Confidentiality is a frequent issue in clinical practice; should or shouldn’t a clinician involve significant others, especially family, in an identified patient’s psychiatric care? And, assuming the answer is yes, to what extent does the treater solicit information from or disclose information to the family?
When Bob Dylan said, “The times, they are changing,” he could well have been referring to psychiatric treatment. From the 1930’s through the 1980’s psychoanalysis was the Cadillac of psychiatric treatment. Information an analyst received outside treatment—four or five days per week of 45-50 minute sessions with the patient free associating on the couch— was perceived as a germ contaminating the psychoanalytic operatory. Before 1987, the word neurosis preceded anxiety, depression, and obsessive compulsion in DSM, the standard manual of psychiatric diagnosis. In Freudian terms, neurosis—aka the neurotic process—is how unresolved unconscious conflict results in psychiatric symptoms. Even though neurosis’s validity as a concept could not be verified by independent observers, neurosis remained the cornerstone of psychoanalytic theory and treatment for anxiety and mood disorders.
After 1987, however, neurosis was eliminated from the DSM and diagnoses became purely descriptive, giving clinicians of varying orientations objective criteria on which to base their assessments. Although at the time many felt that the death of neurosis meant psychiatry had abandoned the unconscious mind, that wasn’t the case at all. Rather, biological psychiatry had entered its adolescence. Evidence was accruing that medication effecting brain chemicals known as neurotransmitters ameliorated symptoms, so psychiatrists could offer relief to patients whose anxiety attacks, depression, and obsessions and compulsions didn’t respond to psychoanalytic therapy. Also, after ravaging the population unchecked for most of the twentieth century, psychiatrists could offer medicines to sufferers of schizophrenia and bipolar disorder, common conditions that psychoanalysis never claimed it could reach.
Granted it was in the best interest of pharmaceutical manufacturers to have established criteria by which to include and exclude patents from clinical trial s of new medications, but the irony is that over the succeeding generation, DSM criteria have been used to verify effectiveness of psychotherapies other than psychoanalysis, most notably Cognitive Behavior Therapy (CBT) either alone or in combination with psychiatric medications for many psychiatric conditions
In trying to establish patients’ diagnoses, psychiatrists came to recognize that patients’ subjective report of their symptoms didn’t always tell the whole story. As the psychoanalytic model of treatment faded, family input came to be viewed as helpful, in some situations essential. For example, at intake many bipolar patients presenting with depression downplay or fail to report manic and hypomanic episodes. Many depressed patients are too symptomatic or afflicted with global negative thinking to give an unbiased history; not to mention adolescents and young adults who are urged to seek psychiatric help who arrive saying, “I’m not sure why I’m here,” or, “I’m here because of my parents want me to.” To devise an effective treatment plan, the psychiatrist needs all the help he can get.
In practice, most patients are supported by family or friends, eager to share their perspective on the history and severity of the index patient’s symptoms. Assuming a new patient has no objection, I invite him or her to bring a family member to one of the initial sessions. Naturally, if the patient objects I respect their wishes, although I keep in mind that conflicted family relationship are important to explore.
As treatment proceeds, I never reveal details of the index patient’s sessions unless there is a very compelling reason. For example, one impulse-ridden teenager said she was going to participate in statutory rape, so the family had to be informed. A manic individual impulsively liquidated his IRA to fund a highly-speculative investment in precious metal derivatives. A recovering bipolar disordered substance abuser relapsed on intravenous heroin and was in denial about the seriousness of the risk.
Assuming there are caring and concerned others—which there usually are—and the patient agrees to have their family involved in their care—which families usually welcome enthusiastically—I propose an open model of communication at the outset of treatment, when the ground rules for therapy are established. Significant others are invited to share their observations about the patient’s behavior and progress, or lack thereof, with the caveat that I will share those observations with the patient. It helps immeasurably to know if a patient is misrepresenting the seriousness of his symptoms; or abusing substances; or in an unhealthy relationship.
At the same time, I assure the index patient that under no circumstances will confidences be shared unless someone’s health or well-being is imminently threatened. I never agree to be coopted into collusion when a family member calls saying, “Don’t tell Jack of Jill that I called.” That would undermine trust and the therapeutic alliance.
Rather than feel undermined or mistrusted, open communication usually contributes to successful outcomes by providing information critical to diagnosis and treatment. Of course, every therapy is unique and patients need to know their boundaries are respected, so it is up to the therapist to assess what he hears from family and determine when it is appropriate to recommend that a family member pursue psychiatric care for himself.
For the broad majority, operating like this makes patients feel cared about, and reinforces for families that their contribution is essential to their loved one’s recovery.
Family at therapy session photo available from Shutterstock