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Chapter: Essentials of Psychiatry: Professional Ethics and Boundaries

Avoiding Dual Relationships

Psychiatrists should avoid treatment situations that place them in conflict between therapeutic responsibility to patients and third parties.

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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