Resolving the dilemma of multiple relationships for primary care behavioral health providers.

Abstract

Swedish Family Medicine Residency, Littleton, Colorado and the Colorado Health Foundation, Denver, Colorado Practitioners working in primary care (PC) encounter a different model of patient care than those who practice in a traditional outpatient psychotherapy setting. PC physicians commonly serve multiple members of the family and are typically serving numerous patients in the same community. Given the lack of financial sustainability for the behavioral health provider (BHP) position, it is uncommon that a practice will have more than one BHP and therefore, there is increased likelihood that the BHP will be asked to provide services for a family member or roommate of a patient seen in the recent past. The ethical code regarding multiple relationships can sometimes pose challenges that require careful forethought and clinical anticipation. The ethical code, if followed too rigidly in the population-based care model of PC, could potentially be harmful to patients who otherwise have no access to mental health resources or would not seek traditional care. This paper proposes a framework to aid anticipatory decision making regarding multiple relationships in the PC setting, with the goal of reducing potential patient harm and maximizing potential for care opportunities.

Managing sibling referrals: Ethical considerations for integrated pediatric primary care.

“…However, several factors serve to mitigate the risks. First, the expected treatments rely heavily on psychoeducation and skill-building and do not require high levels of vulnerability or self-disclosure (Ivey & Doenges, 2013). Thus, discussion of shared environmental factors and treatment overlap may be more acceptable to the siblings and their parents.…”

“…First, potential risk is quantified via the rubric presented below in Table 1. In this rubric, risk is assessed in the areas of therapeutic duration and level of service involvement, as recommended by Ivey and Doenges (2013), as well as three additional areas relevant to the assessment of sibling referrals described above: expectations of privacy, shared environmental contributors, and treatment conflict. This rubric is intended to evaluate the potential for harm from multiple relationships before they are formed, at the point of referral.…”

“…However, in our experience, sibling referrals are common in integrated pediatric primary care even when alternative referrals exist. Primary care physicians themselves routinely treat more than one child from the same family, and this practice is not only common but desired by both physicians and the families they treat (Ivey & Doenges, 2013). Unlike psychologists, primary care physicians do not seem to consider such a practice as bearing any special ethical risk (Ivey & Doenges, 2013).…”

Interprofessional collaboration: Ethical considerations for school psychologists.

“…Therefore, it will be important for Dr. Perez to ensure that boundary crossings do not become boundary violations. Dr. Perez should consider potential power dynamics and the anticipated duration of the relationship before entering into a multiple relationship and make clear with clients the process for terminating services (Ivey & Doenges, 2013; Zur, 2018). Dr. Perez might also consult with colleagues, consider the practicality of the multiple relationship, engage in conversation with the client about the multiple relationship, and consider other alternatives or solutions before entering into a multiple relationship (Gottlieb, 1993).…”