Interviewing family members alone

[thelastpsych]

Hey guys, I'm fresh out of residency, and as such, I am having a hard time dealing with some grey areas of MH. One of them is interviewing family members/getting collateral. During residency, I was taught that you should NEVER interview (in an outpatient setting) a family member without the patient being present , as that would greatly break rapport, or - in more paranoid or psychotic patients - even foster their delusions and paranoia. I was taught that ONLY in rare cases should you break this rule, mainly when patients were an immediate risk to themselves or others.

Now, as an attending, I'm starting to wonder if that is truly the case: of course I'm not talking about revealing information about the patient, but just getting collateral alone, as some family members seem very hesitant to talk about the patient with them present, specially with regards to SI/HI, psychosis or feeling safe around the patient at home. I've become a bit more pragmatic nowadays, usually asking the patient it is okay for me to talk to their family alone, and trying to gauge their reaction, but I don't know if that is the right approach.

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[wolfvgang22]

You're doing fine. Continue to be pragmatic and get consent from your patients to speak to friends or family to get collateral information when necessary. It sounds like you are already mindful about the rapport and confidentiality issues.

 

[mistafab]

Yeah I speak to family alone all the time. I make sure patient provides permission before. I make sure the patient agrees what can and can’t be talked about (generally).

I make sure to do more soaking up of information, rather than disclose - sounds like you are also cognizant of what is ethical/fair to disclose.

If I’m planning to have a predominantly disclosure/explaining talk, then I typically prefer to have patient in the room for it (I.e. talk natural history BP1, reviewing early signs of mania/depression).

 

[smalltownpsych]

That is an odd teaching that they had, I prefer your approach. Sometimes talking to the family with the patient is the absolute worst idea. Often I use the strategy of divide and conquer when dealing with a family system that has varying levels of dysfunction even if that dysfunction is mainly arranged around the presence of severe mental illness. Sounds to me like your teacher had a bit of a paranoid perspective probably from their own family dynamic. Any rigid interpersonal rule comes out of a dysfunctional pattern is one of my rigid rules of thumb. 😉

 

[Celexa]

As you note, there is an intrinsic error in only talking to family when the patient is present unless there is imminent risk when at times that imminent risk cannot even be discovered unless you talk to the family member by themselves!

Taking a nuanced approach which incorporates the specific patient factors and preferences is a good thing. How often you end up needing to speak to family members by themselves will vary. In a geri population or SMI you will need to more often (so many geri pts neurocognitive impairment downplay or straight up don't remember symptoms and the severity of the situation can only be elicited out of their earshot) and in a young adult patient pop you may need to go the other direction and set boundaries specifying that you WON'T speak to family unless there is an acute safety concern (to encourage the pt to own their own medical care and swat away overly involved helicopter parents). Etc. There's no one size fits all approach.

 

[allantois]

I can’t stand talking to parents/spouses of 20 some year olds. I usually advise them that I will only talk to family during their appointment time

 

[whopper]

Sometimes the patient is in a situation where they don't communicate effectively. E.g. moderate to worse autism, in which case, and IMHO only a few minutes, I understand if you the patient's family member is seen without the patient. What you were taught in residency works most of the time, but not all the time.

Sometimes the family needs to bring up information to you that they feel uncomfortable discussing with the patient present. Careful. They could have their own bad agenda that's not in the patient's interests. Never take anyone's report at face-value unless you have good trust and reason to believe the patient.

Some other situations are you should allow patients to talk to you alone even if the family members want to be involved. Their presence can be helpful but it can also be negative depending on the family dynamics.

 

[FlowRate]

Sometimes getting collateral is really important but getting some of those same patients to bring in their family member is much more difficult than getting their family on the phone.

I more typically run into the reverse situation where family members by default walk in to have the appointment together. Lately I'm finding that most of the time with people >30 who are there with a spouse it's not an issue (and frequently helpful if >60). It's the 18-30 with their parents that is often problematic and requires setting boundaries/having the parent leave.

 

[whopper]

Patient comes in, tells me he doesn't have Bipolar Disorder. OK fine. Why see me? "I don't have Bipolar Disorder." Yeah I get it, then why schedule an appointment to tell a doctor you don't have a disorder so you don't need treatment? "I don't have Bipolar Disorder. Whatever. Guy at the end of the meeting insists I write a note saying he doesn't have Bipolar Disorder. I tell him no. I tell him I'll write a note where he claims he doesn't have it, but for the rest of the meeting he was defensive and evasive so I don't know if he has it or not.

Days later the same guy's wife calls the office and tells us this guy has Bipolar Disorder. I tell her there's no HIPAA clearance so we're not saying anything. She inserts herself and keeps telling me HE HAS BIPOLAR DISORDER. We hang up the phone after telling her 3x nicely we can't say anything.

So then she physically comes into the office and starts yelling at us he he has Bipolar Disorder. I call up the patient, tell him what's going on and tell him we're going to have the police remove her from the office. He yells at me he doesn't have Bipolar Disorder. I let this re-enactment of the Jerry Springer Show go on for another 10 minutes and I tell him he's terminated and tell her she's no longer welcome at my office, and if she shows up again we're getting a restraining order on her.

Never ever take a patient at face value unless you know them to the point where they're trustworthy. I have a colleague that saw this same bozo a few years later, and my colleague was stupid enough to write down the guy didn't have Bipolar Disorder. The wife flipped out, somehow managed to get a hold of this guy's note and my colleague wouldn't hear the end of it for months.

 

[allantois]

Sometimes getting collateral is really important but getting some of those same patients to bring in their family member is much more difficult than getting their family on the phone.

I more typically run into the reverse situation where family members by default walk in to have the appointment together. Lately I'm finding that most of the time with people >30 who are there with a spouse it's not an issue (and frequently helpful if >60). It's the 18-30 with their parents that is often problematic and requires setting boundaries/having the parent leave.

I will call/video chat with the parent/family member during the appointment whether the patient is in person or also on video

 

[comp1]

Your residency taught you weird stuff. If you think it'll be helpful, interview the patient alone, then interview the family member alone. Normalize it, make it no big deal and it will, indeed, be no big deal. If it somehow still becomes a big deal, then you're well onto your way with diagnostic clarity already. The problem with this isn't the interpersonal dynamics at all, it's actually having the time to do all these separate interviews in a single timeslot. Maybe your residency was just trying to make you efficient...