The dilemma of treating the ones we love

When one of my sons was young, if I ever tried to have a serious talk with him about something he would say “Mum, don’t use your counselling voice on me!”. I never knew whether to be pleased or offended!

My son was quite young at that time but not too young to recognise the change in me as I approached a difficult discussion. What he recognised as my “counselling voice,” was probably a tone that suggested I was trying to remain empathic but still keep some emotional distance. It’s possible, knowing me as an emotional person, that this stranger trying to have a rational discussion with him about something difficult was not really his mother!

When does parenting become “treatment”?

My son’s observation has come back to me recently as I ponder the issue of where we need to draw the line in our decisions about treating our own family members. In the realm of prescribing and referring for physical illness, this boundary is straightforward, but in mental health the boundary can get much more blurred. Much of what we do as thoughtful parents has an element of therapy in it.

How do we know when to get someone else to help? How do we know when our children need help that we cannot provide? What if we feel we are qualified enough and are the best person for the job but in reality we’re not? What can we do if we are well qualified to give them the psychological support they need and do not know anyone who is professionally more qualified than we are? And, importantly, what if they see somebody else for help and we disagree with the therapy being provided?  

The Medical Council of NSW recommends that wherever possible, medical practitioners should not treat themselves or members of their own families for reasons that include, maintaining professional objectivity and difficulty exploring sensitive areas. In its Guidelines, the APS affirms that “combining family or personal relationships with a professional relationship is ethically problematic because the objectivity of the psychologist is compromised, and the psychologist’s judgement is likely to be impaired”. I’m sure same precautions apply to other health professionals.

But when does the normal behaviour of a caring parent, child, or sibling cross over into therapy?

Here’s a situation to consider…

Imagine that you have a beloved 14 year-old daughter who has become depressed. You have tried your best to help her, but she is not getting better. She has become socially withdrawn and has lost weight. You realise, before it’s too late, that you need some assistance from another health professional, so you ask your colleagues to recommend someone for her to see, because you don’t want to send her to a friend as that may also confuse the therapeutic relationship. It’s difficult because you know almost everyone in the local area who works in adolescent mental health.

You go to the family doctor (well done for having one if you are a GP yourself!)  who obediently refers your daughter to the child and adolescent psychiatrist you’ve been recommended by colleagues The psychiatrist decides your daughter is at risk of an eating disorder and wants to start her on medications for her depression. You disagree. Medications are not your preference for her, and you feel psychological intervention should be the first step. You think she has lost weight because of her depression not because of an eating disorder. You remove your child from his care and decide that you can look after her yourself.

This might be where the problems really begin

Once we’ve sought outside help, what should we do if we observe our family members, especially our children, receiving what we consider to be sub-optimal care? Do we lose our rights as a parent to make decisions about care because we also happen to be health professionals?

When the person in question is our own child, we are actually at some personal and professional risk. If we remove them from care on the grounds that we are dissatisfied with the care that they are receiving we may not be being objective in our decision making, we could be risking not only being reported as a neglectful, but also as a professional for professional misconduct.

What can we do?

We need to remember that we may not have all the information necessary to make a comprehensive treatment plan. Our child may not have been completely honest with us about tricky things like sexual history, abuse, drug and alcohol history or suicidality. They may be protecting us in a way that they would not need to protect an outside observer - or protecting themselves from our distress.

It’s equally important to remember that as a parent we are entitled to get a second opinion (via our GP) if we do not agree with the first assessment.

That said, there may also come a time when what we need to do is trust and accept the advice of other health professionals and understand that, with our own emotional involvement, objectivity may be out of reach. That doesn’t mean we can’t still be the (informed and concerned) parent in the story, we just can’t be the treating professional.

References

Guidelines for Self-Treatment and Treatment of Family Members Medical Council of NSW  Version 6 2014 https://www.mcnsw.org.au/sites/default/files/procedure_-_guidelines_for_self-treatment_and_treating_family_members_pdf.pdf

Good Medical Practice – A Code of Conduct for Doctors in Australia, Medical Board of Australia/AHPRA (2009) https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx

General Practice Registrars Position Statement on providing care to practice staff and other colleagues https://gpra.org.au/2019/03/08/gpra-position-statement-s02/ 

Australian Psychological Society Code of Ethics https://psychology.org.au/getmedia/d873e0db-7490-46de-bb57-c31bb1553025/18aps-code-of-ethics.pdf