The Honorable Joseph R. Pitts: As a treating professional, is knowing that you may share information with a family member of that individual if you '"reasonably believe it is necessary ... in order to protect the health, safety, or welfare of such individual or the safety of one or more individuals" likely to help in that individual's treatment and recovery, or hurt their treatment in any way?
Dr. Michael Welner: It will only help. The best of psychiatric treatment echoes best medical practice in that it recognizes supportive family as assets rather than the enemy, even when you are never in touch with them and even when they have their own peculiarities.
Consider that every physician, not just psychiatrists, educates patients about signs and symptoms of their illness, side effects of treatment, and steps to self-efficacy. But what happens when the patient leaves the office? What are the potentials of their support system? In the best of treatment relationships, the patient designates a key member of their support system whom they authorize to contact the doctor and to get details about their condition and treatment plan. Good practice of medicine recognizes that if the support system is trained and sophisticated, the good work you do in the office extends to the home and community. When situations arise, even when the patient needs to reach out to you, they are less panicked and less isolated in their recognition and reaction to a panic attack, a hallucination, a misperception of the environment, a cavernous low after a rejection, a bad impulsive decision, and an unexpected physical change that may or may not be a side effect. I give patients my cell number and tell them they can call me anytime. If their family members are part of that village of medical support, they can call me if their relative has authorized our discussion.
There are those, however, who choose to isolate. Paranoia, family antagonism, intrusive or manipulative relatives, and other insecurities are just some of the reasons patients shut down access to family and caregivers. Indeed someone else who pays for treatment, transportation, food and shelter may feel entitled to access to the physician, but it’s always the patient’s call and is respected and protected. Sadly, that creates a void as soon as the patient leaves the office, and makes any treatment potentially less effective because as soon as the patient leaves the office, any of the above challenges that arise must be handled alone. If the patient calls me, that patient is the sole informant and I may be unable to gauge the accuracy of the history, the completeness of the account and what I might not have been told, and of course, the seriousness of decline, urgency of the situation, or risk. However, treatment can still be very effective and usually is.
With that noted, as soon as serious mental illness becomes particularly acute, and not responsive to medication changes, unpredictability is the norm. Bad outcome may not come, or it may. There is no accounting for the probabilities. And in the case of the family uninformed, there is no one to help out who is educated, trained, and in a position to give help auxiliary to the treatment. Maybe such help proves to be unnecessary, maybe not. The psychotic patient falling apart and person in crisis, who does not allow support system contact, is akin to a ship sailing in the Arctic with no rudder. Maybe one won’t hit an iceberg and will simply drift. Maybe one will.
As a doctor and with current commitment standards of acute dangerousness, you can do nothing more than see the patient more frequently or otherwise, wait for the phone to ring with news that things are more alarming, and hope that nothing irreversible happens first. Usually, nothing does. So one resists any temptation to be heavy handed.
Many vocalized ideas stay that way. If a patient is aware that threats or attacks are likely to be conveyed to family, the patient may be less likely to convey said threats. The mental health professional cultivates a climate in which a person can express suicidal, violent or destructive fantasies freely.
Keeping a patient in treatment enables those ideas to be revisited later, and builds capital with the patient for when disclosure to a family member might be necessary. It is a professional responsibility to explore with the patient the significance and likelihood of acting on those fantasies and actions, and beyond a perfunctory, “Are you thinking of hurting yourself today?” or “You wouldn’t really do that (again), would you?” That happens far too often to admit.
When I do not have permission, the best I can do now is attempt to persuade the patient to give me permission. Allowing harm to the health, welfare and safety of the patient without engaging the family if such contact would protect the patient, and without arguing the case to the patient, hurts the treatment. Such passivity enables personality pathology instead of setting limits and conveys treater indifference when the patient needs just the opposite.
The ability to communicate to caregivers or intimate family during crisis situations is therefore a therapeutic tool in the toolbox. If it is unnecessary, it stays there. When it is needed, it can be relied upon. In some crisis situations, there are solutions that do not warrant communicating with the family. On other occasions, the prospect of communication, if the patient does not welcome it, can be a treatment negotiation that results in the ultimate goal of protecting the parties at risk.
Consider the situation of a husband who speaks of repeatedly beating the stuffing out of his defenseless, dependent, and submissive wife. A person behaving this way is not going to be responsive to “Have you considered how she feels?” That person might better be coaxed with:
“Have you considered what the reaction of your brother (who employs the patient) might be about knowing you have been injuring your wife?”
“No. He might fire me, or tell my wife’s family.”
“Why is that?”
“Because he’s like that, and he likes them.”
“Isn’t that reason enough not to keep doing this?”
“She doesn’t like to go out, and she doesn’t like to talk to them much lately.”
“So? What difference does that make?”
“She’s not going to tell them, and no one’s going to see her.”
“So? Why does that matter?”
“He’s not going to find out.”
“But what would be his reaction..”
“Who cares? He’s not going to find out”
“Are you aware that as a physician, I have responsibilities to ensure your safety in treatment and to keep you safe from any consequences of your behavior?”
