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Exir
04-20-2013, 01:17 PM
This is part of a WIP, so my decision on what story I'm going to write will depend on the reality of the matter. The question is US-specific.

When a child sees a therapist (outside of school, not a school counselor), does she need permission from parents? Common sense tells me this is the case, but I'm not familiar with the exact protocol, the details of paperwork involved, or the legal liability the therapist will have to shoulder in case of a breach of protocol.

I'm asking this in the context of a precocious kid looking for a therapist in the yellow pages and basically showing up at her office. (For the sake of plausibility, the girl doesn't go see the school counselor because she often gets in trouble and so doesn't trust the school counselor, regardless of the professed confidentiality.)

cornflake
04-20-2013, 01:40 PM
Your larger problem is that a kid doesn't have insurance under his or her own name and is unlikely to have the cash to pay for therapy.

How old a kid are we talking about and what's the issue? There are some things that will trigger calls to authorities. Also, are you talking about a 'therapist' or a psychologist?

Exir
04-20-2013, 01:48 PM
About 9.

Going by what I found on Google, isn't a therapist a medical practitioner of psychological treatments (without drugs) and a psychologist an empirical researcher? So it will have to be a therapist.

The kid is naive enough to think she can pay for the therapy with her pocket money. The technical details of finance have never really occurred to her. I haven't decided on the precise nature of the issue. Is it necessary to answer the question? What I have in mind is maybe difficulties in her family situation, with her parents and her step-siblings, but nothing outright abusive that could get social services involved (at least not in the beginning of the story). And perhaps the therapists, feeling sorry for the kid, is willing not to take payment. But again, whether she actually decides to take the kid or show her the door depends on the reality of things, what's at stake, etc. So I'm not making any decisions until I know the real-life ramifications.

cornflake
04-20-2013, 02:42 PM
About 9.

Going by what I found on Google, isn't a therapist a medical practitioner of psychological treatments (without drugs) and a psychologist an empirical researcher? So it will have to be a therapist.

The kid is naive enough to think she can pay for the therapy with her pocket money. The technical details of finance have never really occurred to her. I haven't decided on the precise nature of the issue. Is it necessary to answer the question? What I have in mind is maybe difficulties in her family situation, with her parents and her step-siblings, but nothing outright abusive that could get social services involved (at least not in the beginning of the story). And perhaps the therapists, feeling sorry for the kid, is willing not to take payment. But again, whether she actually decides to take the kid or show her the door depends on the reality of things, what's at stake, etc. So I'm not making any decisions until I know the real-life ramifications.

No. A psychiatrist is a medical doctor. Psychiatrists are kind of the top of the pyramid, as it were, only in that they can do everything - talk and other therapies and prescribe all medications as well as other medical interventions. Psychiatrists can also do research if that's their interest, or some combination of research and clinical work.

A psychologist is a Ph.D or Psy.D, and can do all kinds of therapy (not every one can or does do every thing obvs., for all of this stuff; I just mean in a general sense these fall under these job titles), or may engage in research if that's their interest, or some combination of clinical work and research. There are a couple of states that allow prescription-writing privileges for psychologists, but most don't.

Therapist is kind of a catch-all term. Sometimes people refer to a psychologist or psychiatrist whom they do talk therapy with as their therapist, but in great generality, therapists are mostly those with MAs in some area of counseling or sometimes clinical psych or even social work.

I asked about the nature of the issue because, as I said, some things would trigger authority involvement. If your character went in and said someone had beaten her or touched her inappropriately or some such, the person would have to report that to CPS, etc. No way her parents don't find out then.

As for whether a therapist would tell, seems kind of unlikely one wouldn't, but I could see someone putting it off maybe. Dunno, that's kind of interesting. That you want it to be a therapist makes it trickier, as there isn't the same kind of single, powerful governing body.

Exir
04-20-2013, 02:56 PM
OK, thanks for the distinction between the three terms. Pretty helpful.

So to answer your question, no, it's never anything as serious as physical abuse & molestation.

Where does that leave me, the girl, and the psychologist?

Buffysquirrel
04-20-2013, 03:09 PM
I don't think it's so much that the child needs permission to see the therapist as that the therapist may need parental permission to treat the child.

