Privacy Laws Should Not Exclude Families

By Dr David Laing Dawson

“Frustration over mental health disclosure doesn’t trump privacy protection: experts” (CBC News, Halifax)

This story makes specific reference to a 21 year old who committed suicide after 3 trips to the University Health Services, only one of which her mother knew about.

Years ago, as a young psychiatrist with but one and then two very young children of my own, I am sure I “respected” the privacy of many of the teens I saw and treated. Usually our clinic staff saw them alone, and then invited the parent(s) in, and didn’t disclose anything the teen adamantly refused to share. I can’t remember the official age of consent at the time, but some years later it became 12. I remember this because a social agency asked me to see a 12 year old caught stealing. I said I would like to see his mother with him. They said, “We will have to ask his permission.” My mouth fell open. “What? You need to get permission from a 12 year old before you talk with his parents? That is nuts.”

Before that moment my thinking had evolved. Not least because I realized how outraged I would be if a doctor, counselor, psychiatrist did not tell me about important, serious things my daughter might disclose to her.

Working in a clinic that saw many teens, and consulting to local High Schools, I decided I could treat an 18 year old as an adult, and a 14 year old as a child. The child would always be seen with his or her parents. In between 14 and 18 the child had to prove he or she was “adult”, in order to be seen alone. And by adult I mean have at least a rudimentary sense of personal responsibility, at least a rudimentary sense of the consequences of certain behaviors, at least a rudimentary sense of not being the center of the universe, at least a lessening of that knee jerk oppositional response to parents and any other authority, and at least a small decay in that adolescent sense of omnipotence.

Of course, within the first half hour of any interview most teens demonstrate that they are not adult in the above sense and then I would say, “I will have to talk with your parents.”

They never fought me very hard on that because, really, they need and want their parents to know about their troubles. They want their parents to parent them. And that includes setting boundaries (protecting them) as well as loving and supporting them.

There was a time when I would ask a teenager something privately, working on the assumption that a.) In the presence of his parents he would not reveal the truth, and b.) His parents may not be ready to hear the answer. Sexual activity and orientation for example.

But my thinking evolved again. I concluded that, instead, a.) There is nothing I as counselor, physician, psychiatrist should know about a teen that his or her parents should not know and b.) Most family secrets are known or suspected by other family members already, and c.) If the parents have a bad, primitive, nasty reaction to the news, it would be better to have it in my presence.

So now I always see a child or teenager with his or her parent(s) and I ask whatever questions I need to ask. And I watch and I listen.

Occasionally I am talked into seeing a teen alone by a parent who insists I do so, and occasionally because the parent did not show up. It is always a futile exercise. It is not far off the metaphor of the blind man describing an elephant. There is one exception to this of course. Once in a while we run into a teenager who is more mature than either of her parents. In social work jargon, this is the ‘parentified’ teenager looking after the welfare and feelings of her parent(s).

I am talking about teenagers here, but it is not age that defines them. It is social, psychological, financial, emotional dependence on others. Their welfare depends on others.

But none of us is an island. Our health, our mental health, our welfare depends on others. So my policy of seeing teens with parent(s) has expanded to anyone who is financially, emotionally dependent on another. That includes college students, young “adults”.

I am seeing them because they are in trouble. If the trouble has to do with drugs, alcohol, relationships, money, failing – parents are in a better position to help than I am, or, at least, their support is necessary. If the young person suffers from a mental illness, then I may be able to treat that illness with or without the parents, but I want them informed and helping and supporting.

Health professionals put themselves in a bind when they see a young troubled person alone and he or she specifically says, “I don’t want my parents to know.”

To prevent that bind, privacy trumping parental concern and good care, we need merely see them together. The patient and his or her family. Together. In the same room at the same time.

So include them right from the beginning. Even bad parents, those who do all the wrong things (well-intentioned or not) should be included. For the child spends far more time with, is more dependent on, is more influenced by or reacting to, his parents than myself. Include them. Teach them if you can. Even if the teen objects before entering the interview room, persist, because he will change his mind very quickly once he understands he will be heard as well.

Don’t give up on parents, family, until you see with your own eyes that they are hopeless, unhelpful, or destructive. When that is the case, unfortunately, we must counsel, treat, care for, look after someone who is not yet an adult as if he or she is a responsible, self-sufficient adult.

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36 thoughts on “Privacy Laws Should Not Exclude Families

  1. I have been enjoying your wordpress sharing and have to admit that the wisdom comes after years of practice and evolving practice. Yes, it makes sense and thanks.

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  2. A criteria of the Canada Health Act is accessibility. And that means accessibility to the best care possible. How can a vulnerable person get the best care possible when the system allows the artificial creation of divisions within families which when a paranoid person is involved can make things worse. I believe that psychiatrists need to be think of the long term repercussions of such a strategy. It is way better to work with the whole family from the beginning. Psychiatrists may be in the picture for the short term, but the family is in for the long term doing what they possibly can to help their loved one.

