The Recovery Process: Confidentiality and Families

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

Recovery includes having a good social support system – family members and friends who believe in the patient’s recovery. The health care system fiercely guards the patient’s personal information. How do we as mental health providers best communicate with the patient’s family?

There are differing attitudes about talking with families. In a study by Phyllis Solomon, Ph.D., most providers interpreted confidentiality policies conservatively, and 54 percent were confused about the types of information that are confidential (Psychiatric Serv. 2003;54:1622-8).

The need to ensure that communication is optimal is further demonstrated by the findings of a recently devised instrument called the Confidentiality Issues Test, or CIT. The CIT, as outlined by Tina Marshall, Ph.D., and Dr. Solomon, contains scenarios, descriptions, and questions about confidentiality issues and family members (Am J. Psychiatric Rehab. 2012;15:97-115). The following two questions come from the CIT, and the answer in bold is the correct one.

First Situation

A woman calls you about a patient on your caseload and identifies herself as your patient’s mother. You have no release, but the patient has mentioned that he visits his mother frequently, and you have no reason to believe that the caller is a danger to the patient. The caller says she wants to make sure that her son’s case manager gets certain very important information about his financial and legal situation –information that he often does not mention to staff.

Which answer is correct?

1a. All you can say is that you cannot give out any information about patients without a release, including whether any particular person receives services at your agency.

1b. You are only allowed to take the caller’s name and contact information and tell her that if any information can be released, someone will get back to her.

1c. While stating that you cannot give out any information, you are allowed to ask the caller about the information she is concerned about conveying and say that if it turns out that her son is a patient there, you will make sure the information gets to the right person.

1d. Since the caller is an immediate family member and has important information, you are allowed to confirm that the son is a patient at your agency, but not to release any other information.

Second Situation

A patient has told you (or someone at your agency) that she plans to take an overdose tonight, and has a large number of pills saved up at her apartment. You know that she has a roommate, and you have the roommate’s contact information, but you have no signed release to talk to the roommate.

Which answer is correct?

5a. Even in this situation, you must get a signed release from the patient to be able to call and talk to the roommate about the patient’s safety.

5b. You do not need to have a release to talk to the roommate if there is a question of imminent death or serious injury to the patient, as long as the information you share is restricted to the issue of the consumer’s safety.

5c. Neither of the above choices is correct.

5d. Not sure

Almost 50% of behavioral health providers who completed this test believed that even without revealing any information about a client, they could not listen to a family member or a significant support person without a release from the patient, or were unsure whether they could, according to Dr. Marshall and Dr. Solomon. Staff also indicated that they would attempt to avoid being in a situation where they had to implement a policy that seemed too fraught with difficulties.

Most patients, and especially those with chronic mental illness, need assistance in monitoring and managing symptoms as an important part of recovery. Families are the first to notice symptoms; families bring the patients to the emergency room; and families are most affected by their relative’s disability. Family conflict can arise when the family member does not understand the illness or the symptoms – and does not understand how best to respond to an ill relative. Families want to offer support but need some information about their relative’s illness and treatment. What can you divulge to families?

First, the patient needs to understand the role of the family in managing the illness. When patients understand that their family/friends can be helpful and agree to give the family members ways to be helpful, they usually are willing to have their family members come for a visit. A family consultation clarifies where the boundaries are between the patient, the mental health providers, and the family members. The family member does not need to know "specifics," but does need to know how to respond when difficulties arise so that the family member does not get overly anxious and then does things that are unhelpful.

A conversation with a patient about sharing information with family members might go something like this:

Doctor: "Suzi, if you have a side effect from your medication, what should your husband do? Is the side effect life-threatening, or can you call in the morning to get advice? We have talked about if you have a side effect you call me, and we can discuss it. If your husband gets too worried because your side effect is frightening, then there is conflict about how to manage the symptom. So, if your husband knows what we discuss about side effects, then things at home will be calm. What do you think?"

Patient: "Okay, I understand. That sounds good. The less worried he is, the more he will let me alone."

D: "Are there other situations where you think that if your husband had more information, he might be less anxious and therefore less on your back about things?"

P: "Maybe if he understood my depression more – that I get forgetful or too tired or feeling hopeless ..."

D: "How would it help if he had more information?"

P: "He would not start to talk to me in that angry voice, then get on the phone and complain to his mother."

D: "Do you think he would agree to come in so that we could talk about ways to manage your symptoms?"

P: "Yes, but you have to promise not to talk about other things."

D: "What other things do you not want me to talk to her about?"

P: "I don’t want you telling him that I feel suicidal."

D: "Do you think he knows?"

P: "Yes, but I don’t want him talking about it with me."

D: "Don’t you think he would be more settled if he knew you could successfully use your safety plan? Your plan is for you to do something to distract your thoughts and to counteract the feelings, then to call me or the emergency number if you are needing further help. Remember the plan you have? You have used it a couple of times."

P: "Maybe, yes, perhaps."

D: "Put yourself in his shoes. Wouldn’t you be more comfortable knowing that there is a good safety plan in place?"

P: "I guess so."

D: "Okay, think about it, talk to him, and let’s schedule a meeting. Also, if you want, you can both go to the family support group we have."

P: "Okay, I’ll talk to him."

Staff also can offer nonconfidential information to family members and friends. We make it clear that we are not authorized to acknowledge whether the person is receiving treatment at the agency but can still answer general questions such as those dealing with diagnosis and treatment. We can provide written educational material and information about community resources. We can say that family involvement is important and that with the patient’s agreement, family members and friends can be involved in treatment; and we can listen to whatever they want to tell us.

Here is a quick summary of points to remember when it comes to confidentiality issues:

1. Discuss goals of family involvement with patients.

2. Educate staff about the benefits of involving family.

3. Provide guidance to staff on what to discuss with families and how to talk to families.

4. Ensure that your staff understands what is and what is not confidential information.

5. Remember that you can always listen to what a family member or friend has to say.

6. Keep in mind that serious risk trumps the need for a release of information to family or friends.

Confidentiality is vital. It safeguards patients’ trust and allows patients to work toward their own recovery. There are consent procedures for releasing confidential information, and some agencies have forms specifically designed for families. These forms specify the types of information to be released to a designated family member or significant person, and have a longer time frame of 1 year. These forms allow information to be communicated verbally rather than in writing.

When staff members understand the rationale and goals of involving family and friends, and if they receive training in how to approach patients and their families, willingness will be greater to implement a family-friendly approach to recovery.

Dr. Heru is with the department of psychiatry at the University of Colorado Medical School. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.