Wednesday, March 24, 2010

Independent Treatment: The Whole Truth

Every article I have read in the psychiatric literature about "split treatment" (The psychiatrist prescribes medication while another professional provides psychotherapy.) reveals a bias against this practice. The article by Drs. Mossman and Weston (Splitting Treatment: How to limit liability risk when you share a patient's care Current Psychiatry 9:3) continues the tradition. While purporting to help psychiatrists avoid malpractice suits related to independent treatment, this article will likely send plaintiffs' attorneys scurrying to the authors' doors for expert testimony to support antiquated theories based in myth. I hope to provide the whole truth, which may appeal more to defense attorneys, not to mention patients.

Mossman and Weston would have you believe the story started "not long ago," when "insight-oriented psychotherapy was the primary treatment" provided by psychiatrists. Not so. The truth is that psychiatry's dalliance with psychotherapy has probably spanned less than half the time since psychiatry's birth; is already a thing of the past; and 100 years from now will probably be viewed as a little blip. There have probably always been many psychiatrists who eschewed psychological treatment approaches, preferring ECT or medication, but psychiatrists only became enamored of psychotherapy with the introduction of psychoanalysis by Freud, who was himself a neurologist.

The terminology betrays the bias in discussions of this subject. "Split treatment" implies inferiority to "whole" treatment (without foundation). More accurate, less pejorative terms include "joint treatment" (which the authors do mention at least once), "collaborative" and "independent" treatment. The authors use these latter terms to designate types of "split-care relationships," but I argue that these terms may in fact be synonymous with split treatment. Collaborative care implies coordination, but still the non-psychiatrist provides the psychotherapy. This term has also been used to designate treatment models in which a primary care physician, rather than a psychiatrist, provides medical management. The term "med check" likewise demeans the medication management or psychopharmacology visit.

Independent care, rather than designating a type of split care, accurately and without bias describes the reality: When a psychiatrist prescribes medication, and a psychotherapist provides psychotherapy, each is an independent, presumably licensed or registered, professional. Neither assumes responsibility for the actions of the other, regardless of who wears the deepest malpractice pockets. What Mossman and Weston fail to mention is that each of these professionals may be "treating" something different. The psychiatrist may prescribe paroxetine for panic disorder while the family psychotherapist treats marital conflict or parenting problems. Yet another psychotherapist, a psychologist perhaps, may provide cognitive behavior therapy for the panic disorder, but even when the two professionals thus treat the same problem for the courts to hold either responsible for the actions of the other is a grievous error. Frequently the psychiatrist may treat a "brain disease" with medication or rTMS while the psychotherapist helps with life problems, related or unrelated to the psychiatric -- or other -- illness.

Another erroneous assumption in the Mossman Weston article, and indeed most discussions of independent treatment is that the duration of the two treatments coincides. In fact many psychiatric conditions require lifelong medication either for symptom control or for prevention. Psychotherapy, however, usually stops after certain goals are reached. This may apply especially to cognitive behavior therapy. No patient should have to continue 45-50 minute sessions indefinitely to satisfy the needs of the psychiatrist who has become stuck in the rut of psychotherapy. And psychiatrists who require all patients to be "in" psychotherapy for the duration of treatment have an obligation to inform each patient that other psychiatrists may require only short medication management visits.

Did I mention the patient? I read the Mossman Weston article twice or more and found no mention of what the patient wants. I regularly encounter patients in my practice who do not want psychotherapy. We must respect what the patient wants, even if ultimately we must guide some patients in a different direction. Some patients, too, want only psychotherapy. And even if the patient wants both, how many psychiatrists can provide skilled psychopharmacological treatment as well as excelling at a variety of different psychotherapies. The patient who needs CBT in addition to medication deserves the best CBT psychotherapist, and that will not likely be the psychiatrist. The patient with a substance use disorder may need a chemical dependency counselor. The patient has a right to choose which psychiatrist and which psychotherapist or counselor from whom he or she wishes to obtain treatment.

Myth: Psychiatrists are the best psychotherapists. Psychologists, social workers and others can possess skills in psychotherapy equal to or better than many psychiatrists. Medical school may provide essential foundations for a psychopharmacology practice, but not for psychotherapy.

Myth: The psychiatrist should judge the competence or credentials of the psychotherapist. This is absurd. No medical school, internship or residency trains any physician in how to "credential" a professional of another discipline. Would this be expected of a primary care provider in the same situation? I think not. Mossman and Weston say "find out if the potential collaborator is credentialed." Even they, however, do not tell us what they mean by credentialed. Would a drivers' license suffice? If the patient's hairdresser or massage therapist provides advice or comfort, must the  psychiatrist confirm registration or licensure? This raises another question. Suppose the patient wants to use a clergyman as a counselor, a Rabi or priest perhaps. Should the psychiatrist then check with God about this individuals "credentials?" Should she "respectfully inquire" about malpractice insurance? The irony in this is that how the courts view this issue may hinge on whether this counselor bills the patient for services. And yet psychotherapists in training programs may provide service at no charge, not to mention other givers of advice in the context of completely informal relationships. Must the psychiatrist then inquire about financial arrangements? What about an alcoholic patient's AA sponsor? I say it's none of our business, and none of our responsibility.

Myth: "Psychiatrists have a duty to ensure that their patients receive good care." The psychiatrist only has a duty to provide good care himself unless there exists a formal supervisory relationship as in a clinic.

Logistical problems: From time to time a patient will have the audacity to consult a non-physician psychotherapist, counselor, or, the latest thing, life coach, without obtaining the psychiatrists permission. Now the abused psychiatrist must decide whether to punish the patient by discharging them on the spot (while carefully avoiding the appearance of abandonment of course), contact the psychotherapist to coordinate care, or ignore this new problem. Perhaps the psychiatrist should add language to the already encyclopedic policy statement each patient probably glances at before tossing in recycling, language demanding that the patient inform the psychiatrist before daring to consult any other professional. Then there is the matter of staying in contact. Assuming the psychotherapist has the courtesy to return phone calls, remember that patient authorization for release of information may expire after 90 days. This means you must make sure that each such patient reactivate written authorization at least that often even when stable treatment dictates visits only a few times per year. It also means that at the very time when communication would seem must critical, when the patient fails to keep an appointment or return calls, providers may not have a way to obtain authorization.

Liability wrongly attached to independent treatment is not a problem for the psychiatrist to solve by knowing through which hoops to jump to avoid liability, but for the courts to solve by attending to reality and obtaining competent expert testimony that supports reality, instead of sour grapes psychiatrists who can't stop living in the past and give up an unjustified bias in favor of integrated treatment. We had enough of a problem with scarcity of psychiatrists before health care reform that psychologists and nurses were able to convince legislatures to give them prescribing privileges. With millions of Americans newly able to afford psychiatric care we should make it easier, not harder, for psychiatrists to focus on what only they are able to do best, psychoparmacotherapy, and leave the psychotherapy to non-physicians.

See also: The Real Reasons Psychiatrists Want to Provide Psychotherapy


  1. The landscape, unfortunately, is littered with those who sought "therapy" from unqualified persons. Whether someone has an MD, Ph.D. or whatever isn't really the thing that is paramount. It's whether or not they are qualified to supply the service and their ethics.

  2. If your thoughts are negative, think how you can tap into your strengths to help you turn these negative thoughts into positive ones, freeing yourself up to make the event or situation a successful one. Having a cognitive behavior therapy session could hep you be more positive.