The status and rights of young people in relation to health care are often topics for public debate. In mental health care, where risks may be high, the debate can be particularly intense. In this context, models of mental health care that acknowledge the special vulnerability of young people and advocate proactive and protective services contrast with those that emphasize young people’s rights and agency and that promote their capacity to choose how and whether they will utilize professional support. The views and interests of caregivers and patients may be polarized in line with these two different models. Physicians need to demonstrate competency in communication with both groups (1).
There is increasing evidence concerning high levels of mental health needs among children and young people in the United Kingdom (2–5). Self-harm is reported to be widespread among young people in school (6), and suicide rates continue to be disproportionately high among young men despite progress toward the government targets of substantial reductions in rates in England and Wales (7). In this context, families and professionals will be aware of the risks posed by young people in distress.
Professionals working with young people in distress have to negotiate a path between the two models of care described above and against a background of heightened awareness of risk. Professional education provides an opportunity for trainee practitioners to familiarize themselves with these models and to apply them to practice. Such skills are relevant for both psychiatrists and family physicians, who are usually the first port of call when mental health problems emerge and, in the United Kingdom, play a key role in acting as gatekeepers to specialist mental health services. Most mental health care in the United Kingdom continues to be delivered at the level of primary care by family physicians, or General Practitioners, as they are also known. However, some question how sensitive primary health services are to young people’s health needs (8, 9).
The research reported here originated in an earlier study (10) that involved interviews with 46 parents of young people who had taken their own lives. This study identified confidentiality as a key barrier to effective communication between parents and professionals caring for their son or daughter. Parents spoke of being excluded from discussion and decisions about their child’s needs and treatment and described professionals as failing to acknowledge their expertise as caregivers. The current study aimed to explore the negotiations and decisions practitioners make when working in more depth with both parents and young people in distress. A range of approaches and attitudes in relation to both confidentiality and the practitioner’s levels of proactive engagement with both parents and the young people in distress was identified. These, we suggest, offer useful material for the education and training of doctors and psychiatrists.
The study was undertaken in partnership with PAPYRUS, a voluntary organization working to prevent young suicide in the United Kingdom, which had contributed to the earlier study described above. A volunteer sample of 30 family physicians from urban, suburban, and rural locations in England were interviewed. Academic-based medical teachers who had contacts with a range of primary care physicians recruited participants to the study. This was therefore not a randomly selected sample but, rather, a group of interested practitioners whose participation in the study may have been prompted by their interest in and sympathy with the subject matter. It is likely that the practice they described represented examples of informed or good practice in their sector rather than the full range of work undertaken with this patient group.
More than half the group (18 of 30) were over 40 years old, suggesting that this was a fairly experienced group of clinicians. The slightly higher number of women (16 of 30) reflects the increasing numbers of women in primary care in England and Wales. The group as a whole had an average of just over 10 years of experience as a family physician. Two of the clinicians were South Asian in origin; the rest of the group defined themselves as white European.
Telephone interviews were undertaken using a semistructured interview schedule that elicited accounts of how the respondents would work with the protagonists of a scenario they had received beforehand. The scenario, which is reproduced in Appendix 1, describes Ben, a 20-year-old student, as underweight, reclusive, and uncommunicative. In the first stage of the scenario, his mother communicates her concerns about Ben to the family physician. The second stage of the scenario depicts Ben attending a consultation with the family physician and disclosing previous suicidal thoughts and treatment with antidepressants.
The interviews were recorded with the participants’ permission; ethical approval for the study was given by the NHS Research Ethics Committee. Data were coded and analyzed by emerging themes using standard approaches to the analysis of qualitative data (11).
The family physicians participating in the study were clear about the need to protect a young person’s right to confidentiality and argued that confidentiality facilitates the development of trust between doctor and patient. One said, “The benefits of providing the confidential service are far greater than the problems that they cause because it encourages young people to access you.”
They identified a range of approaches in managing the conflict that could arise when parents, such as the mother featured in the case study, are anxious and seeking reassurance and intervention. One family physician described a “slight bending of the rules” in such circumstances; another saw the rules being “slightly more blurred” for a young person, particularly if still a child (a 15-year-old, for example). Although all were very clear concerning their duty to breach confidentiality in situations of high risk (such as when child abuse is an issue), they noted that in practice this could be contentious and difficult. One observed, “It is very thorny and you often end up on the wrong side of the parent because they perceive you as not helping them.”
A number of different approaches to handling this situation were outlined by the family physicians interviewed. Some suggested explaining the rules of confidentiality to parents and explicating the benefits of confidentiality, as this doctor illustrated: “The consultation is confidential. …She will probably say something like ‘But I’m his mother and I need to know.’ And my answer to that is, ‘Yes, but you would not be too pleased if I discussed your personal problems, if you were in difficulties, with your son.’”
