The Betrayed PatientA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2,3Kendall L. Stewart, MD, MBA, DLFAPANovember 8, 2013

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.3The emotional pain and stress that follow a betrayal commonly trigger medical visits for a variety of medical conditions.

Why is this important?

1While open marriages do exist, most people can’t sustain them.2 People desperately want to feel special.

• A lot of folks have affairs.• Apparently, men cheat more often

than women do.• Infidelity, whether suspected or

discovered, almost always causes great pain.1

• Infidelity may be involved in up to 90% of first-time divorces.

• A good number of your patients will attempt to survive the affair—and some will succeed.

• They will look to you for insight and help.

• After mastering the information contained in this presentation, you will be able to answer the following questions:– What is an affair exactly?– How do betrayed patients feel?– How do betrayed patients behave?– What 10 steps should the

betrayed partner take?– What 10 steps should the partner

who betrayed take?– How should you respond to the

betrayed patient?

What is an affair exactly?

• It depends.• Perceptions rule.• Sometimes there is no debate that one occurred.• Then there is jealousy.1

• Delusional jealousy is even more serious.• Any “competitive bond” is a good working

definition.2

• Sexual intercourse is not required.• Secretive Internet chat, sexting3 and porn

qualify.1An accomplished professional woman recently told me she could not be seen talking to me if her husband were present.2When you engage in any behavior you would not want your partner to know about, you’re on the slippery slope.3While the incidence is controversial, up to 50% of young adults may engage in this activity.

How do betrayed patients feel?

• Numb and raw• Angry and detached• Violated and responsible• Abused and vengeful• Disgusted and jealous• Helpless and powerful• Victimized and guilty• Hopeless and hopeful• Worthless and superior• Anxious and calm• Hateful and loving• Resentful and relieved• And more1

1Vascillation is the rule.

How do betrayed patients behave?

• Impulsively• Destructively• Revengefully• Hurtfully• Angrily• Spitefully• Murderously• And, rarely, deliberately and thoughtfully

What 10 steps should the betrayed partner take?

• Manage your feelings.• Avoid making matters worse.• Consider your options.• Engage professional help to obtain an objective

perspective.• Document your feelings in a journal.• Allow yourself to grieve.• Avoid impulsive decisions and indefinite procrastination.• Clarify your expectations.• Prepare for the worst.• Employ healthy distractions.

What 10 steps should the partner who cheated take?

• Document the reasons for ending the affair.• Make a “public” commitment.• Prepare to grieve.• Cut off all contact with your lover.1

• Avoid all situations in which you will be tempted to lower your guard.

• Do not retreat into a drugged fog.• Distract yourself with healthy activities.• Seek out nonjudgmental people who will hold you

accountable.• Invest in healthier relationships.• Get professional help.

1This must be deadly serious. No eye contact. Burn all mementos. Promptly report all sightings. Move to Alaska. Change churches. Etc.

The Betrayed PatientA Patient-Centered Therapeutic Process

• Prepare me for the long haul.1

• Give me hope that I can succeed and that I will feel better.

• Encourage me to keep a journal of my feelings.• Recommend that I not behave impulsively when I am

upset.• Support me when I do that anyway.• Urge me to avoid insisting on details of the affair by

reminding me that I will have to live with what I learn the rest on my life.

• Gently point out that I can make matters even worse.• Bear with me when I repeat myself.• Encourage healthy distractions.• Point out the power of the status quo.• Explain the competing pressures of my painful limbo

and my fear of the future.

• Listen to me.• Accept my feelings.• Explain the grief reaction I am experiencing.• If you can’t give me the time I need, refer me to

someone who can.• Help me identify my options.• Help me choose the best option.• Help me develop an objective pro and con list for

each option.• Be patient with my uncertainty and inconsistency.• Clarify the process that I should follow to heal this

breech—if that is the option I choose.• Clarify the process my partner should follow to

recover from this injury.• Challenge my unrealistic expectations.

1When partners do everything perfectly (and they never do), recovery to the level of trust before the betrayal takes five years.

How can you access the OU-HCOM psychiatry flash cards online?

• Go to Quizlet.• Create a free account.• When you receive a confirmatory email, click on the link

to activate your new account.• With your activated account open in another browser

window, click on this link to join the class.• You can download the free Quizlet app to your iPhone or

import these learning sets to the more robust Flashcards Deluxe app.

• Enjoy. I hope you find these cards helpful.• Please post your feedback or suggestions on the Quizlet

site.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011

• Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012

• Blitzstein, Sean, Lange Q&A Psychiatry, 2011• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

How can you contact me?

Kendall L. Stewart, MD, MBA, DLFAPAVPMA and Chief Medical OfficerSouthern Ohio Medical Center

Chairman & CEOThe SOMC Medical Care Foundation, Inc.

1805 27th StreetWaller Building

Suite B01Portsmouth, Ohio 45662

740.356.8153

StewartK@somc.org KendallLStewartMD@yahoo.com

www.somc.orgwww.KendallLStewartMD.com

Are there other questions?1,2

Safety Quality Service Relationships Performance

1Learn more about Southern Ohio Medical Center.2Learn more about our Family Medicine and Emergency Medicine Residencies.

Justin Greenlee, DODirectorFamily Medicine Residency

Thomas Carter, DODirectorEmergency Medicine Residency