    Liked by 1 person

    1. great information…agreed that families should be included in the process in the system..the care provider can provide valuable information for the person to receive the best possible care.

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  3. Dr. Dawson – I appreciate your rational and common sense approach to treating children and adolescents. In my 36 years treating families and individuals, specifically with addiction and trauma issues, I refuse to see children and adolescents without parental/ caregivers participation. Utilizing Family Systems Theory approaches, this ensures that I am not in any manner, creating or working “in a bubble” with the child/adolescent.

    Within two weeks of initial evaluation, I assist parents with the creation of a written behavioral contract, clearly stating their behavioral expectations as rules connected to a complete list of privileges which their children are given, ex: cell phone, computer, cars, etc. The completed contract is presented to the child by the parents, either in session or privately at home, signed by all, complete with the list of privileges.

    This contract becomes a basis for parenting sessions and individual sessions with the adolescent, who is made aware that parents are involved. Parenting sessions include forming strategies of reasonable restrictions of privileges if the contract is not followed and/or adding privileges for exceptional good behavior. In addition, the parental contact creates a regular opportunity for assessment of parental competency and the state of the parental relationship, which, if necessary, are addressed.

    Having also clinically supervised many social workers in agencies and private practice, it is my opinion that those who view privacy as an iron clad wall often are experiencing inflated counter-transference issues concerning their role as confidant and auxiliary “parent-like friends”. This creates a false sense of security for therapist and patient, and can completely undermine the authority of the patient’s parents.

    As a firm respecter and practitioner under confidentiality law, I am clear about the limitations and innate vulnerabilities of my role, I encourage all caregivers to remain conscious and aware of who we are and who we are not.

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    1. Does the child get to take a contract out on their parent (HAHAHAJAHAJAHAHAHAHAJA! 😁) too?
      For instance, the parent would have to improve their parenting in these ten ways, or else face punishment from their child or someone acting on behalf of the child:

      #1 no more sexual or physical abuse abuse of the child

      #2 no more threatening to send the child away or lock them up

      #3 no more blaming the child for “burdening” the family

      #4 no more comparing the child to their “more successful” siblings

      #5 no more forced psychiatric drugging of the child

      and

      #1 more hugs and kisses for the child

      #2 more inclusion and more meaningful inclusion of the child in the family’s meals, discussions, vacations, etc.

      #3 more time and money invested on the child’s interests

      #4 more compliments on the child’s personal qualities, achievements, etc.

      #5 a more positive attitude toward the child when the parents out in public with the child or speaking publicly about their child

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    2. I agree with your statement “Having also clinically supervised many social workers in agencies and private practice, it is my opinion that those who view privacy as an iron clad wall often are experiencing inflated counter-transference issues concerning their role as confidant and auxiliary “parent-like friends”. This creates a false sense of security for therapist and patient, and can completely undermine the authority of the patient’s parents.”

      I certainly think that many therapists think that they really are wiser than they are. They often have a limited agenda. We see many psychologists for instance huntng for things that are not there and turning the patient against their parents. I have in mind the therapist who was in contact with Susan Inman’s daughter who was later found to be suffering from a a major psychotic disorder. In that case,the therapist went in with her own agenda and caused much strife and hindered getting access to appropriate medication and thus effective treatment fast . Susan biography of events is a very good thoughtful book about how her daughter regained her sanity.

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    1. I know many people who would have included their parents without their consent, would find this retraumatizing and a complete breach of the trust necessary for effective therapy. Also I have also known many for whom discussing family secrets would not be just uncomfortable but also extremely dangerous for them. It is widely known that mental health professions are woefully inaccurate in predicting violent behavior. I’ve seen how the effects of unresolved inter generational trauma have dangerously torn and forever alienated family members from each other. I hold that family members should only be included at the request of the client or they represent an immanent danger to self or others; otherwise I don’t believe you’re providing ethical therapy but rather social control.

      Liked by 2 people

      1. Social control ? Here we go again with questionable logic . Does this person actual know how trapped a person is with an untreated serious mental illness ? Yes there are some families who do not pass muster, but in my experience most of the families whom I have known, hang in there through thick and thin. When someone is trapped by a psychosis they perceive most and particularly the family as the enemy.

        For heaven’s sake listen to what the family observes but the physician must also respect the confidentiality of the family until the ill person’s illness is brought under control. The person with the illness is potentially very unpredictable until stable .

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      2. The person with the illness needs his/her voice heard and should not be neglected. Family therapy often silences that client permanently. Be very, very careful! Remember who needs the focus.

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    2. I think that dr Dawson was referring to patients who are teens. I am assuming that adults can chart their own course with respect to how to involve their families, bearing in mind that for the vast majority, family support greatly enhances treatment and recovery.