The harsh message of confidentiality conveyed to parents could be balanced by reassurances. One outlined the content of a possible response to a worried parent: “I am very sorry; I appreciate your situation, that you are worried about him. You must be reassured that I will do everything that I can do, that he will allow me to do, to get him better, but I cannot discuss what that is. I cannot even tell you that he has been to see me.”
Focusing on general issues offered another way of communicating with parents without breaching confidentiality, as another doctor indicated: “I can hear what (his mother) is saying and I can make notes on his record about what she said, so that if I do see him then I’ve got an aide memoire from what his mum’s said, but then I cannot say anything specific about him at all. I can just talk in general, for example, about depression, changes in life like going away to university, all those things, but nothing specific about (him). And certainly nothing from his past history that she may or may not know.”
Some family physicians advocated the approach recommended in U.K. professional guidance (12, 13), which encourages medical practitioners to seek the patient’s permission to share information with others. One outlined this possible approach to a young person: “‘Would you mind if I discussed (things) with your parents? If your mother phoned me, you know, do you want me to talk to her?’ And if he says no, I’m categorically not to discuss with her.”
Acting as an intermediary in this way, some of the family physicians felt able to maintain communication with both parents and the young person. One explained how he or she would provide parents with feedback, such as, “He … specifically said that he did not want to be discussed with his parents, but … I would be very keen to pursue looking after him, to maintain some continuity of care.”
Engaging With the Young Person
Considerable variation was also found in the extent to which these family doctors were prepared to work proactively to engage with a young person. In relation to the first stage of the case study, a range of responses to the concerns raised by Ben’s mother was found. These included a noninterventionist approach, as one family physician explained:
“Ben at 20 is grown up, so we cannot drag—we cannot even at a younger age—we cannot drag him in. I would just have to encourage Mrs. Smith to try and get him to come in. I do not feel that there is anything. I cannot go round or I cannot phone Ben up and say ‘You know, your mum thinks there’s something wrong with you, will you come in and see me?’ I think that would have to come from him. Which is very difficult sometimes.”
A semi-interventionist approach, which involved writing to or telephoning Ben, was outlined by other family physicians, as one illustrated: “I guess it is possible to try and ring him at home and say, ‘You know, your parents have come to see me and they’re very concerned about you and have asked me to talk to you,’ and try a direct approach.”
The more interventionist responses included the possibility of a home visit. This was seen as possible, without Ben’s agreement, if there were suggestions that he was actively presenting a risk to himself (suicide) or to others (violence or psychosis). In the absence of such features, Ben’s agreement would be required to make a home visit, as this family physician noted: “If Ben would not come to the surgery, but would accept a home visit, then I’d come and visit him at home if that is what he wanted, but I could not just turn up and say I’d come because his mother wanted me to.”
A small minority of family physicians said they would be willing to make a home visit without agreement from Ben, as one illustrated: “I would be prepared to make a visit to him on a one-off, without his consent, you know.”
Only one of the family physicians was totally interventionist and would urge Ben’s parents to “bring him” to the surgery: “(I) would probably tell her to book him an appointment and bring him, to put him in the car and bring him. To be a little bit pushy on it with him.”
Some of the family physicians proposed sidestepping the issue of their own level of engagement by suggesting that Ben might be prepared to talk with other people, rather than the family doctor, and suggested voluntary or community-based organizations or a nurse as being less threatening and less stigmatizing.
When the issue of treatment for Ben was considered, a number of the family physicians identified referral to a counseling service as the favored route. These included National Health Service (NHS) or local government services, voluntary organizations, and services specifically targeted for young people. However, a small group of family physicians envisioned taking on a substantial role themselves in assessment and treatment. For some this appeared to be a consequence of service shortfalls or lengthy waiting lists in their locality, as one indicated: “I’d try to see them myself frequently and make a relationship. I’d try to offer treatment; I’d try to find appropriate management. Somebody I saw a couple of years ago who I really had quite a lot of worry over, eventually I managed to get her some cognitive analytical therapy, which is not particularly easy to get in our area.”
Some considered providing an ongoing series of sessions that would be relatively informal, as this doctor proposed: “I would want to probably spend a number of sessions talking to Ben and trying to get to know him and reduce his resentment of me interfering.”
Others, however, saw themselves delivering a form of psychotherapeutic treatment, as this family physician outlined: “I might be keen to at least start some sort of therapeutic intervention myself; I mean, we would be talking about 4 to 6 months.”
The family physicians expressed considerable sympathy for the parents in Ben’s situation and others like them. They spoke of the need to reassure parents and to direct them to sources of help. As noted above, reassurance was seen as the counterpoint to protecting a young person’s confidentiality: “You can reassure her that you did see him… . You can be reassuring without actually divulging what went on in the consultation.”
