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Relationships with families, carers and friends (others?) by John Sawkins

There is always a potentially difficult relationship between service users, carers and professionals. Open dialogue seeks to address this issue through allowing every party in the relationship to have a frank interchange, based on honesty and mutual respect. Hence it is disingenuous to attempt to misrepresent the idea of showing “insight”.

Power differentials in caring

For professionals, this usually equates to taking medication, as directed. Carers and families therefore mistakenly interpret the assumed lack of insight on the part of the service user as indicating some bizarre and illogical refusal to comply, insisting that: “how can you expect to get better if you won’t take the medication the doctor has prescribed?”

True insight would involve looking into the relative risks of taking versus not taking the drugs, along with the potential effects of long-term exposure to the product. If the service user is deemed to lack capacity or the means to do this, a carer or advocate could do this on his/her behalf in the spirit of “supported decision making” (as opposed to substituted decision-making).

Instead of insisting that the medication is therapeutic for the service-user, all concerned should be perfectly clear about the true reason for its being administered: our society demands that its citizens behave in an acceptable manner. Therefore, if you, the service user, choose to operate outside of these reasonable limits, we have the right to modify your behaviour accordingly, whether with drugs or behavioural therapies.

Consequently, if you exhibit disinhibited behaviour, hypersensitivity or hyper-connectivity, we reserve the right to intervene. It will be explained to the service user that complying with the State’s requirements is non-negotiable, so, if they have any insight, they will understand why they have to accept medication or some other means of behaviour modification.

The triangle of professionals, carers and service users can result in a form of ganging up by any two of these parties against the third. The difficulty for the carer – and I have been in this position myself – is that, having sided with the professional as to what is in the best interests of the service user, trusting relationships within the family start to break down. Not only is the bond between parent and teenager then irrevocably damaged: most often, other relationships such as marriage start to break down.

compulsory medication

It is interesting to contrast the view of the service user with that of the carer. The former may want the latter to be kept informed of what is happening to him/her: whether their sudden personality change might be down to a change or increase in medication, for example.

On the other hand, they may have made their wishes abundantly clear in their advanced directive that on no account should their next of kin be told. (Usually they will have identified a friend or advocate instead). Equally, the carer/friend may want chapter-and-verse, in certain circumstances, whilst in others feel that they wish to respect the right of the service user to confidentiality.

And confidentiality (alongside human rights, data protection, risk assessments) is at the heart of the dilemma presented to us all. We must always ask ourselves whether the reasons given for not sharing information are genuine: on occasions, they can be ways of protecting the professional, as opposed to the service user. (Does the service user really refuse to see the carer, or is this seen in his/her best interests by the professional?)

We all accept that confidentiality should be maintained, yet we acknowledge that there are situations where it can – indeed, often, must – be breached for the very survival of the service user. We are not saying that the opinions of every imaginable interested party be sought and acted upon: merely that crucial information from close friends or others not in the immediate family, but tangentially related to the service user, is not overlooked. This could include indications on social media that the service user might be contemplating suicide.

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