Family involvement is of particular importance to patient safety in mental health care services, where communication with and involvement of family members may help to prevent patient deaths. Investigations of deaths in acute mental health care regularly highlight inadequate involvement of families (NCISH 2018; Manuel et al 2018; NHS Resolution 2018). Indeed, staff themselves highlight how involving families is best practice (Littlewood et al 2019). Clinicians emphasised the value of a two-way dialogue, whereby family members feel able to share their concerns about a patient’s current well-being and safety, which may lead to action by the health care team. Clinicians, in turn, can involve family members by informing them when patients miss appointments or are non-adherent with medication.

However, family involvement can be challenging in mental health care settings. Clinicians also reported difficulties in negotiating confidentiality and privacy (Landeweer et al 2017) which can hinder information-sharing (NHS Resolution 2018). Whilst families can provide an effective source of support to some patients, for others, difficult family relationships may contribute to their distress or mental health problems. In a minority of cases families are part of the problem and the individual may need considerable help addressing that without their families present. These decisions are made further complex in that patients should ideally be offered the choice of whether to involve a family member or not, for example to bring them to an appointment within an SFI (as recommended by Bryan Sc Rudd 2018). In some cases the patient may not be able to make a judgement in their best interest or feel unable to say no. Someone very suicidal may decline permission to share information and wish to keep their family at arm’s length. In such situations, best practice would be to have a number of professionals involved so that someone can work directly with the patient (ideally delivering an SFI) whilst another professional supports the family. As a rule of thumb family involvement should be the norm if the patient wishes this or if the patient is so high risk that the family can play a critical role in their safety. However, families who contribute directly to a patient’s poor mental health, for example through bullying or abuse, may need to be discouraged from too much involvement. This is part of the complexities of clinical practice and the patient, their interests and autonomy should be at the heart of any decision. These complex scenarios highlight the importance of reflective practice and supervision. The key guide here is to be willing and flexible and model this for your client as willingness and flexibility are critical to getting out of the suicidal “cul-de-sac”.

Ethical dilemmas may often arise with young adults where the family have significant rights and the adult may be reluctant to involve them. Best practice in some university mental health teams has changed in recent years as a result of one family’s campaign who lost their son from suicide whilst he was at university. He was known to be depressed and under the care of the Bristol University mental health team, but the parents were not informed, and he died by suicide. As a result of the family’s resolve to change that practice, the university introduced an “opt-in” system in which students can give consent for a parent, guardian or friend to be contacted if there are “serious concerns” about their wellbeing. In the academic year 2019-2020 94% of students at Bristol University chose to opt-in to let family or friends be contacted - and there were 36 cases in which contacts were subsequently made. See bristol-university-warns-parents-of-student-suicide-concerns-bsgvx890n.

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