The Challenges of Split Treatment

To the Editor: In her Practical Psychotherapy column in the May issue (1), Marcia Kraft Goin, M.D., elucidates some of the challenges inherent in the common practice of splitting medication therapy and psychotherapy between two clinicians—most often clinicians from two distinct disciplines and with different training. As a doctoral-level social worker and psychotherapist who has worked in outpatient psychiatric settings for the past ten years, I am keenly aware of the advantages and disadvantages of split treatment.

The primary advantage is that patients are more likely to benefit from the assistance offered by two clinicians. The primary disadvantage, as eloquently described by Dr. Goin, is the potential for splitting between clinicians—almost always to the detriment of the patient. Use of the strategies advocated by Dr. Goin can certainly reduce the disruption in treatment caused by such behavior.

A second disadvantage of the system, one that Dr. Goin did not identify, is that because younger psychiatrists know that patients have someone else to talk with, they may not develop the basic interviewing and psychosocial intervention skills necessary for diagnosis and management. I have often been appalled by the failure of residents and young psychiatrists to observe the cardinal rule of all communication: it matters little what the speaker says—even if the speaker is a well-credentialed and superbly trained physician—but what the listener hears.

Many scholars and writers have decried the current fixation on biological psychiatry as a root cause of physicians' inability to interact with patients in a therapeutic, compassionate, and effective manner. The consequences of this phenomenon are ill-conceived medication recommendations, failure to tailor medication regimens to the individual needs of the patient, and the overselling of medication as the answer to symptoms that in fact may be rooted in a patient's poor health habits and lifestyle.

At the beginning of her column, Dr. Goin describes a patient who displayed hostility toward the psychiatrist and a pleasant attitude toward the psychotherapist. The psychiatrist felt constrained from exploring and dealing therapeutically with the patient's sudden hostility because she was being reimbursed for only 15 minutes with the patient. Why insurance reimbursement should be a factor in the resolution of such a vital therapeutic matter is beyond this writer. It is my understanding that clinicians, whether they are psychiatrists or psychotherapists, are paid to be effective, not simply to meet with a patient for 15 minutes or 50 minutes. Current standards of practice can usually accommodate the delivery of effective treatment within certain time frames. Nevertheless, is it not understood that at times a procedure such as a medication monitoring interview may take longer than 15 minutes?

Indeed, the vignette illustrates a partial misconception of the power of third-party payers on the relationship between clinician and patient. Is it not our first duty to provide appropriate medically sound care without regard to whether we get paid for our services?