Family physicians also noted parents’ own needs for support in a situation where they were supporting a young person in distress. Some advocated keeping communication open with the family, so that parents could “continue to come to discuss concerns with me.” Others felt that it might be helpful for the parent(s) to see another person in the primary care practice; for example: “If the family, if the mother, sort of became depressed or very anxious, I would encourage them to see one of my colleagues.”
Other family members or local networks or agencies were also identified as a means of offering parents support.
Using Consultation and Support
The family physicians frequently commented on the difficulty they experienced in balancing the needs of parents and their children, and they emphasized the complexity of the decisions they were making. In the face of these difficulties, a number of them spoke of the need for consultation with colleagues.
Since they were general family physicians, discussing the case with a mental health specialist was another useful option identified: “I would want to talk with one of the clinic’s psychiatrists, really, because it is most important; also, it is most important to maintain the young person’s trust and it is in the middle of the spectrum, which is a bit murky.”
Concerns about liability were also evident in suggestions that the Medical Defence Union might be able to offer relevant advice, as one family physician outlined: “If we were not sure, we would talk to our colleagues, and we would also possibly on occasions talk to the Medical Defence Union, who are wise men who help us with medical legal insurance and things.”
Adolescent depression is underrecognized in primary care, although many young people consult their family physicians (14). General practitioners spend less time in consultation with adolescents than with other patients, and many feel that adolescents are hard to communicate with and fear overmedicating them (15). The uncertain status of many young people, who may be adults legally but who remain financially and emotionally dependent on their parents, is also an issue that can evoke conflicting responses among practitioners. However, specific educational interventions for family physicians can have sustained beneficial effects on the quality of consultations (16). Eliciting colleagues’ views was considered valuable by study participants, and child psychiatrists have been used to teach family physicians specific strategies for work with young people, such as enabling adolescents to mobilize help for themselves by identifying a confidant, using activity scheduling, and self-reinforcement (15). Other approaches have involved encouraging family physicians to stress the likely resolution of symptoms and to invite depressed young people back for follow-up appointments (17).
In this study, the family physicians’ approaches to both managing dilemmas of confidentiality and deciding on levels of engagement with a young person like Ben covered a wide spectrum. Some practitioners were more prepared than others to find ways of protecting a young person’s confidentiality while reassuring his parents. Some were more willing to be proactive in seeking to engage Ben in treatment, despite his signaled reluctance to receive help. Likewise, a number seemed prepared to provide support to Ben’s parents. Some chose to take on these roles themselves; others were more inclined to utilize other community or family resources. These findings illustrate the degree of discretion available to family physicians and highlight the potential for variations in care and in referral practices to their colleagues in secondary care.
Our respondents had opted in to the study and were likely to be practitioners with an interest in young people’s mental health whose practice in this area was well developed. In a wider sample of family physicians, the range of practice and attitudes is likely to be greater. Caregivers may find such differences confusing and, like the parents participating in the earlier study, some will feel excluded and devalued by professionals who operate at the lower end of the caregiver participation spectrum. Jones’ (18) study of U.K. family caregivers’ experiences of supporting relatives with mental health problems revealed that most received very little information from psychiatrists or other professionals. A recent study (19) of caregivers and people using mental health services in the U.K. found that only 12% of service users were routinely asked by professionals to consent to sharing information with others. Similarly, only 1 in 4 caregivers in the same study were told that “confidentiality” was the reason information was not being shared with them and were provided an explanation of what this meant.
In the U.K., professionals’ attitudes to parents of young people with mental health needs may still be shaped by some of the suspicion and hostility associated with work on family dysfunction (20) and with interpretations of early work (21) on expressed emotion in families. Although more recent approaches (22) emphasize the role of the family as a therapeutic partner, some of these early attitudes linger and may be reinforced by higher levels of recognition of abuse in families.
Training needs to provide practitioners with opportunities to examine their own attitudes in relation to these ideas. The vignette and the examples of practice generated by this study can be used as the basis for problem-based learning exercises. Students can be required to identify and practice a range of responses to the dilemmas that arise when caregivers’ and patients’ wishes and interests fail to coincide. Such approaches are engaging, and their authenticity makes them attractive to students. They have the potential to generate lively debate and appear best suited to learning contexts that facilitate group discussion. They may prove more cost-effective than measures commonly used in medical training, such as simulation, which are labor intensive (1).
In the context of this study, the use of a case scenario proved fruitful in eliciting considerable detail about the professional decisions and practice of family physicians. The evidence generated by this approach has the potential to inform training in this field for a range of mental health professionals. The case study methodology is a familiar tool in professional training and education and can be used by students to explore and elucidate professional dilemmas and conflicts such as those identified by this study.