Family input should not be mandatory in treating mental illness
Information can be disclosed without patient’s consent if risk is judged sufficient
The college strongly supports family education and involvement in a patient’s care where both parties are happy with that involvement
The recent verdict in the case of Deirdre Morley has thrown a spotlight on the care of people with severe mental illness, and the role that families can and should play in their treatment. Morley was found not guilty by reason of insanity of murdering her three children. Her husband, Andrew McGinley, has argued that the deaths of the couple’s children may have been avoided had he been more centrally involved in his wife’s treatment.
Moreover, Una Butler – whose children were killed by her husband in a murder-suicide in 2010 – has said it should be mandatory for a partner or spouse to be involved in the treatment of a family member suffering with mental-health issues if children are involved.
These cases are tragic in the extreme and my heart goes out to Andrew and to Una and to their wider families for the distress and pain they are suffering. I am conscious that even in writing about this issue I risk causing them further hurt and I most certainly do not wish to do that. However, they have raised a serious point which demands careful consideration. I should stress that I make these comments without any knowledge or reference to their individual situations.
It is very clearly the view of the majority of members of the College of Psychiatrists that, while family involvement in the treatment of a loved one for mental illness should always be encouraged, it should not be made mandatory in law.
There are two reasons for this.
First, while many families are supportive and helpful, others are not. Domestic violence and abuse are enormous problems in some family homes. If certain patients decline to involve their families, despite encouragement to do so, it is vital that they are given time and space to explore their reasons. Revealing violence or abuse can help some people to address their mental illness and build their recovery on their own terms. Forcing family involvement in such cases could be harmful.
Second, confidentiality is the cornerstone of all medically delivered healthcare and healthcare generally. It can be challenging for people to decide to engage with mental-health services and it is often very important for them that their privacy is maintained.
If family involvement was mandatory, it might deter some people who need support from seeking it out. Even where a family is supportive and helpful, the fact that others would know about their attendance at a mental-health service could be the reason for some people deciding not to access the help that they need.
That does not mean for a moment that families have no role to play. Indeed, the college strongly supports family education and involvement in a patient’s care where both parties are happy with that involvement.
It is also important to state that the principle of medical treatment being confidential is not absolute. In this, psychiatrists, like all other doctors, are guided by the long-established customs and practices of the wider medical profession and guidance from the Medical Council which states that “disclosure without consent” can occur in certain circumstances, including “disclosure in the public interest”.
Such disclosure, the council says, “may be made to protect the patient, other identifiable people, or the community more widely”. It cautions doctors: “Before making a disclosure in the public interest, you must satisfy yourself that the possible harm the disclosure may cause the patient is outweighed by the benefits that are likely to arise for the patient or for others. You should disclose the information to an appropriate person or authority, and include only the information needed to meet the purpose.”
It is entirely understandable that when terrible tragedies happen, people want to do whatever they can to prevent a similar event ever happening again. They would move mountains in order to reduce, even slightly, the chance that another family would go through the same horror which they have experienced. But the hard truth is that measures to entirely eliminate risk aren’t possible, and even if family involvement in mental-health care were legally mandated, that would not necessarily prevent tragedies from happening in the future.
So what can we do? Psychiatrists can encourage family involvement. If a patient requests that no information is given to their family, they can be prompted to review that decision from time to time. Similar, if families refuse to be involved, they, too, can be encouraged to reconsider their position over time. Situations evolve and people change their views.
If the patient continues to oppose family involvement in their care, professionals can often still listen to families, who commonly have essential information that they wish to share. Furthermore, if the professional feels that the risk is sufficient, they can disclose certain information without the patient’s consent, although it is ultimately impossible to predict harm to self or others with any degree of accuracy in an individual case.
It is a delicate balance, yet it is one which we must get right to minimise the risk of tragic outcomes.
Dr William Flannery is president of the College of Psychiatrists of Ireland and a consultant psychiatrist