This linky looks useful: http://kspope.com/consent/


Ethics in Psychology: Professional Standards and Cases, 2nd Edition by Gerald P. Koocher and Patricia Keith-Spiegel. New York: Oxford University Press, 1998.
Excerpt: "Obtaining consent to treatment from a minor presents another set of issues.... Although a small number of states (e.g., the Commonwealth of Virginia) permit minors to consent to psychotherapy independently of their parents, such authority is an exception to the norm. In some states, such services could conceivably be provided as adjuncts to a minor's right to seek, without parental consent, birth control, or treatment for sexually transmitted diseases or substance abuse. Usually, however, a parent's permission would be needed to undertake psychotherapy with a minor client...."

strictlytopsecret
04-20-2013, 03:10 PM
The answer is usually "no".

Minors cannot consent to their own treatment -- neither psych nor medical (except in limited circumstances).

In some states, the age at which persons can sign their own informed consent forms is younger than 18 in certain circumstances. You'll want to find out the exact age for patients in the state in which your story takes place.

cornflake
04-20-2013, 03:12 PM
OK, thanks for the distinction between the three terms. Pretty helpful.

So to answer your question, no, it's never anything as serious as physical abuse & molestation.

Where does that leave me, the girl, and the psychologist?

If she were 16 this would be less of an issue. There are a bunch of things - there's patient confidentiality, which a Dr. would be unlikely to easily breach without good cause (though in the case of minors the guidelines are usually discussed with both the parents and child beforehand); however, there's also the basic issue of consent - a minor cannot consent to therapy, though this is sometimes determined by maturity less than age nine is going to be a harder sell. If the Dr. thinks it's in the girl's best interests, I could maaaaybe see someone trying it but I think it'd also open someone up for a lawsuit, censure or worse, etc., so I can certainly see someone refusing. Helpful, no? :D

Exir
04-20-2013, 04:02 PM
OK, so I think I have a basic outline:

The girl, because she doesn't trust the school counselor, only spouts BS to him/her.

She goes to see a therapist with her pocket money. Therapist decides to take her as patient pro bono (maybe accepting the pittance as a token gesture). She asks the girl first if she can talk to her parents, but the girl is adamant that this is the last thing she wants. So the therapist, feeling sorry about the girl, reasons that giving her some help is better than none at all.

I guess choosing therapist rather than psychologist means the regulations are less strict.

And the fact that it isn't exactly coloring within the lines probably makes the story interesting... of course if the therapist is a star who has her whole career ahead of her she would be less willing to get involved, so some interesting character exploration there...

strictlytopsecret
04-20-2013, 04:11 PM
Therapist . . . asks the girl first if she can talk to her parents, but the girl is adamant that this is the last thing she wants. So the therapist, feeling sorry about the girl, reasons that giving her some help is better than none at all.

This wouldn't happen. Informed consent isn't a request. It's a legal necessity. The therapist wouldn't merely ask the girl. The girl wouldn't even get past the front desk.



I guess choosing therapist rather than psychologist means the regulations are less strict.Informed consent is required regardless of the specific sub profession (e.g., social work, psychology, counseling).


And the fact that it isn't exactly coloring within the lines probably makes the story interesting... of course if the therapist is a star who has her whole career ahead of her she would be less willing to get involved, so some interesting character exploration there...No therapist I know would do this under almost any circumstances.

It sounds like you want your nine year old character to receive psychotherapy without the informed consent of her parents. The reality is that, unless you're talking about some very specific circumstances, this just will not happen.

Exir
04-20-2013, 04:16 PM
OK, downer, but good to know now rather than later.

Pyekett
04-20-2013, 05:18 PM
The questions of being able to consent to mental health services and having resources for funding them will differ based on location. In the US, this means looking at it on a state-by-state basis.

For example, in Washington State 13-year-olds can consent to outpatient mental health services on their own (http://depts.washington.edu/hcsats/PDF/guidelines/Minors%20Health%20Care%20Rights%20Washington%20Sta te.pdf), but they have to be 14 to consent to STI testing without parental notification. In Pennsylvania, adolescents 14 years and older (http://www.pacwcbt.pitt.edu/Curriculum/303ChldhdMHIssIntro/Hndts/HO8ConsentforMHTreatment.pdf) can consent to voluntary outpatient mental health treatment. In California, it's 12 years old (http://www.teenhealthlaw.org/fileadmin/teenhealth/teenhealthrights/ca/CaMCConfMentalHealthChart12-10.pdf). [Links are to various state government regulation websites.] Different states have different laws. Right around 13 years is a common age at which to demarcate changes, although what falls on either side of that line depends on the state.