      Liked by 1 person

  4. I was going to write that families should be included in the “circle of care”, but changed my mind after reading “circle of care:sharing personal health information for healthcare purposes. 2015…There are no caaregivers now just health custodians..

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  5. Two comments use strong words: “toxic” family and “traumatizing”.

    My blog addressed families, people who live together or are dependent on one another in some important way.
    If a “toxic or traumatizing” family member is not in your life; if you are not dependent on him or her; if you are not living in his or her house, then certainly he or she should not be a participant in your therapy.
    But if you are living in the house of a parent you consider traumatizing or toxic, or accepting money from him, or dependent on her emotionally, I will want, I should, I must see for myself. As every family and couples counselor knows, how one family member describes a relationship in the home can be quite the opposite of how other family members describe it.
    I do not want to be seeing a teen or young adult and find myself, over and over, nodding in sympathy over complaints that a parent is ruining your life, or is too controlling, or making too many demands of you, without seeing for myself if that is actually true. Otherwise I am doing you a terrible disservice, supporting your deflection of responsibility onto another.

    I recognize there exist some pretty bad parents, some because of mental illness of their own, some because of circumstances beyond their control, some because they just do not know how to be parents, some because they are nasty people.

    I see far too many kids whose fathers are in jail or mothers addicted. Clearly these fathers do not attend the session, and when the mother does, it is quite apparent she needs help herself. Nor do I call the father and invite him to our appointments when he gets out of jail. Now if he shows up and the kid wants him there, or is living with him, he will be included. And I will ask the father directly if he is clean and sober and in a program. And I will arrange treatment for him. And I will teach him as best I can how to be a father to this child.

    And if and when I can agree with you that your family is toxic, or traumatizing, I will sigh deeply and help you find a way of surviving and moving past your experiences.

    And I recognize that some parents and stepparents and foster parents inflict abuse and sexual abuse upon their children and teenagers. But there is a clear line here and it has been crossed. Those are, quite simply, criminal offenses, and should be dealt with accordingly.

    My blog was written in part to counter the current default position of many doctors, counselors and therapists who see the child, the teen, the transition age student alone. It is often wrong to do this, and as another comment mentioned, a counter transference problem, a therapist’s over inflated but personally gratifying special role in the life of this young person.
    Unless you plan to adopt the teenager and take him home with you, you are but a wise adult passing briefly through his life, dispensing a bit of wisdom. He won’t be talking about you ten years from now, but he will still be talking about his parents.

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    1. I see your point and I my heart pounded that you are the decider about toxicity before you will see a teenager without the parent. In my case, my resident parent did not want to have anything to do with therapy (too bad) and my non-resident parent was across the United States. I did eventually move with this parent, who, although abandoning me for ten years, did attend therapy with me and it was helpful. Not everybody trapped with a toxic parent(s) has the opportunity that I had. Please keep this in mind when you choose to be the decider. I cannot imagine how I ever would have recovered if my resident parent even wished to be part of my recovery. It took me 50 years to really recover, so the struggle was worth it.

      Liked by 1 person

  6. Because the money saved from de-institutionalization was not reinvested into community supports, many people with serious mental illness live with their families. There is simply not enough affordable housing. This number is from 50 to 90 percent (Chan and O’Brien, 2011). The medical community and other health professionals need to factor this in when determining whether the family should be involved in treatment plans.

    A 2014 report about family caregivers from EUFAMI reports that almost half the participants (46%) were not happy with the support they’ve received from medical/healthcare staff and 38% do not believe they are taken seriously. 44% are not satisfied with their ability to influence decisions about the care of their relatives. One third are depressed and 90 percent want help with their responsibilities.

    Regarding Privacy Legislation, Recommendation 14.4 of the MHCC Family Guidelines states “Where a relative chooses not to involve the family caregivers, ensure that the reasons are explored, discussed and documented and that the service providers provide (to the family) basic information required to support the family member…….

    Perhaps lives could be saved if this recommendation were implemented.

    Regarding Discharge Planning, Recommendation 24 of the MHCC Family Guidelines states
    “Establish protocols in hospitals for a clear process of involving family caregivers in discharge and follow-up care plans, including guidance about relapse, crisis prevention, and a recovery plan for both the person with the mental illness and the family caregiver….

    Again lives could be saved if this recommendation were implemented.

    Because families support the majority of seriously mentally ill people (until they finally burn out), it would make sense to seriously consider Recommendation 31 of the MHCC Family Guidelines which states “Invite family caregivers to participate in reviewing mental health services, identifying gaps, and designing plans to address these gaps with policy designers and mental health service administrators.

    Implementing these Guidelines will take a cultural shift within and without the current mental health system. Change happens when all stakeholders are informed of the facts. Unfortunately it takes years to bring about change and in the mean time, preventable tragedies occur.

