Ethical Management of Multiple Relationships in Primary Care

1. Session #D3b Friday, October 11, 2013 Ethical Management of Multiple Relationships in Primary Care Laurie Ivey, Psy.D. Director of Behavioral Health, Swedish Family Medicine Timothy Doenges, Ph.D. Staff Psychologist, VA Eastern Colorado Healthcare System Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Gain an understanding of how the IPC setting can create unique ethical challenges • Learn to use a matrix to help navigate ethical dilemmas that arise when a behavioral health provider is asked to work with 2 patients who know each other. • Gain experience applying this matrix to scenarios commonly encountered in primary care.

4. Contrasting Professional Approaches • Primary Care Physician—Sees whole family • Behavioral Health Provider—Ethical cautions around multiple relationships

5. Definition of Multiple Relationships Drawing from the APA Code of Ethics (2010) multiple relationships occur when: • A psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. (p.6)

6. Definition of Multiple Relationships Additionally, the APA code (2010) states: • A psychologist refrains from entering into a multiple relationship if the relationship could reasonably be expected to impair the psychologist's objectivity, competence, or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists. (p. 6) ***Multiple relationships are NOT ALWAYS problematic***

7. The Problem 1 physician who works 210 days/year will have patient range of 700-4200 depending on frequency of visit Practices typically draw from 1 geographic region 1 BHP only because of $$$ (Kathol, Butler, McAlpine, & Kane, 2010) (Murray, Davies, & Boushon, 2007)

8. Demand for Behavioral Health Services • 60% of PCP visits have psychosocial component • 40-63% of patients having psychological problems are being treated in PC • When patients are referred out, only about 10% will comply (Cummings & VandenBos, 1981) (Kessler & Stafford, 2008) (Smith et al., 2003)

9. Demand for Behavioral Health Services • If there are rigid constraints some patients will get no services • Some interventions are not available in traditional out-patient mental health centers (e.g. health behavior change) • “accountable care” which includes the provision of better care for lower cost / population management via registries (Rittenhouse, Shortell, & Fisher, 2009)

10. What services can I ethically provide? • Maximize benefits and avoid harm • Distinction between traditional mental health settings & BHP is crucial • BHP consultation, psycho-education, MI, health behavior change, referral, brief tx, co-facilitation of group visits, etc. • The relationship dynamics and risk for harm to the patient are different

11. Matrix for Ethical Decision-Making Regarding Multiple Relationships in PC RISK DIMENSIONS

12. 4 Steps for Using the Matrix: • Assess the current relationship along the three dimensions (patient #1). • If relationship high risk category on multiple factors, the potential for harm is higher and other relationship should be entered with caution. • Assess the potential relationship along the three dimensions (patient #2). • If the relationship high risk category on multiple dimensions, then treatment with patient #2 should not be initiated. • If it is mid-range or to the left side of the dimension, the relationship may be permissible and the BHP should move to step three.

13. 4 Steps for Matrix cont. • Examine potential harm if Patient #2 is not seen. • Does the patient have alternate resources for behavioral health services? • What is the likelihood that the patient will follow through with an outside referral? • Could a limited service or consultation be provided without causing harm? 4. Obtain consultation if still unclear about risk of harm.

14. Case 1 Jennifer (patient #1) is a 45 year old Latina woman who has been seeing the psychologist Dr. Vine for 2 years for Posttraumatic Stress Disorder. She is finished with her therapy but brings her son (patient #2), who has no health insurance, to see his PC physician because he has developed debilitating anxiety. The physician asks Dr. Vine to join the appointment for a consultation. Ethical questions: • Could the multiple relationships in this patient encounter cause harm to either patient? • What types of services could be provided to the son in this scenario? • What are potential contributors to bias in this situation? Step 1: Assess Current Relationship along the 3 dimensions of the matrix Step 2: Assess Potential Relationship along the 3 dimensions of the matrix Step 3: Potential harm if Patient NOT seen

15. Case 2 Dr. DeLaney (a physician) asks Dr. Vine (the BHP) to consult with her and Janet Reed (patient 1), who is struggling with depression. The consult is completed and the 3 agree to meet again in one month for follow-up during a regular office visit with the physician. The next week Dr. Demo, another physician in the practice, asks Dr. Vine to meet with him and Celine Martinez, a patient who frequently presents to the practice in an emotionally agitated state. When Dr. Vine and Dr. Demo walk into the room, Celine Martinez (patient 2) and Janet Reed (patient 1) are sitting together in the exam room. It turns out that they are roommates. Ethical questions: • Could the multiple relationships in this patient encounter cause harm to either patient? • What types of interventions can ethically be provided to each patient? • What are the potential contributors to bias in this situation, and can they be ethically navigated?

16. Case 2 Dr. DeLaney (a physician) asks Dr. Vine (the BHP) to consult with her and Janet Reed (patient 1), who is struggling with depression. The consult is completed and the three agree to meet again in one month for follow-up during a regular office visit with the physician. The next week Dr. Demo, another physician in the practice, asks Dr. Vine to meet with him and Celine Martinez, a patient who frequently presents to the practice in an emotionally agitated state. When Dr. Vine and Dr. Demo walk into the room, Celine Martinez (patient 2) and Janet Reed (patient 1) are sitting together in the exam room. It turns out that they are roommates. • Risk of harm to either patient is low for one-time consults and/or brief interventions. • Either patient could be referred to another provider if they have financial resources • Could potential harm resulting from the loss of an opportunity to intervene and does this outweigh the risk of multiple relationships harming one or both patients. • BHP may help physician deal with frustration re: patient 2

17. Case 3 Based on their diabetes registry, Mountain Family Medicine has decided to hold diabetes group visits. They encourage all patients with HbA1C levels above 10 to attend this visit. The BHC’s role is to do a standardized mood assessment with each patient and lead a discussion about depression. Janet and Sue attend together. They are roommates, both with diabetes. Ethical questions: • Could the MRs in this patient encounter cause harm to either person? • What types of services can ethically be provided to the roommates in the group visit? • Is there a risk of bias in this situation? • From the beginning, both have the same level of relationship with the BHC and both consented to participate. • With all group visits, a group discussion about confidentiality and expectations about protecting each other’s privacy is an important initial intervention. • If either patient needed follow-up for their mood issues, another matrix would need to be completed based on patient recourses, duration and nature of the follow-up. • Potential benefits of the roommates attending the group together is a consideration (i.e., mutual support in managing diabetes, reciprocal reinforcement of concepts learned, sharing transportation expenses, etc.)

18. Reference Ivey, L. C. & Doenges, T. (2013). Resolving the dilemma of multiple relationships for primary care behavioral health providers. Professional Psychology: Research and Practice, 44 (4), 218-224.

19. Learning Assessment Audience Question & Answer

20. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!