Confidentiality and Mental Health

It is timely to publish a collection of British perspectives on confidentiality. Legislators are grappling with issues of privacy, access to medical records and justifiable releases of confidential information. In Australia, new federal and state statutes regulate the collection of, and access to information related to health. In Canada, the ethics of mandated breach are vigorously debated. And in the USA, the terrain beyond Tarasoff has fundamentally altered psychotherapeutic practice.

In the United Kingdom, pressures on confidentiality are felt from, on the one hand, the Human Rights Act 1998; and, on the other, a ‘blame culture’ which retrospectively determines the causes of medical errors and publicises these. A frequent finding is of poor communication between different agencies.

This book arose from a conference on held in Sheffield in 1998. Nevertheless, it seems to have avoided the faults of collections that collate disjointed papers but avoid the words ‘conference proceedings’. The authors cover a number of fields, in particular those of psychotherapy and psychoanalysis. Professions allied to medicine, and legal contributors also contribute chapters, although it would have been interesting to hear more of non-doctors, in particular describing clinical scenarios specific to those disciplines.

The introduction is by Bill Fulford. He identifies the challenges posed to practitioners and to traditional bioethics, and successfully grounds the issue in clinical practice. Fulford argues that the issues are best addressed not by regulation, but by communication; and not by seeking universalisable action-guiding principles, but by learning from casuistry and the values of service users.

The next three chapters address adult services, and specifically suggest a number of realistic vignettes which express problems of confidentiality in psychiatric practice. In forensic psychiatry, community psychiatry and the doctor-patient relationship, the authors explore ways of addressing breach of confidentiality, maintaining a focus on awareness of ethical principles as well as legal consequences.

Child protection and the status of information about children and adolescents are then discussed. These two chapters successfully communicate the complex loyalties invoked by dealing with children and families, and the vulnerability of the patient group.

Following this, four different perspectives are offered, focussing on social work, nursing, situations of dual responsibilities (eg prisons) and the challenges posed to psychoanalysis.

          The two legal contributors provide an interesting overview of contemporary case law, including cases from the European Court of Human Rights. Their reasoned commentaries are succinct and thought provoking.

In the penultimate chapter, the research implications and their regulation are addressed comprehensively. The book finishes with a discussion of the group processes during the conference, drawing parallels between the vexed issues raised by confidentiality, and their exploration by groups of psychiatrists. There is an appendix containing the General Medical Council guidelines on confidentiality.

This is, overall, an excellent collection. The contributors have a wide range of experiences, and succeed in developing arguments rather than merely pointing out the issues. Some positions are quite polemic! The volume is reasonably consistent, although some of the middle chapters are weaker than the initial chapters and legal commentaries.

This book will date, but in the meantime it provides an invaluable resource for understanding the pressures on mental health professionals in an increasingly complex terrain. Dealing simultaneously with increasingly paternalistic laws providing for detention, and with the expectation of ‘partnership’ with service users, is highly challenging. This book doesn’t set out to provide answers, but explores the nature of the tension between confidentiality and breach. It should be mandatory reading for mental health professionals in the UK, and the contributors have solid ideas to offer to an international audience.

© 2002 Danny Sullivan

Confidentiality and Mental Health is also available from Amazon.co.uk.

Danny Sullivan graduated in medicine in Australia in 1994. He has since completed a Masters Degree in Bioethics and a Masters Degree in Medical Law. He is training in psychiatry at the Maudsley Hospital and Institute of Psychiatry in London, UK, and remains an Honorary Research Associate of Monash University.