I don't know of any states that allow consent to these services without parental notification as young as 9 years old, but I haven't looked at it on a state-by-state basis for a long time.

Some areas may have publically funded mental health services--such as drop-in clinics--which people can access free of charge. Access may be limited by geographic area of residence, socioeconomic status, etc.

You might be able to work around this if your therapist is not in a therapeutic relationship with the child, but just a friend. This is dicey. Be careful in how you lay it out if you do this, and get folks in the know here or elsewhere to vet it. But, for example, if the therapist were a neighbor the child knew anyway, and if the parents knew the child was going over to, say, work in the front-yard garden with the neighbor, then the child could ask about what the neighbor does for a living and try to hire him or her. The therapist could decline gently but say they could talk as friends, maybe? I don't know. Others will.

shadowwalker
04-20-2013, 05:31 PM
When my son was in counseling with a psychologist (dealing with the repercussions of my depression) I had to give my permission, but what they discussed was strictly between the two of them. (He was 13 at the time.)

ArtsyAmy
04-20-2013, 06:41 PM
She goes to see a therapist with her pocket money. Therapist decides to take her as patient pro bono (maybe accepting the pittance as a token gesture). She asks the girl first if she can talk to her parents, but the girl is adamant that this is the last thing she wants. So the therapist, feeling sorry about the girl, reasons that giving her some help is better than none at all.


I just don't see this happening in real life. Professional standards and legal restrictions would prevent the therapist from accepting the client without parental consent (as others have indicated). Plus, if a nine-year-old seeks therapy and "is adamant" that her parents not be contacted, the therapist would likely report this to child protective services. Reporting requirements vary by state. Certain professionals, such as therapists, may be required by law to report suspected child abuse. In the state where I live, all adults, regardless of occupation, are required by law to report suspected child abuse. Therapists tend to be very aware of necessary cya measures--I think your therapist would make the call to cps, and then cps could determine if protective services were needed.

Hope you're able to figure out something that will work for your story.

-Amy (used to be a social worker for Child Protective Services--investigated reports made through the child abuse hotline, later became a psychiatric social worker)

LJD
04-20-2013, 06:50 PM
I'm asking this in the context of a precocious kid looking for a therapist in the yellow pages and basically showing up at her office. (For the sake of plausibility, the girl doesn't go see the school counselor because she often gets in trouble and so doesn't trust the school counselor, regardless of the professed confidentiality.)

In Canada we have the Kids Help Phone (http://www.kidshelpphone.ca/Kids/Home.aspx). Information on this was provided to us in school, and I definitely knew about it at age 9. This is the sort of action I could easily imagine a kid taking at that age outside of school without the complications brought up here. It is confidential except in the case of abuse, I think, and counsellors are not merely volunteers but have a social services background. Probably not what you want for your story though, and I don't know if there is something similar in the US.

Exir
04-20-2013, 08:01 PM
All very helpful. I had an inkling that I may be stretching it a little, so I'm glad I know what the real deal is before I committed substantially to my premise. Back to the drawing boards then :-) Some of the alternatives suggested here could be explored.

Thanks!

cornflake
04-20-2013, 09:40 PM
I didn't know some states had floors on what ages could seek their own services.

OP - check your state, because NY has no floor. Same as for, say, reproductive care, anyone can seek mental health care at any age and can have it stay confidential. Whether it does is kind of at the judgement of the professional as to whether it'd be harmful to involve parents.

That's why I put confidentiality first in my answer above, but nine is harder - 16 is simpler as I said, they're free to place themselves into inpatient even. However, it's legally possible in NY and appears it may not be so in other states, which seems odd to me (I'm not debating that it's factual, just sensible, heh).

