Readers Describe Complex Factors in Approaching Confidentiality
Abstract
Patient status and history and family dynamics are among the factors that help determine to what extent family should be involved in an adult patient’s treatment for psychiatric illness.
In the September 2 issue, Psychiatric News asked readers to respond to the question, “What Would You Do?” in the following scenario: “You are treating a patient with bipolar disorder and a past history of suicide attempt. He appears to be stable, but he tells you that recently he has stopped taking his medication. His parents are anxious to know of his progress, but the patient is 25 years old and has not authorized release of information about his treatment to family members. Would you disclose to the parents that the patient has ceased taking medication?”
Here is a sample of responses:
The dilemma for clinicians—can and should they disclose relapse-relevant information to the immediate family if the family appropriately asks about clinical status?—is one that is ideally anticipated well in advance of its occurrence. That typically means having a frank discussion with patients when they are well, along the lines of a psychiatric advanced directive. For example: “In a clear-cut life-and-death emergency, I will need to speak with your emergency contacts, the same as if you were having a heart attack or a stroke and couldn’t communicate and advocate for your own best interests. But, what should we do if the hazards aren’t so obvious? Do you really want your immediate family to be in the dark?”
Knowing that family communication styles are themselves highly relevant to the outcome of bipolar disorder, it makes sense to identify the role of the family up front as one component of the overall treatment plan; if the patient decides to withhold permission for relevant dialogue with the family, it’s then the treater’s job to point out how they are setting themselves up for trouble.
Perhaps the most effective intervention is for the clinician to underscore his or her overwhelming concern for the patient’s welfare. The clinician can offer to be a moderator of communication between patient and family by proposing a joint meeting where all stakeholders and the patient are present, to air concerns and minimize surprises by making everyone’s fears explicit, and, consequently, shared.
Ethics Expert Responds
Response by Paul Appelbaum, M.D., the Dollard Professor of Psychiatry, Medicine, and Law; director of the Division of Law, Ethics, and Psychiatry; and director of the Center for Research on Ethical, Legal, and Social Implications of Psychiatric, Neurologic, and Behavioral Genetics in the Department of Psychiatry at Columbia University College of Physicians and Surgeons:
The responses above point to a number of key issues in dealing with confidentiality vis-à-vis family members. Drs. Goldberg and Dixon both underscore the importance of planning ahead. For many patients with serious mental disorders, situations in which familial involvement may be helpful are all too common: discontinuation of medication, development of suicidal ideation, relapse of substance abuse. Helping patients think through these issues in advance and identify when the involvement of family members may be helpful relieves clinicians and patients alike of the burden of having to deal with these questions at times of crisis.
A second take-home message is that no single approach is right for all patients. As Ms. Clouston notes, not all families are helpful in facilitating treatment. Indeed, some family members, sometimes because of their own psychopathology, can undercut psychiatrists’ efforts to treat their relatives effectively. Thoughtful involvement of families means assessing whether their engagement in the treatment process is likely to be useful. Dr. Finston seconds the need for approaching each situation on its own terms, pointing to the probable consequences of patients’ noncompliance as important determinants of clinicians’ responses.
All of this is possible within the constraints of HIPAA and other statutes governing psychiatrist-patient confidentiality. Although there will undoubtedly be cases like the one in the vignette where, lacking patients’ consent to contact family members and fearing relapse as a result of nonadherence to medication, psychiatrists find themselves in a bind, the number of such instances can be minimized by thoughtful advance planning jointly with patients.
Inasmuch as the therapeutic alliance often stands as the core of any good treatment, it becomes critical to tackle head-on the pitfalls of “privacy and confidentiality” conflicts when the patient and treater share the mutual goal of averting preventable harm to the patient.
Joseph F. Goldberg, M.D. (Clinical Professor of Psychiatry - Icahn School of Medicine - New York, New York)
Your discussion of information sharing seems to omit one key consideration: many families of mentally ill individuals are not capable advocates for the patient. They may have played a role in the development of the disorder. They may not have the resources to provide the sort of support you’re assuming. The family might not trust psychiatrists (or other mental health professionals). I see countless stories of patients (mostly with bipolar disorder) whose families don’t buy into the prevailing paradigm of mental illness. They shame the patient. They discourage various aspects of treatment. Hearing that a medication is potentially addictive, they discourage the patient from taking it. They simply “don’t believe in mental illness.” Even the well intentioned may minimize the seriousness of the illness.
Candy Clouston, M.S., M.B.A. (Chicago, Illinois - Ms. Clouston is a patient reviewer of psychiatric papers that appear in the British Medical Journal.)
Unfortunately, much of life is too ambiguous to be reduced to algorithms and checkboxes. I personally look for common sense to guide me. Here are the factors I would consider:
Why has the patient stopped taking the meds? This is a common occurrence for many young people with a mental health diagnosis. They feel better, consider themselves “cured,” and stop the meds. For them, the diagnosis and meds feel like an assault on their worth and potential “attractiveness” to peers. But there are other reasons to explore—side effects, paranoia about the actual medications, etc.
Treatment context (private patient, community mental health center, etc.) determines both the time and resources available to address this issue. The task is to evaluate who is or has been a resource for this person, whether he takes medication or not. That way, regardless of what the patient decides, there are people in his life who can “watch out” for him.
What do I expect to happen if the patient stops taking meds? Of course, I would talk with the patient about continuing the medication and educate him in detail about what he can expect if he stops. That way, if he relapses, he can catch it early. The downside of pressuring someone is that you alienate him. Usually better to work with patients to titrate down slowly and have them return for appointments. That way you can work together as a team to discover the minimum dose.
Peggy Finston, M.D. (Private Practice - Toms River, New Jersey)
An extensive and consistent body of research has provided evidence that the inclusion of families in the care of adults with a variety of mental disorders is associated with better outcomes for everyone. Yet, such inclusion is the exception rather than the rule.
One simple and person-centered strategy that has been tested and found to be effective is called REORDER—REcovery ORiented DEcision-making for Relatives’ support. This approach can easily be embedded in routine care and starts with the basic premise that family involvement does not have to be all or nothing. Clinicians talk with patients about who is in their family, help them define their treatment goals, and inquire about how families can help them meet their treatment goals (or not!). Patients are asked to weigh the pros and cons of family involvement and are included in the discussion of whether to involve their families and, if so, how. A randomized trial of REORDER produced a fivefold increase in family contact with care in a manner that was respectful of both patient and family needs and preferences.
REORDER does not address every situation in which family contact and information may be desirable. But it creates an easily implemented structure and process for meeting the needs and optimizing outcomes of both patients and families.
Lisa Dixon, M.D., M.P.H. (Director, Division of Behavioral Health Services and Policy Research and the Center for Practice Innovations - New York State Psychiatric Institute - New York, New York) ■
The Psychiatric News article “Confidentiality: When Does It Give Way to Other Ethical Imperatives?” can be accessed here.
