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Wednesday, October 12, 2011

Dilemma 6: Referral and Treatment Boundaries

A psychologist receives a phone call from a well-known internist in her area.  The psychologist is involved in a busy practice, specializes in treating eating disorders, and receives only occasional referrals from this physician.  The physician wants the psychologist to treat his 17-year-old daughter, who suffers with what he describes to be an eating disorder and perhaps some Borderline Personality Disorder traits. 
The physician explains that he has been medicating her for about four months with Prozac and Klonopin, once he became aware of her eating disordered behavior.  Because of his status as a well-known internist, he does not want to refer his daughter to a psychiatrist because he believes that he can handle the medication piece of her treatment.  He will also pay for all treatment in cash, as he wants as few people and organizations to know about his daughter’s issues.
Feeling somewhat uncomfortable with the medication management issue, the psychologist indicates that she will have to call him back after looking at her schedule.  The psychologist then phones you for an informal consultation.  The psychologist expresses her concerns about working with a patient whose father is prescribing medication.
Are there any ethical considerations in this dilemma?
What are the potential pitfalls in the scenario?
What are potential advantages in this scenario?
What are some of the suggestions that you may have for the psychologist about accepting or declining the referral?
What concrete steps might be important before calling the physician back?
 Are there additional considerations for how to approach the referring physician when calling back?


Dav id Herman said...

I think that the ethical considerations involve the issues of level of risk to the child (i.e., does she need hospitalization rather than outpatient treatment) and the conflict of interest of father's wishing to medicate the daughter himself rather than referring her to a psychiatrist. The treatment plan he wishes to implement is imposing his decisions on the psychologist. However, the psychologist has the ultimate responsibility for determining what the optimal treatment interventions would be after evaluating the daughter herself. There are clearly separation and control issues involved in the father's contact. Also, there are questions of his motivation for maintaining secrecy. The question of abuse and/or neglect must be considered. Clearly there is narcissism, since he values his professional reputation and public recognition over the wellbeing of his daughter. The pitfalls enumerated are many and the problems thorny. The potential advantages include finding a way to help the daughter heal. I would suggest that the psychologist make written note of the pros and cons of accepting the client. I would recommend that there be a clarification of roles and boundaries. Well known or not, father's duty is to see that his daughter gets the best possible treatment, not to protect his professional reputation. Given the privacy rights the daughter would have with the psychiatrist or any professional she sees for treatment, it seems that the father's concern for secrecy is related to his narcissism and fear of discovery. But discovery of what? In calling the father back, I would explain that it is part of the psychologist's duty to provide the prevailing standard of care and to engage in best practices. Then I would explain what those things entail: First, establishing boundaries in a respectful but clear manner. I would indicate that psychologists are required to make an independent evaluation and determination of diagnostic considerations and interventions, much the same way that the father must do when he is referred a patient. I might also raise the question with him of what he would think if a person came with him and presented a treatment plan such as his. I also would indicate that best practices require that the psychologist refer to a psychiatrist, especially since the problems present potential danger to the daughter's health, if not overall wellbeing. I would ask the father if he wanted time to make a decision or if he was ready to commit on the phone. I do not believe that the father's evasiveness about sending the daughter to a psychiatrist and paying in cash are clear indicators of neglect and/or abuse. However, I would certainly screen the daughter an father both to see if a call needed to be made to child protective services. Also, I would ask the father for medical clearance from the family physician if the daughter is believed to have an eating disorder. She may require hospitalization for medical problems prior to being eligible for outpatient therapy.

John Gavazzi said...

Thanks for your response and participation.

A number of issues emerge in this dilemma. First, the father-physician wants to be a treating professional as well as father. We have an article cited on our blog about this phenomenon with physicians.


Having worked with physicians and their relatives, I am not as suspicious about the father’s motivation to mantain privacy. From my experience, physicians prefer as much privacy as possible, realizing how easily confidential information is accidently released.

From my vantage point, an eating disordered daughter presents as a complex clinical situation. The issue that the psychologist needs to resolve is if she feels comfortable with the parent-physician being the prescribing professional and what boundaries or recommendations she might have about the clinical situation. Depending on how the psychologist evaluates the clinical variables, she may decide to evaluate, to evaluate with conditions or not accept the referral.

Accepting the referral without further discussion or not accepting the referral does not create any ambiguity for the psychologist.

For the uncertain psychologist, she may want to speak to several issues with the physician-father prior to accepting the referral and scheduling an appointment.

One of the most salient concerns is the multiple relationships involved with the referral. Is it within the psychologist’s comfort zone to have father as prescriber and part of a potential family therapy situation? Does the father-physician have the insight that he may become part of his daughter’s treatment? What expectations does the father have about his role in the treatment?

Additionally, having little knowledge about the situation from a phone call, it is unclear the relationship that the father has with the daughter. As examples, do they have an enmeshed-conflicted relationship? Do they have a distant relationship? The nature of their relationship remains unclear.

Third, the issue of informed consent is important. Part of the informed consent may include the multiple roles involved in the situation, the potential for the daughter to be referred to a different prescribing professional, and the psychologist’s concern about the multiple relationships.

There are several suggestions that I would have for the psychologist prior to making an appointment.

My first suggestion is that the psychologist needs to educate the father about roles and boundaries of therapy. Since the physician-father apparently respects and trusts the psychologist, helping father appreciate the issues related to boundaries and multiple relationships is important.

Second, it is important that the psychologist communicate that she will be working with the best interests of the daughter. While the family system and the father are important, the psychologist’s focus is to work toward the daughter’s goals in therapy, which may not align with the father’s expectations about therapeutic direction, process, or goals.

Third, if the psychologist accepts the referral, she needs to explain that she will see the daughter and the family as an evaluation (that may take several sessions) to determine the clinical complexity of the daughter and the family system. The psychologist will also be assessing if she is the best person to be working with the daughter and/or family system.

Depending on the variables, the psychologist may recommend a different psychologist or that the daughter works with a different prescriber. To me, it is important for the father to understand and agree that the psychologist will evaluate the situation first, then decide how further treatment proceeds.

Those are my suggestions to help the psychologist work with the challenges of this vignette.

I am curious as to what other think.

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