I checked to make sure. In case (http://nyehealth.org/images/files/File_Repository16/pdf/white%20paper%20final%20072110%20clean%20version.p df)-


... a minor of any age may seek outpatient mental health services without parental involvement if a parent or guardian is not reasonably available, or the provider determines that parental involvement would be detrimental to the course of treatment, or the parent or guardian has refused to give consent and a physician determines that treatment is necessary and in the best interest of the minor. N.Y. Mental Hygiene L. 33.21(c); 14 N.Y.C.R.R. 587.7(a)(3)(iii) (2001).Where parents have refused to consent and a physician determines that the minor should receive treatment anyway, the physician must notify the parents of this decision, but only if clinically appropriate.

Exir
04-21-2013, 12:04 AM
Wow, interesting. New York sure does it differently, no? Thanks for the heads up.

Pyekett
04-21-2013, 01:40 AM
Great info, cornflake. Thanks for the cite. I'm reading through.

Buffysquirrel
04-21-2013, 04:17 AM
One alternative possibility would be for the child to befriend a retired therapist. There wouldn't be a professional relationship, but there would be potential for the retired person to help as a friend.

Lyra Jean
04-21-2013, 05:14 AM
Maybe the kid could find one of the helplines. Like the Suicide/Depression helpline or something like that. I know they are volunteers but perhaps the kid can explain that they aren't depressed but that they just need someone to talk too.

JoNightshade
04-21-2013, 05:30 AM
One alternative possibility would be for the child to befriend a retired therapist. There wouldn't be a professional relationship, but there would be potential for the retired person to help as a friend.

This is what I was thinking. Kid hears so-and-so was a therapist, shows up on doorstep with her pennies saved. Therapist is like, uh, I'm retired, I'm not gonna take your money, but do you wanna come in and talk? I could see a non-practicing professional doing this in the interest of sounding the kid out - just to make sure social services don't need to be called, the kid is okay, etc.

Exir
04-22-2013, 10:55 AM
True. I was thinking along the lines that the therapist may take the pennies as a token because she doesn't want to make the kid feel like she's putting her down, and returns it anyways by the end. but your ways seems better and more realistic.

Flutterlight
04-22-2013, 01:45 PM
The issue with the therapist getting paid for their services, then they might be liable to being sued for malpractice if the kid's parents find out they bypassed getting parental consent to paid sessions.

An alternative to the retired therapist would be if friend of the kid had a parent that worked as a therapist. If the kid trusts her friends' parents and feels open to talking to them, they could have kind of pseudo sessions where the parent doesn't get paid but the kid gets help from them.

If you need to get rid of the friend, have the two kids take horseback riding lessons at a small stable, or something. In my experience, they only let one kid ride at a time, so that would give the MC about 30 minutes of talking with the friend's parent.

Pyekett
04-22-2013, 05:07 PM
I think that particular issue is less with the accepting of money than with the establishment of a therapeutic relationship. When one accepts money for services as a therapist, it does make the establishment more clear, but it isn't the only way to incur professional duties and obligations.

So, for example, a therapist who volunteers pro bono at a free clinic can't then turn around and share private information publically. It's the therapeutic relationship that binds them to confidentiality, not the money--even though the money is a very specific way of making that relationship clear, it isn't a necessary component.

Sometimes plot twists turn on (for example) giving the lawyer a dollar to clarify that he or she is bound by client confidentiality. But you don't have to pay a lawyer for the lawyer to be bound by ethical and professional regulations. That is a much less vague line. Money exchange just puts you firmly on one side of it.

frimble3
04-23-2013, 08:11 AM
I would think that a child who knows enough to look for a therapist, and specifically one that won't tell the parents, would feel reassured by the clarity of 'here's a dollar, you're now officially my therapist' . Especially if there's any history of being lied to or betrayed by adults. Even the small betrayals of promising something, then not fulfilling the promise. Or treating the child seriously to her face, then joking about her to other adults.

Pyekett
04-24-2013, 06:33 AM
Oh, I think it's likely the kid would want it. I think it's unlikely the therapist would do it, for all the reasons listed above. But I suppose a lot depends on how it's written.

Captcha
04-24-2013, 08:25 AM
Isn't there also an issue of the kid having enough time alone to be doing all this? If I were in contact with a nine year old who regularly had a significant chunk of free time when the parent didn't know where the kid was and the kid was out making contact with strange adults, I'd seriously consider calling the child protection authorities for that alone.

Nine is YOUNG.

Exir
04-24-2013, 11:00 PM
It doesn't have to be a significant amount of time. One hour once a week is fine.