Confidentiality and the Family: 5 Guidelines for Better Outcomes

Families are an underutilized resource in psychiatric practice. Given the current practice of brief hospitalizations, families are expected to provide more illness monitoring and in-home care. When family members are included and welcomed as members of the treatment team, patient care improves and the psychiatrist’s job is easier. Reaching out to the families of patients can help psychiatrists generate clearer diagnostic formulations, develop more effective treatment, and plan for emergencies.

What should psychiatrists do when patients don’t give permission to contact their families?

Many psychiatrists erroneously believe that the sharing of information with others, without the patient’s explicit consent, is prohibited by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA violations may have serious consequences, so it is important to have a clear understanding of what the HIPAA 45 CFR 164.510(b) rule entails as well as its intended use.¹ The following information is extracted from the website of the US Department of Health and Human Services and provides guidance for health care providers. Here are some guidelines:

(1) Health care information may be shared with relevant individuals present when the patient has given prior approval, or simply does not object¹

(2) Asking a friend to be in the interview room provides the implicit right to disclose information in their presence

(3) Clinicians also have the authority within the Privacy Act to share information based on their professional judgment, believing that there would be no objection to its discussion. For example, a clinician may share information about medication with those providing transportation from the hospital

(4) If the patient is not present but has requested an individual to gather information for him or her, or is incapacitated by an emergency, a physician may once again use best judgment in sharing information. This may include a proxy picking up of medications from the pharmacy or receiving other protected information

(5) Physicians should be aware of state laws within their region of practice that may affect the use of the Privacy Act within scenarios of emergency or safety concern

Using these guidelines, family members (or friends) who accompany the patient can be invited into the interview and the benefits of their inclusion explained. Most evidence-based family interventions are psychoeducational, where illness symptoms and treatments are explained and feelings and beliefs about the illness are explored. When patients understand the goal of family intervention is psychoeducational, they are more likely to agree.

Family involvement is often misunderstood as being a hindrance to individuation, when in fact family-oriented interventions can improve patient functioning, agency, and autonomy. This is often the case when young adults are forced, because of illness, to return home to live with their parents. The use of shared decision-making may help the patients frame their long-term goals in line with the goals of the family.²

Psychiatrists can help the patient prepare for the family meeting. With a clear agenda, the patient will be less anxious and be more accepting of family members working with them. Psychiatrists can proceed, using one of the most underutilized evidence-based interventions in psychiatry-family psychoeducation.

References1. US Department of Health and Human Services. Does the HIPAA Privacy Rule permit a doctor to discuss a patient’s health status, treatment, or payment arrangements with the patient’s family and friends? http://www.hhs.gov/hipaafaq/notice/488.html. Accessed April 8, 2013.
2. Swindell JS, McGuire AL, Halpern SD. Beneficent persuasion: pechniques and ethical guidelines to improve patients’ decisions. Ann Fam Med. 2010;8:260–264.