Avoiding Dual Relationships
Psychiatrists should avoid treatment situations
that place them in conflict between therapeutic responsibility to patients and
third parties. Examples of dual relationships in psychiatric practice in-clude
clinicians treating their own relatives and friends, the same therapist
employing concurrent family and individual therapy paradigms with a given patient,
and clinicians testifying as fo-rensic witnesses for current psychotherapy
patients. Although it is a very common practice (Epstein et al., 1992), accepting psy-chotherapy patients referred by one’s
current or former patients embraces certain risks that must be considered (Pope
and Vetter, 1992). For example, a current patient might refer an attractive
friend for therapy as a way of either seducing the therapist or sabotaging the
treatment (Langs, 1973).
Role conflicts are quite widespread (Pope and Vetter,
1992) and interfere with the practitioner’s single-mindedness of purpose as a
healer. Chodoff (1993, pp. 457–459) placed special emphasis on this issue by
arguing that advocating for the needs of the mentally ill was one of
psychiatry’s primary societal respon-sibilities. By eroding public trust, dual
relationships interfere with the ability of psychiatrists to carry out their
vital functions in the community.
The burgeoning expansion of prepaid care in the USA
in the last two decades has provoked concern about a new source of role
conflict for psychiatrists. Managed care has been espoused as an important
modality to reduce unnecessary treatment by encour-aging preventive care and
promoting cost-consciousness among physicians (Fries et al., 1993). Stephen Appelbaum (1992) argued that
psychotherapists practicing under the old fee-for-service model were more
inclined to provide unnecessarily prolonged treatment than those working under
an organizational system that prevented direct monetary involvement between
patient and practitioner.
On the other hand, increasing coverage of the
population of the USA under a system of managed care has generated serious
concerns regarding potential conflicts of interest (McKenzie, 1990). This
disquietude is particularly noticeable in the field of psychiatry. Many managed
care organizations (MCOs) have severely restricted the number of psychiatrists
within a given community allowed to serve on their treatment panels. Patients’
access to their regular treating practitioner have been further limited, even
when the doctor is allowed to enroll on the panel. For example, under the rules
of some MCOs, a psychiatrist might be prevented from maintaining continuity of
care for out-patients needing hospitalization. During their hospital stay, such
patients must be attended by a preselected group of psychiatrists who conduct
all hospital treatment for the plan.
Although there is little scientific data to support
the conten-tion that restricted managed care panels are necessary for lowering
costs, it is important that both patients and clinicians be informed about the
hazard such a system of care entails. Since participation on a panel is often
contingent on cost-efficiency profiles, psychia-trists who derive a significant
portion of their income from a given MCO are discouraged from advocating for
patients needing more expensive care. In addition, some MCOs refuse to pay for
inte-grated treatment for mentally ill patients by psychiatrists enrolled in
their panel. Instead, these MCOs insist on a split treatment model in which the
patient obtains psychotherapy from a social worker or psychologist and is
allowed only brief medication man-agement visits with a psychiatrist.
Psychiatrists attempting to do medication management under this model often
have little contact with the psychotherapist, are very restricted in the
frequency and duration of visits with the patient, and are thereby limited in
mak-ing overall clinical decisions that might become necessary. Such a
situation creates an ethical bind for the psychiatrist in which the medical
responsibility is not accompanied by a commensurate degree of authority to
direct the treatment process.
In the face of reports of physicians claiming they
were terminated from managed care contracts because they protested treatment
denials, fear of retaliation for patient advocacy has mounted (McCormick,
1994). Judge Marvin Atlas (1993) has suggested that psychiatrists who fail to
give informed consent regarding the risks to the patient of their role
conflicts would be exposing themselves to civil damages in the event of an
ad-verse outcome. Although the extent of the legal duty to disclose risk
factors under managed care is unresolved, Paul Appelbaum (1993) proposed that
mental health clinicians inform beginning patients that payment for treatment
under managed care might be stopped before the patient feels ready to
terminate.
Limitations as to who may serve on a managed care
panel and what functions the clinician may perform are other factors that have
strong potential for creating disruption in the continuity of care. For
example, Westermeyer (1991) described seven case histories in which psychiatric
patients treated under managed care committed suicide or suffered serious
clinical deterioration. Clinically uninformed managed care practices appeared
to serve as critical aggravating factors for each of these patients. In the
cases of two individuals who killed themselves, the employer had switched
contracts to different managed care companies and the patients were forced to
transfer to new clinicians. These disrup-tions appeared to play an important
role in the patients’ suicides.
Although more research is required to evaluate the
full ramifications of managed care on psychiatric populations, recent studies
suggest that some groups face adverse outcomes under this system. For example,
Rogers and colleagues (1993) found that, on average, patients with depression
who were treated by psychiatrists under prepaid treatment plans acquired new
limita-tions in their physical or day-to-day functioning over a 2-year period,
whereas those treated in the traditional fee-for-service setting did not.
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