Navigating Complicated Relationships in Primary Care

Jeffrey T. Reiter, PhD, ABPPCo-Director, Primary Care Behavioral Health Service,

HealthPoint Community Health CentersSeattle, WA

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # B2aOctober 28, 20111:30 PM

Handling Complicated Relationships

• Complicated relationships are common– Prior contact w/ one patient may provide BHC with

knowledge about another (e.g., a family member or neighbor)• The patients might (not) know about the multiple r/s

• Longitudinal care can pose challenges– Patient history obtained at one point in time might be

information a patient wants to protect later (e.g., a patient is seen in a conjoint visit then a year later seen in a conjoint visit with a different partner)

Handling Complicated Relationships

• Relevant APA Ethics Standards:• 4.01 (Confidentiality)• 10.02 (Therapy Involving Couples or Families)– When psychologists agree to provide services to

several persons who have a relationship, they take reasonable steps to clarify at the outset (1) which of the individuals are clients/patients and (2) the relationship the psychologist will have with each person.• What If related pts present independently for care?

Handling Complicated Relationships

– Real-World Scenario for Complicated Relationships:• A 26 y/o man was being seen by the BHC, chronically

depressed/suicidal, often complained of parental intrusion• Patient’s mother called the BHC (even scheduled appt in

son’s name) on two occasions, asking to discuss son’s case• Rebuffed on the calls, the mother established as a patient at

the clinic and was referred to BHC by her PCP for depression– During the visit, the mother repeatedly asked about her son

– Dilemmas: Now both mother and son are patients• Should the son be informed of the mother’s actions?• Should the BHC continue to see both mother and son?

Handling Complicated Relationships

– Real-World Scenario for Longitudinal care challenge:• A 40 y/o man and 42 y/o woman are both known to me

from independent visits– Both have mood, alcohol and drug problems, and attend AA– Both have marital problems (recently divorced, divorce in progress)

• The woman returns after long absence, has just met a man in AA she “feels in love with.” It is the man known to me.• The man returns after long absence, has now met a woman,

she brought him to clinic. It is the woman known to me.

– Dilemmas:• Confidentiality concerns w/ both pts and prior partners

Summary Thoughts

• Primary care poses some unique and different challenges involving confidentiality and patient relationships– Smaller clinics (esp CHCs, where other care

options are limited) can in particular pose challenges

• Despite this, thoughtful attention to ethics can prevent harm– “What is in the best interest of the patient?”