Thursday, May 24, 2012

When Independent Treatment Goes Dysfunctional

What does a psychiatrist, or even a primary care physician, do when she harbors doubts about the patient's psychotherapy? As I have opined previously I believe the advantages of independent psychotherapy and medication management (or other biological treatment, such as TMS) outweigh the disadvantages. But when the physician does not know the psychotherapist well because the patient chooses his psychotherapist or the physician does not know the psychotherapist well, problems can arise, for example when there is:
  • No sign of improvement after extended treatment.
  • Evidence of boundary violations or other impropriety in the relationship.
  • Failure of the psychotherapist to respond to phone calls or other attempts to establish or maintain contact for coordination of treatment.
  • Lack of evidence of effectiveness of the treatment approach for the patient's disorder.
or when:
  • The physician has a vague negative sense about the psychotherapist from past encounters.
  • The physician dislikes the psychotherapist.
  • The physician knows that the psychotherapist dislikes her.
One might expect to resolve some of these problems with a phone call, email, or other communication, but a persistently dysfunctional treatment team can ultimately harm the treatment. Which relationship should take precedence over the other, the medication management relationship in which the patient spends ten minutes with the psychiatrist every three months, or the psychotherapy relationship consisting of fifty minute meetings weekly? Medication may work the same regardless of how you feel about the person who prescribes it. This may not hold true for psychotherapy. At what point should the physician impose an ultimatum: Find a new psychotherapist, or find a new psychiatrist?


  1. I think that the focus of all things therapeutic needs to come down to technical expertise. The like/dislike factor is played out in a number of settings including inpatient teams and administrators who tend to dislike any clinician who does not agree with them. In that regard the way professionals manage any "personality conflicts" is critical because if they are supposed to be on the same team these conflicts inevitably play out in suboptimal patient care.

    Regardless of the dynamics, if there is an impasse irrespective of the cause I think a new arrangement needs to be negotiated. I would not exclude transferring care of the patient to a psychiatrist with whom the therapist can communicate. The only exception would be a clear lack of expertise on the part of the therapist. Assessing that from afar with no meaningful communication is fraught with difficulty but there are some clear markers.

  2. ...hmmmm. Interesting. Out of curiosity, are there times when you refuse to see patients because they choose not to be in psychotherapy?

    Ultimately, it is up to the patient who he or she values more (the psychiatrist or the therapist). A good psychiatrist is hard to find. Trust me on this one. I know. And some people would be useless in therapy without meds. You might be surprised how many people would choose their 15 minutes every three months with you over their psychotherapist.

    I actually didn't know there could be such a serious issue with the psychotherapist that the psychiatrist would want to quit working for the patient. If it's an issue of the psychotherapist being unprofessional and not wanting to work with the psychiatrist, you might want to just tell the patient. It's not backbiting. It's a matter of business. Tell the patient that the psychotherapist refuses to coordinate care with you. And then make a referral to one you think that you and the patient can work with. I would want to know, as a patient, if my psychotherapist wasn't responding to my psychiatrist. And I would want my psychotherapist to tell me if my psychiatrist would not coordinate care with the psychotherapist. I would also be interested to hear if my psychiatrist thought there was a problem with the therapy. Or have my psychotherapist tell me that there was something wrong with the psychiatrist's diagnosing and med management. A lot of psychotherapists don't want to lose business and refer a patient to someone else if things aren't working out. If you suspect the therapy isn't working out and the patient should go elsewhere, that might be something your patients would want to hear. Psychotherapists (and I have heard this from more that one person) will sometimes try to blame the patient when therapy doesn't work out...but that doesn't explain why therapy was suddenly so much more effective with another therapist.

    If you are at a point where you think that you might actually want to quit, then it probably is best to say something. The patient is paying a lot of money for all of that treatment, and they deserve to know if something is wrong with the treatment. I've had to fire a couple of doctors because of poor coordination of care (they had the worst front desk service imaginable). I know that's a different kind of care coordination, but patients need to know what kind of care they're getting for their money.

  3. Wonderful comment Jane, great questions. As for losing business, that raises the issue of referring only within a group practice. You know each other better, and expected communication can happen easier, but the patient has a right to choose a professional outside the group. I am also reminded by you about using the patient to monitor the psychotherapy. My stock question is, "What are you working on with ___________ in psychotherapy?" I get worried when the patient can answer that. There are also problems that meds don't solve, and I expect a competent psychotherapist to address them in some way.

    But does it work better to criticize or question the other professional through the patient, or should we attempt to sort things out at the professional "level" first?

    1. "But does it work better to criticize or question the other professional through the patient, or should we attempt to sort things out at the professional "level" first?"

      I think in your post, you are talking about professional relations that are consistently bad. It's not problems that will be solved through communication with the other professional. I didn't fire the two doctors from my past because the care was bad once or twice. Their front offices consistently sucked in ways that had huge consequences for my health. And one of them really should have been fired long before I fired him, but I waited until the front office did stuff that was unforgivable. I was smarter with the other doctor's office. He was fired within a few months, when I realized his front office is consistently dysfunctional. It's problems that won't be solved through talking it out. The whole setup is bad and you need to just jump ship.

      I did actually try to work it out with one of the doctors. But he got really defensive and didn't want to hear any complaints. I've heard over and over again that complaining is pointless and you need to just fire the doctor, because they tend to be really defensive about the front desk.In my experience, professionals don't like admitting when they are wrong and have a philosophy that if you don't like their care then you can just go somewhere else.

