Confidentiality in mental health: negotiating the negotiated order?

1
Confidentiality in mental health negotiating the
negotiated order?

• Tony Evans
• SPSW
• University of York

2
Confidentiality

• Keeping private information confided within a
  clinical relationship
• Important health right
• Particularly in mental health

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A problematic right

• Public Interest - Balance of judgment
• European Convention Artl. 8 - not absolute
• Joined up services - IT
• Mixed economy of care

4
Negotiated Order Perspective (NOP)

• From a study of the operation of psychiatric
  hospitals
• Complex organisations involving vague goals
  employing range of professional actors.
• Organisational policies not applied uniformly,
  reflecting the choices and preferences of local
  actors

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Negotiation(s)

• negotiation with
• the process of give-and-take, of diplomacy, of
  bargaining which characterises organizational
  life (Strauss et al 1965 148).
• negotiating ones way past an obstacle
• seek to get around their superiors using
  techniques such as withholding information
  and displaying varying degrees of cooperativeness
  in charting or in attending meetings (ibid
  159).

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Confidentiality and the NOP

• Managerialism - nowhere to negotiate? Rules and
  spaces
• From total institution to community changing
  context of service user/professional relationship
• What rights? Whose rights?

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The Study

• 4 MIND day centres
• 6 women, 11 men, all white European
• Interviewsthemes experience of confidentiality
  practices views of confidentiality response to
  context
• -Group not representative
• Making connections, extending understanding,
  questioning assumptions

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Importance of Confidentiality

• Safeguarding privacy
• Relief / unloading
• AND participation, providing information as part
  of process of understanding and deciding what
  will help

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Experience of Confidentiality practices

• Understood official confidentiality
• Patchy information about rights from
  professionals
• Learnt by experience/from peers

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Contrasting experience

• Hed the psychologist said the notes he was
  writing was for himself, and they obviously
  wasnt. Because then the psychiatrist had them
  in front of herI started thinking, well, hang
  on, how many other people know about it here?
• when I was with her she never, ever made a
  note. She never wrote anything down unless she
  was telling me what she was doing and why she was
  doing it. But then it never went anywhere unless
  she found that I needed more professional help

11
Disclosure and confidentiality

• Their views
• Disclosure
• NoCrimeRISKCare 
• Routine exchange
• One to one - seek permission
• To agency - only whats necessary

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Confidentiality and wider information rights

• DISCLOSURE
• INTERPRETATION
• DECISION-MAKING

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INFORMED DISCLOSURE

• Id like to know more why the questions are
  being asked. We should be more ...more respected.
  I think we should be allowed, if we dont want to
  talk about it, not to say anything.

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SENSITIVE INTERPRETATION

• Youd say a word, and theyd make such a thing
  of it. I would say this is how something
  happened, but then to have it written in my case
  notes that it was paranoia I know it happened.
  I can look back. But it was just put down as
  paranoia no acknowledgement of my truth. It was
  as if they didnt believe anything Id said. They
  just recorded their own interpretation.

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SHARED DECISION-MAKING

• I would have liked to have had more information
  about the whole process of the assessmentI feel
  that sometimes they feel empowered by the
  knowledge that they have and that the patient
  wont understand their condition as well as they
  do rather than actually being explained what it
  is so that they might be able to do something
  practical themselves

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Assessing Confidentiality

• Small Minority Disengaged - fixed distrust
• Most cautious engagement - conditional
• ... there are some you cant converse with in
  there, and there are others, a few, that you
  can.

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Negotiating Confidentiality

• Tend to start with idea of negotiating with
  professionals
• But if distrust/lack of respect negotiate around
  
• avoiding disclosure The only way I can test
  people is if theyve let me down. And theyve let
  me down in a way where, thats it, if thats the
  score, Im not going to say nothing else.
• playing the game I feel Ive got a
  constructive relationship with my current
  consultant, but at other times Ive played the
  game, known what answers to give.