, but it is present implicitly when parents are excluded from treatment.  I can hear it in their choice of words or sense it in their tone of voice.  These therapists tend to view parents as irrelevant to treatment (at best) or disruptive to treatment (at worst), and thus keep parents at arm’s length. As a result, many parents of adolescent patients are relegated to the role of chauffeur. They drive their child to her appointments and pay for her treatment without ever knowing what is going on in those sessions.  Imagine how dis-empowering this feels for parents.

There are several problems with excluding parents from their adolescent’s mental health treatment:

  1. Parents have a legal right to be informed about their child’s treatment and a moral responsibility to oversee their care.  After all, they are typically paying for treatment, or paying insurance premiums that cover the cost of treatment.  And parents are ultimately responsible for their child’s well-being.

  2. Excluding parents from their teenager’s treatment can further alienate teens from their parents at the very time when they need parental support the most.  When parents are kept in the dark, the stage is set for splitting and triangulation.

  3. Parents can provide therapists with extremely valuable  information that is unlikely to be obtained from the adolescent herself.   Parents’ observations and perspectives can help the clinician conduct a thorough assessment, make an accurate diagnosis, and develop and implement an effective treatment plan that fits within the family’s culture and preferences.

  4. Excluding parents from their teenage son or daughter’s treatment is a missed opportunity for built-in structure, support, and accountability in reaching treatment goals.

  5. Treating the adolescent in isolation from her family is much less likely to be effective.  Many mental illnesses impair the patient’s ability to develop insight, report symptoms accurately, or take responsibility for her recovery.   Parents can help their teens take recovery-oriented action irrespective of the teen’s willingness or ability to comply.

Rather than excluding parents from their adolescent’s mental health treatment, I promote and practice the opposite approach.   I view parents as the leaders of their child’s treatment team, and I empower them to take charge of guiding their teenager to health.

If you are a therapist who treats adolescents, your relationship with the parents is just as important as your relationship with the adolescent patient. Parents need to trust your judgment and treatment methods. They are, after all, entrusting you with their child’s health and bright future. You earn parents’ trust by maintaining open lines of communication, by providing them with empirically-sound literature on their child’s condition and the treatment approach you are taking, by respecting their parental instincts and taking seriously their experiences with their child, by supporting them emotionally, by absolving them of guilt and self-blame for their child’s disorder, and by empowering them to take constructive action to help their child get well.   In the process of earning parents’ trust, you are also nurturing a sense of cohesion among the adults involved in the adolescent’s care.  You and the parents become a team, working together on behalf of the teenager.

Empirical research has demonstrated, and my own clinical experience has confirmed, that adolescent treatment generally works best when parents are fully informed and actively involved.   For example, Family-Based Treatment (FBT; also known as the Maudsley Approach) is twice as effective as individual therapy in helping adolescents recover from Anorexia Nervosa or Bulimia Nervosa.  Family-Focused Treatments for youth with mood disorders, anxiety disorders, and substance abuse have also proven to be more effective than approaches that target the adolescent individually.  These family-based and family-focused treatments have one thing in common: the clinician views the family as the patient’s greatest resource in recovery and welcomes the family into the treatment process with open arms.

I advocate for open communication, respectful cooperation, and full collaboration between the professionals who treat adolescents and the parents who love and raise them.  Together, we can create a circle of safety to protect and support vulnerable teenagers as they go through mental health treatment.

There are a number of steps that clinicians can take towards creating and sustaining this circle of safety:

  1. Provide parents with psycho-education about their child’s disorder(s) at the start of treatment and explain to them the research and theory behind the treatment interventions you plan to pursue.  Have this conversation with parents in person, giving them an opportunity to ask questions and express concerns.  Provide them with relevant literature and online resources.

  2. Provide parents (as well as the adolescent patient) with a written treatment plan at the start of treatment.  I recommend that the treatment plan contains the following information: a.) the patient’s diagnosis or diagnoses, b.) primary symptoms that will be targeted, c.) the treatment approach that will be used, d.) type and frequency of parental involvement, e.) specific interventions that you plan to use, f.) referrals to other professionals if indicated, g.) short-term treatment goals, and h.) long-term treatment goals.

  3. If there are other adult family members involved with the adolescent’s daily life (e.g., grandparents, older siblings) consider involving them in the treatment process, if appropriate.  Other family members can provide valuable insights and auxiliary support to the adolescent.

  4. When there are other professionals involved in the adolescent’s treatment, ask parents to sign a release of information authorizing you to communicate with them to coordinate care.  Provide the other professionals with copies of your treatment plan, speak with them over the phone, and make yourself available for ongoing communication as treatment progresses.  It is essential that all treating professionals are sending consistent messages to the family and are working cooperatively towards the same treatment goals.

  5. Make yourself accessible to parents throughout the week so that they can contact you if questions or concerns arise between sessions.  Allow parents to speak with you privately if they wish.

  6. If the adolescent’s parents are separated or divorced, make an effort to include both parents in the treatment as much as possible.

  7. If you are providing individual therapy to an adolescent, make a point of inviting parents to attend part of a session at least monthly.  You can use this time to ask parents for their observations, answer their questions, and provide them with a progress update.

  8. Once treatment goals have been reached, involve parents in the creation of a written relapse prevention plan which will help the family identify signs of struggle in the future and intervene appropriately when needed.

Mental health treatment is time-limited, but family is forever.  Once you have created that circle of safety and worked collaboratively with the parents to support the adolescent’s return to wellness, you can safely step back and leave that robust circle intact.

About Sarah K Ravin Ph.D.

Sarah Ravin, Ph.D., is a licensed psychologist in private practice near Miami, FL. She earned a BA in Psychology and English Literature from Smith College in 2001 and a Ph.D. in Clinical Psychology from American University in 2008. An advocate for and practitioner of evidence-based treatments, Dr. Ravin specializes in Family-Based Treatment for adolescent eating disorders as well as Cognitive-Behavioral Therapy for anxiety, depression, OCD, and related disorders. Dr. Ravin is a professional advisor for FEAST: Families Empowered and Supporting Treatment for Eating Disorders, an active member of the Academy for Eating Disorders and the Association for Behavioral and Cognitive Therapies, and the author of an award-winning blog on eating disorders and related topics in psychology. http://www.blog.drsarahravin.com//