      I take it you are not talking about one or two isolated problems with the psychotherapist. The therapist just sucks or the relationship simply doesn't work. However, if you believe in the relationship with the patient, then talking to the patient about the problem is probably the best course of action.

  4. One thing I'm "talking about" you remind me I didn't really talk about was that I think it does the patient a disservice when the psychotherapist suggests meds to the pt. I would prefer they discuss it with me first.

    When you talk about "consistently bad" I can't relate. With psychotherapists either the method of treatment is not effective or appropriate, they're doing really crazy things, or they don't return my calls. Disappointment in physicians like you describe is a little more straight forward to me.

  5. I find it interesting that you dislike the psychotherapist suggesting medications to the patient; yet, you have the right to criticize the psychotherapist's treatment approach. I do agree that the psychiatrist should talk about medications, while the psychotherapist should conduct therapy. You may ask questions but I highly doubt that you can determine what therapy is effective or appropriate for the patient. Why don't you do it yourself?

    In my experience, psychiatrists do not return phone calls. It's rare that a psychiatrist will want to coordinate treatment with the psychotherapist.

    1. Thank you for your comment.My experience is that it is the PSYHIATRIST who does not return phone calls etc.

  6. It's not so much whether the psychiatrist has a "right to criticize" the psychotherapy, but the courts hold us responsible, and maybe we should feel obligated to let the patient know if we think the treatment is hurting or not helping. For more on why I don't do psychotherapy now go to my earlier post linked above. I'm embarrassed for my colleagues who do not return phone calls.

  7. And I disagree with the courts: psychotherapists are independent licensed professionals, and psychiatrists are not trained in assessing their qualifications. Psychiatrists should no more be held responsible for the acts of a patient's psychotherapist than for a patient's attorney.

  8. Hmmm...actually your stuff was more straight forward to me. I hate to fire a good doctor because of the front desk. Do you want a bad doctor with a wonderful front desk? That's why I clung to one of the doctors for as long as I did and tried to work it out. It wasn't him. It was his front office. He was not the reason that he got fired, and so that complicated matters for me.

    By the way, the office manager/receptionist was also his wife. I don't know what this tells us.

    Your examples are actually about the psychotherapist doing nutty things, not returning your calls, possibly psychologically harming your patient, etc. That makes it pretty straightforward for me! It's not that the psychotherapist didn't return your call cuz his receptionist doesn't relay messages to him. It's not like you get a receptionist, who promises to tell the therapist that you called, and then she loses the message and it gets buried in her scheduling book somewhere. The psychotherapist's care isn't hindered because the front desk keeps messing up on scheduling appointments, so the patient is in distress. The psychotherapist is just a nutter or doesn't return calls.

    Though I have to give them a break. I saw a psychologist a long time ago who admitted that it was really hard for him sometimes with his wife. She was an absentminded office manager. She would mess up on booking appointments, working with insurance companies, and whatnot. And he could not criticize her at all. Because you can't talk to your wife like you would an employee. I know a lot of psychiatrists and psychologists have their wives running their offices for them, and that can really complicate matters. It's not like they can just fire their wives or get mad every time she forgets to mention Moviedoc called.

    Speaking of may want to check on whether your calls are not returned because the therapist won't return them or because the receptionist is not relaying the message. Hmmmm...

  9. Bad idea using spouse as office staff. Boundary problems: For example, the pdoc whose practice I took over many years ago. His wife, intoxicated, called me to give her opinion after hours regarding a pt transferred to me whose chart she had been reading.

    My theory about failure to return calls: They don't have authorization yet. I must be more careful to NOT mention a pt's name when I leave a msg, usually on the voice mail.

    A good doc should be responsive to your feedback about poor staff.

  10. I found this blog entry to be incredibly one sided. Why is the author presuming that it is the THERAPIST who is incompetent, ineffective,harming the patient, etc?
    or that medication is more effective than therapy?
    Empirical studies have proven that CBT is as effective , as anti-depressants in the treatment of depression, have they not?
    I am hardly against medication.
    However, I am currently being treated with a highly skilled therapist at a top group practice in New York. The group only practices C.B.T .and D.B.T. and EVIDENCED BASED psychotherapy. They are involved in research, and have published widely.
    I realize now how much time I wasted in what passed as "psychotherapy" with psychiatrists.
    I do not intend to offend any psychiatrist who reads this who practices therapy. I have, found,however, that there is a world of difference between regular"talk therapy" and Cognitive Behavior Therapy which involves highly specialized skills that is simply not offered to psychiatrists in their training.
    I have achieved greater gains in therapy in 2 years of treatment with a highly skilled C.B.T. and D.B.T. therapist than in all too many years of "ordinary psychotherapy."
    Why does the author believe that a psychiatrist is in the position to evaluate the work of a therapist, or worse, that it would be the THERAPIST who does not return phone calls, violates boundaries, etc, and not the M.D. ??
    Lastly, my PSYCHOLOGIST has NEVER answered his cell phone during session. The same can not be said for a number of psychiatrists I have seen. I can not figure this one out. I have never had any other kind of M.D. who answered a cell phone call while in session, while BILLING FOR IT, yet !

  11. Anon, first I'm sorry it took me so long to respond to your excellent comment. I agree with pretty much everything you say and appreciate your saying it here. I'm not presuming anything about the psychotherapist, but it does happen sometimes. A couple patients I treat now seem kind of stuck, not getting DBT or CBT predictably. I'm all to well aware that psychiatrists do those bad things you mention. BTW: I also agree that the psychiatrist may or may not be qualified to evaluate the psychotherapist. It seems the courts and medical boards think we should be able to though. So my post seems one sided because I don't presume to speak for the other side.