Including Significant Others in Health Care Visits: Here to Stay… Or, like Valentines Day, a Short-lived Temporary Celebration? Jerica Berge

 With an entire recent issue of Contemporary Family Therapy focused on Medical Family Therapy (MedFT), a second edition of Medical Family Therapy by McDaniel, Doherty, and Hepworth coming out, and several MedFT training programs (Ph.D.’s, post-docs, certificates, and fellowships) being established around the country, we have hit a high point in the field. It appears that Marriage and Family Therapy (MFT) and health care delivery entities (e.g., Primary Care, Pediatrics, Internal Medicine) may have finally tied the knot regarding the importance of systemic thinking and relational involvement at the center of care-provision.

For example, the value of including a significant other in the health care of a partner—while not standard medical practice yet—is no longer questioned. It is common for a primary care provider to request a patient with diabetes to bring in their significant other to be included in treatment planning. Furthermore, many of the Patient Protection and Affordable Care Act (PPACA) requirements lend themselves to supporting a relational view of health care. "Team” and "group visit” approaches used in federally-qualified Health Care Homes rely on a systemic and relational view of a patient’s health. Additionally, the new CPT (Current Procedural Terminology) codes 90832, 90834 and 90837 are defined as "psychotherapy with patient and/or family member” and the 90846 and 90847 are defined as "family psychotherapy with or without the patient”. Even reimbursement systems are embracing the move towards systemic and relational care. Thus, including significant others in care (i.e., mental and/or physical health) visits may become the "gold standard” in the near future.

There are many advantages of including a significant other in a partner’s health care visit, from getting their buy-in and support for (and involvement in) the patient’s treatment plan, to perturbing their worldview about why their partner has a certain condition. Including a significant other in a patient’s health care visit may ultimately allow the provider an opportunity to increase the likelihood of treatment compliance, understand more about the health care motivations of their patient, and establish trusting relationships which promote collaborative efforts between the patient/significant other/provider subsystem to be mutually invested in a patient’s health and well-being.

I see examples of this type of collaboration often in the residency clinic where I work. Residents are encouraged to bring in patients’ significant others to team visits to get a better perspective of the presenting problem(s). Faculty doctors have couples they have seen for years and model the importance of systemic and relational care to their residents. Patients either bring in their significant other themselves or suggest bringing them in. It seems that providers, patients and significant others all can see the vision of systemic and relational thinking in health care delivery!

I Beg to Differ Tai Mendenhall

Jerica, my long-term collegial sibling, I must counter your enthusiasm with all of this. To be clear: I agree that it is good to see MedFT’s visibility increasing in academic literature and professional circles, and the fact that many health care sites are beginning to recognize the utility of including patients’ significant others in care is a long-awaited change. As a MedFT provider and educator, myself, I am happy to see our guiding tenets gaining some traction after so many years of spinning our wheels. But to be honest, I think that you are looking through lenses here that a bit too rose-colored.

I do not think that we are anywhere near the mainstream or "gold standard” yet. To begin, medicine as we know it is still rigidly-structured around a one-patient-at-a-time model. Our diagnostic and billing codes reflect this, insofar as those "belonging” to individual patients (e.g., 296.32 / Major Depressive Disorder, Recurrent, Moderate Severity or 250.02 / Diabetes Mellitus, Type 2, uncontrolled) are generally paid-for by 3^rd-party payers and those having anything to do with patients’ relationships or psychosocial situations (e.g., V61.2 / Partner-Relational Problem or V62.2 / Occupational Problem) are not. Further, our new ICD-10 mental health billing codes require even more cumbersome documentation that identifies when significant others’ involvement is disruptive (e.g., 90785 for factors "complicating” care delivery), but not when it is helpful.

Alongside this, most biomedical and mental health care providers are still not required in their training to gain experience with or confirm competency in systemic interventions. To my knowledge, MFT (and within this, MedFT) is still the only camp that mandates a large percentage of logged patient care to include family members and/or significant others. And – health care home movement notwithstanding – these systemically trained providers (like you and me!) still tend to earn less than their Psychology counterparts, and their services are still not as broadly recognized as reimbursement-worthy by major payers (e.g., Medicare) in many states.

With our physicians, those who are more likely to work systemically (e.g., Pediatrics, Family Medicine) are paid significantly less than all other medicine specialties. I mean, let’s be real: Have you ever compared the cars or houses (plural) owned by cardiologists, dermatologists, and surgeons to those owned by a family-doc? And, coming full-circle, it gets even worse when you compare that to what we MedFTs live in or drive. Put simply, those who focus biomedically on one-patient-at-time are rewarded handsomely for it. Those who dive into patients’ complex interpersonal and psychosocial worlds are not.

And when we get right down to it, Jerica, you know that many providers find working with individual patients (sans significant others) to be more comfortable. Conversations are more simple, chaos and conflict are less likely, and visits/sessions are more "smooth.” Even our MFT and MedFT colleagues attest to this (I know that you’ve heard them!), recognizing that their individual patient at such-and-such time during the day represents a "break” of sorts from the comparative intensity of couple- or family- work.

I think that we all see the utility of including significant others in care, but the reality is that many (or even most) providers do not do it until they "have” to. When their 1:1 services do not seem to be working, when their patients are "noncompliant” with whatever they are telling them to do, or when they (providers) are overwhelmed and frustrated because the course of care is not going the way that they would like to see it go – only then do they begin asking questions like "What is your wife’s take on all of this?”, "Could you bring your mother in with you next time?”, or "My thinking is that it would be best to talk with both of you about how to eat well with this new ‘diabetes diet’.”

I think that all of us (providers and patients alike) tend to take the people who are most important in our lives for granted – at least until we’re "supposed” to appreciate them (like on Valentine’s Day or their birthday), until we really need them (because of the support that they can offer), or after it’s too late (because we have lost them). I see much of health care following this very path. Including significant others because we’re incentivized to do so, or because we don’t know what else to do, is good. But it’s not ideal. Maybe someday we will all do this naturally. But my sense is that this is still a very long way off.

Jerica Berge, PhD, MPH, LMFT, CFLE is an Assistant Professor at the University of Minnesota in the Department of Family Medicine and Community Health. She received her PhD in marriage and family therapy from the University of Minnesota. Dr. Berge is a Medial Family Therapist at the North Memorial Residency Program and Research Faculty at the University of Minnesota Medical School. Dr. Berge’s research interests include childhood obesity prevention and community-based participatory research around child and family health issues. Tai Mendenhall, PhD, LMFT is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, Director of the UMN’s Medical Reserve Corps’ Mental Health Disaster-Response Teams, and Associate Director of the UMN’s Citizen Professional Center. He works actively in the conduct of collaborative family healthcare and community-based participatory research (CBPR) focused on a variety of public health issues, including more than a dozen community-based projects.