Points of disagreement
Reprinted from the "Families" issue of Visions Journal, 2013, 8 (3), pp. 12-13
There is increasing recognition in Canadian mental health settings that family members are an important stakeholder group. The Mental Health Commission of Canada concludes that, “The role of families in promoting well-being and providing care [should be] recognized, and their needs supported.”1
However, a large body of evidence, accumulated through surveys, family accounts and the experience of administrators such as myself suggests that the family–practitioner relationship has, in many cases, been a strained one. Families haven’t always been given the support they need.
Three sources of tension in the family–practitioner relationship will be discussed in more detail: blaming families, information sharing and disagreements about the model of care. The reader is warned in advance that there are no easy answers here. There is, however, an obligation to try to appreciate the perspective of the other.
There is a legacy of psychiatric theories that implicitly or explicitly blame family members—the mother in particular—for contributing to the son or daughter’s mental disorder. While these ideas have been largely abandoned, research on communication styles continues: for example, the concept of expressed emotion predicts that in social settings and families where there is “emotional over-involvement” and excessive negative comments, people with schizophrenia are more likely to relapse.2 This, according to one author and advocate, is a perspective that “continues to blame families.”3
There are also particular schools of therapy that have been seen as having the potential to blame families. In her memoir,4 Vancouver writer and parent Susan Inman describes involvement with a counselling psychologist whose orientation was to see mental disorder in familial, rather than medical terms. After Inman’s daughter was finally hospitalized, the counsellor advised staff at the inpatient unit that the family was “dysfunctional” and “shouldn’t be around [the daughter] too much.” Later on, Inman was chastised by staff for “not encouraging [the daughter’s] independence”—this in the case of a 15-year-old girl certified to a psychiatric ward.
Parents naturally feel a sense of responsibility, and sometimes guilt, about their child, and if the child is disabled these feelings can be even stronger. Practitioners need to be mindful of this vulnerability, and the damaging effect of judgmental comments.
It’s important to understand that psychiatric treatment in English-speaking countries focuses on the individual. The person with the mental illness is considered the patient, not the family.
Further, what goes on between doctor and patient cannot be shared with the family on ethical and legal grounds. But, is this an accurate interpretation of the law?
Knowledge of the law is important, because the law permits a greater degree of information sharing than some clinicians believe to be the case.
In BC, information sharing with third parties is governed by the Freedom of Information and Protection of Privacy Act (FIPPA).5 This statute permits disclosure when the client consents. It also permits disclosure without consent in two situations: 1) to support continuity of care, or 2) when there are “compelling health and safety circumstances.”
Continuity of care applies between health care providers, such as when a hospital shares records with a family doctor concerning tests undergone by a patient, or when records are transferred between mental health teams. But what about family members of an adult mentally ill person?
The 2005 Guide to the Mental Health Act6 states that if the practitioner “believes it is in the best interests of the client to disclose personal information to the family so they can provide care to the client, the health care provider may do so,” adding that “only necessary information” should be released. Thus, sharing information without consent may fall under continuity of care if the family can be considered care providers. This becomes a weaker argument, however, when there is little contact between the family and client.
Concerning the “health and safety” provision, FIPPA doesn’t provide specific guidelines as to when this would be used as an exception to confidentiality. It would be reasonable to assume that concerns about self-harm and harm to others could be shared with family members involved with the client.7
Ultimately, a decision about breaching confidentiality is more of an ethical one than a legal one. Worried family members may feel “shut out” by practitioners, but there is also the reality that long-term recovery hinges on trust between practitioner and client. Breaching confidentiality can seriously damage that trust.
Models of care
The model of care used by the clinician can be an area of tension for the family. To understand this, readers should be aware that public mental health services in Canada have been shifting their orientation away from what has been called a “medical model.” This model is one where the patient is the passive recipient of psychiatric expertise. The focus is more on symptom remission than on functional recovery, so activities such as employment or schooling may be seen as stressors to be avoided.
Now, health authorities are shifting toward a recovery vision, where self-management and appropriate risk-taking are promoted. Risk-taking, for instance, could take the form of facilitating a client’s employment goals through job-finding initiatives, while reducing their medication dosage to support concentration on the job.
Family members may worry about risk-taking. In a family focus group I facilitate, one of the participants described her unending anxiety concerning her daughter: “There’s a constant feeling of vigilance, especially when the illness is more active—a feeling that if you let your guard down when they are ill, they’ll commit suicide.”
This mother’s fear is supported by data showing that seriously mentally ill people are, indeed, at higher risk for suicide, as well as financial and sexual exploitation, self-neglect and premature death from medical conditions.8 So, family members such as this mother may want clinicians to err on the side of caution—for example, by hospitalizing an ill relative sooner rather than later.
To minimize family–practitioner tensions, practitioners need to be as transparent as possible. They need to explain to clients, family members and other staff why they are using the approach they are using.
Ensuring client safety is paramount in importance, but it is not the only consideration when providing services. Crises must be managed when clients are in the acute phase of their illness, but at other times, recovery work—developing the skills to better self-manage a long-term illness—should be explored.
About the authorSimon is a Manager in Mental Health and Addictions for Vancouver Coastal Health. He also teaches online mental health courses at UBC, Douglas College and the University of the Fraser Valley. The second edition of his text, Community Mental Health in Canada, will be published this year by UBC Press
- Mental Health Commission of Canada. (2009). Toward recovery and well-being: A framework for a mental health strategy for Canada. www.mentalhealthcommission.ca/English/document/241/toward-recovery-and-well-being.
- Raune, D., Kuipers, E. & Bebbington, P. (2004). Expressed emotion at first-episode psychosis: Investigating a carer appraisal model. British Journal of Psychiatry 184, 321-326.
- Solomon, P. (2001). The cultural context of interventions for family members with a seriously mentally ill relative. New Directions for Mental Health Services, 91, 67-78.
- Inman, S. (2010). After her brain broke: Helping my daughter regain her sanity. Dundas, ON: Bridgeross Communications.
- Freedom of Information and Protection of Privacy Act [RSBC 1996] CHAPTER 165. www.bclaws.ca/EPLibraries/bclaws_new/document/ID/freeside/96165_00. Note: The actual wording in FIPPA for this exception to client confidentiality is: “If the purpose for the release is consistent with the purpose for which it has been collected.”
- British Columbia Ministry of Health. (2005). Guide to the Mental Health Act. Victoria, BC: Author. www.health.gov.bc.ca/library/publications/year/2005/MentalHealthGuide.pdf.
- For a discussion about legal guidelines in “duty to warn” situations, see Smith v. Jones  1 S.C.R 455, as described in Tremayne-Lloyd, T. (2001). Right to confidentiality versus duty to disclose: If you can’t tell your lawyer or doctor, who can you tell? Canadian Family Physician, 47, 495-496. www.cfp.ca/content/47/3/495.full.pdf.
- Davis, S. (2013). Community mental health in Canada (2nd ed.). Vancouver, BC: UBC Press.