“Yeah, yeah.”
“What does that mean to you?”
“I can handle myself, but thank you. I’m not suicidal.”
“What about your wife?”
“Oh, she’s not about to go out and get a gun.”
“How do you know that?”
“You’re kidding me, right?”
“Well, the situation at home has to be getting worse for her, no?”
“She wouldn’t dare. No way.”
“Don’t you think you might go too far at some point?”
“I probably already did when I broke her nose in May.”
“And now you’re telling me about clumps of hair on the floor?”
“Whatever. I don’t like you going on about that. That’s not helpful.”
“Well I am your psychiatrist, and I am telling you this is not going to end well. And you are here in treatment so you know you have issues.”
“OK doc, so fix me.”
“I’m trying, but I have not yet been able to get you to hit a pillow instead of your wife’s face, have I?”
“Maybe I need a better doctor.”
“Maybe you need to stop beating the hell out of your wife.”
“Oh, please. Yeah, maybe. And maybe not, but when I do it, it just happens. What can I say?”
“Which is why I asked, if I was your brother, and we were having this discussion, would you say the same thing to him?”
“Come on.”
“And what would he say to you?”
“I don’t know, but I can’t have him fire me. I need the job. And my wife knows that, too.”
“Would he try to keep you from being violent?
“Probably. I don’t know what he sees in that family.”
“Wouldn’t you be glad you talked to him about this before something happens that you can’t hide away?”
“Yeah, well, nothing’s going to happen. Come on, Doc.”
“Well something keeps happening, and it’s my judgment that you are creating a risk for an irreversible situation. That’s my call, and if your wife were here, she might agree.”
“Look, I don’t really want this to happen, and I’m sorry it keeps happening”
“OK, so how are you going to keep this from happening?”
“No divorce. I will not lose the kids.”
“That does not answer my question.”
“So maybe you should refer me to someone else.”
“Maybe. But that does not change my responsibility to prevent an irreversible risk.”
“Oh well, I’m sorry if I cause you stress.”
“You are putting me in a situation where I have to keep the home safe.”
“What?! Seriously?”
“You won’t stop and you can’t stop. You won’t stop with another doctor and we both know that. So what do you suggest?”
“I don’t know what to tell you.”
“I suggest someone who is on your side. And your brother is all you got.”
“You want me to go to him?”
“Is that a bad idea?”
“Awww. I’m not gonna do this, and you’re not going make me. This is ridiculous.”
“Well, do you have someone else in mind?”
“I’m here. I’m talking plenty. That ought to be enough, and if it’s not, tough.”
“Well, if there’s no one else, and you can’t do it, why don’t we do it together?”
“Are you serious? Are you serious? Are you serious?”
“As serious as a trip to the emergency room with a busted nose.”
“Ohhhhh myyy God! I said I was sorry!”
“And you need to be serious because you’ve got me totally on your side, and you need to respect that by getting serious about how we’re going to keep this from continuing.”
“You have a better plan to shut the violence down now that does not involve you avoiding me, fine. What plan is that?
“No, but you are upsetting me with this”
“OK, so do we call your brother together, do I call him alone, or do you have another plan for us to discuss in the twenty minutes remaining of our time together?”
“Oh, hello Phil, and did I tell you I am seeing a shrink? Yeah, sure!”
“Look, what you are doing is going to get you arrested with a violent crime charge or will cause someone in your wife’s family to eventually get violent with you in a way you never saw coming. So let’s make a plan to get your closest supports to help you avoid making these kinds of choices or to better employ strategies to keep you sober, fine? Is there anyone better situated than Phil?”
“Let me think about it.”
“Alright, I’ll just sit and wait while you do.”
What treatment benefit is to be gained from sitting idly by as these behaviors continue, without using the treatment alliance to forge a safer home before it is too late? Modifying HIPAA to enhance the protection of others as above, and in a collaboration as per above, is a valuable tool for risk management when the provider has discretion and acts judiciously using day to day skills and the frequency of the given treatment alliance.
Let’s consider whether the above patient was suicidal, and the son of Pat Milam, who testified a year ago before the Energy and Commerce Committee. None of those advocates who would now shut Pat Milam out from vital information that could keep his son safe know or concern themselves with a son who is never coming back.
This reminds one that a psychiatry “survivor” is in fact a person who survives the morbidity of its illness, as in a cancer “survivor.” Those who argue “survivor” refers to psychiatry itself bring one’s own unresolved personal anger and denial to a Subcommittee pledged to deal with serious mental illness, and mental health crisis. Let us be reminded that Matt Milam is not a psychiatry survivor, because he killed himself within his serious mental illness. My professional experience tells me that Pat Milam’s son would rather be alive today and be a survivor, too.
Semantic arguments about what are “erosion of privacy laws” and the “disrupted doctor-patient relationship” are devoid of any appreciation for how the treatment alliance is an alliance as much as any relationship has its disagreements that are worked through. Privacy laws are not the omerta of organized crime; they are meant to respect the dignity of those who are able to respect their own safety and that of others. And then what, when one can’t?