    Thank you Dr. Dawson for writing a blog that hopefully will trigger a shift in thinking about how psychiatrists and other professionals approach the idea of including the family in treatment. I do know that there are already some thoughtful psychiatrists who do this.

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      1. Sadly there are “dead bodies” already. These are the preventable tragedies which have happened and possibly could have been prevented if these recommendations had been implemented.

        Liked by 1 person

    1. To Kathleen Mochnacki: And that’s exactly why families SHOULD NOT have a legal right to access their Mad family member’s private medical information. If you’ll quit caring for them whenever you want to, and then blame *them* for your choice to leave them in the lurch, you should be BARRED from receiving *any* amount of authority, medical or otherwise, over your Mad family members. And the toxicity of your schizophrenogenic parenting patterns is the answer you should hear, if ever you’re able to muster the audacity to ask your Mad relative’s health care providers why you’ve been put on their no-contact list.

      Liked by 2 people

      1. Thank you Form 22 for your very descriptive reply. It is good that you have brought terms such as ” schizophrenogenic” right into the open. Good for you for being so explicit. You don’t mess around. Keep telling it how it really is. Let’s make these implicit messages that drive the current “anti-oppressive” practice (that actually oppresses the voices of families who do the bulk of the work) more explicit. Let’s get that mysogyny right out there. Mother blaming is alive and well. The average caregiver is female, sixty one years of age and 78 percent are sole care providers. It is not our choice that we care for “them”. That decision was made for us by a system that refuses to provide supportive housing, adequate medical care, adequate pharmacy and spends my tax dollars on “recovery orientated” service that excludes the medical basis for serious mental illness. You have captured succinctly the underlying and unspoken motivations that currently drive an ineffective and impotent system.

        Liked by 1 person

    2. To Ms. Mochnacki,

      Wow. You focused on only 1 word of my comment, misinterpreted that 1 word (I said schizophrenogenic PARENT, not schizophrenogenic MOTHER), and then ignored everything else! Your child went Mad because s/he’d been raised by at least one parent who *may* respond to all of who they are, *if* their words don’t make their mother “work” too hard to accept them. Distorted and selfish! A classic schizophrenogenic parent. Btw, just how long DID it take for you to lock your child up, chemically lobotomize them, or put them out on the curb along with Saturday’s garbage?

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      1. Form 22 sadly the family keeps trying to get help long after those who have a pretty unrealistic agenda have fled the scene. As for “chemical lobotomy” perhaps you were not around before there were no antipsychotics. Had you been able to observe some of those trapped in a serious psychosis prior to 1950, without effective medication, you would plead for something different than your blatant agenda. The medicine is certainly not perfect but it sure helps an awful lot of people.

        Liked by 1 person

      2. Unfortunately, and as I indicated earlier, tax payer dollars have been spent on “mental health advocates” and authors who are very good at selling their books who espouse very similar rhetoric to yours (although way more subtly) while we families are aware of those who are truly ill and do not get the care they need and deserve.

        These “advocates” speak in words that are not as blatant as yours but their family blaming/mother blaming message is still the same. Words such as “schizophrenogenic” are used to hurt people just as other words have historically been used to hurt other marginalized populations.

        But I congratulate you on your honesty, Form 22. It is so refreshing. I would rather deal with an honest bigot any day than those who more subtle and coy in their actions. At least you have the guts to come out and use the “S” word, unlike others who are more cowardly in their righteous protestations about anti-oppression.

        Also, thank you Patricia for your words which helps put things in historical perspective.

        Liked by 1 person

      3. I’m from the U.S. Is the ‘S’ word another no word? The ‘S’ word here indicates crap. I think most labels are ‘S’, even from professionals who hide behind them. I personally do not care for Mad, as that is also a judgment label. Can we get beyond semantics and talk about real behaviors and the effect they have upon us?

        Liked by 1 person

    3. There needs to be a client-centered transition plan from crisis to noncritical living that addresses all phases of living including housing, community health services, food, clothing and community socialization.

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  7. A reading of science writer Jay Ingram’s book (ISBN 978-1-44341-212-4) perfectly titled,”Fatal Flaws: How a Misfolded Protein Baffled Scientists and Changed the Way We Look at the Brain” will enrich all minds on the reality of schizophrenia and related neurological disease.

    I found it equal to Dr. Torrey’s books, with its history of scientific research, to clear away the social myths of SMI.

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  8. Everybody, the powers that be on this blog are starting to censor its Mad commenters. If your comment turns up “missing” after a few hours, DO NOT assume it was due to a malfunction of the wordpress servers!

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    1. I deleted your last post as spam because it contained a considerable number of personal insults directed towards Ms Mochnacki. If you wish to keep posting here, then refrain from the personal insults and identify who you are. What is your name?

      Marvin Ross

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