Combined Psychotherapy and Pharmacotherapy Research Paper

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1. Background And Introduction

Combined psychopharmacology and psychotherapy is a treatment form quite accepted and ubiquitous in modern psychiatric practice (Beitman 1983). It may have its origins in the writings of Fromm-Reichman wherein the role and responsibilities of the analytic treating therapist were differentiated from the managerial therapist, a feature of long-term psychotherapy in the 1940s (Fromm-Reichman 1947). Further explicated by Firman, the rationale of this division of labor was based on analytic principles: the ‘psychotherapist’ should ideally not be in any managerial relationship with respect to the patient so that the patient’s fantasies about the therapist could be viewed and analyzed as material emanating from the patient’s own self (Firman 1982). According to Firman, the usefulness of this relationship is twofold: the ‘outsider’ (managerial) therapist can serve as a negative split object upon whom the patient can focus her own negative features. This serves to allow the tenuous whole-object relationship with the treatment therapist to proceed without jeopardy. Firman viewed the splitting that would occur in such collaborative relationships to be in a therapeutic setting and thus under better and safer control for the patient (Balon 1999, Firman 1982).

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Since then, the techniques used in analytic practice and with patients in long-term psychotherapy have been transferred to almost all types of psychotherapy. Fueling this have been newer and simpler types of psychotropic medication which physicians, other than psychiatrists, feel comfortable prescribing (Horgan 1985, Regier et al. 1978, Schurman et al. 1985) and systems of care which have advocated for lower costs for patient care. Additionally, numerous research studies confirm that the combination of psychopharmacology and psychotherapy treatments are more effective than each alone (Goldsmith et al. 1999, Karasu 1992, Koenigsberg 1994, Manning et al. 1992) adding incentives for therapists to seek consultation for their patients from physicians regarding medication.

In modern psychiatry, collaborative treatment wherein a psychiatrist or other physician provides the medication and manages medical issues while a nonphysician therapist provides the psychotherapy is a common and growing treatment modality. While the field has not definitively defined this paradigm, the American Psychiatric Association published guidelines describing the responsibilities in a collaborative relationship, noting that the psychiatrist and therapist share responsibility for the care of the patient in accordance with the qualifications and limitations of each person’s discipline and abilities (American Psychiatric Association 1980). Various terms have been used in the literature and in clinical care to describe this practice which include medication backup; split treatment; combined treatment; medical management; co-treatment; triangular treatment; collaborative treatment; medical backup, and parallel treatment. For the purposes of this section we will call this practice ‘collaborative treatment.’




What has not been definitively researched, however, are the best methods for providing collaborative treatment. Recognizing the cognitive and emotional problems for all parties, Goldsmith and co-workers and others have sought to better explicate the potential difficulties and sources of conflict (Berg 1986, Bradley 1990, Chiles et al. 1984, Goldsmith et al. 1999, Kingsbury 1987). Others have described the positive aspects of this form of treatment (Balon 1999, Michels 1995).

The remainder of this research paper will focus on some of the highlights of collaborative treatment: the positive and negative aspects, legal and ethical issues, and suggestions for maximizing the collaborative process.

2. Positive And Negative Aspects Of Collaborative Treatment

The combination of psychopharmacology and psychotherapy, or collaborative treatment, has some positive and negative aspects. As noted by Beitman (1983), collaborative treatment is based on a triangular relationship between psychiatrists, patients, and nonmedical therapists. In an ideal world, such a triangle should have just positive aspects, e.g., utilization of special talents. Triangular relationships, however, could also be a breeding ground for difficulties or negative aspects, such as splitting. The negative aspects of collaborative treatment do not arise only from patients’ pathology. As Brill (1977) pointed out, ‘More and more nonmedical mental health professionals began to resist and resent working under the direction of a psychiatrist. They believe that their own professions and therapeutic skills have advanced to the point that independence and self-determination were justified.’ He emphasized the emergence of territorial conflicts arising in collaborative ‘team’ treatment. The territorial or turf conflicts and concerns are a bilateral issue—psychiatrists, as much as nonmedical therapists, frequently view the ‘other side’ as a competitor rather than a collaborator.

Collaborative treatment could benefit the patient only if it is truly collaborative, when positive aspects are maximized and negative aspects minimized. Awareness of the possible positive and negative aspects of collaborative treatment is the first step in maximizing the collaborative relationship (see below).

2.1 Positive Aspects Of Collaborative Treatment

2.1.1 Utilization Of Special Talents Of Both Therapist And Psychiatrists. As Balon (1999) pointed out, both professionals may possess expertise in special areas, e.g., mood disorders, eating disorders. Firman (1982) also pointed out that a psychiatrist who is a skillful psychotherapist could also serve as a second therapist, or a negative split object, on whom the patient focuses many of his her own disowned negative features.

2.1.2 Cost-Effective Utilization Of All Resources. This is an issue especially important to patients. Due to various economic pressures, most patients cannot afford psychotherapy by psychiatrists unless they have good mental health care benefits. In many cases, insurance companies either do not cover psychotherapy by psychiatrists or pay an amount that is not acceptable by psychiatrists. Psychotherapy provided by nonmedical psychotherapists is considered cheaper (a contentious issue; see Goldman et al. 1998) and frequently is covered by insurance companies. Most patients thus can still benefit from the combination of pharmacotherapy and psychotherapy.

2.1.3 Better Opportunity For Patient To Select Therapist With Similar Ethnic And/Or Gender Background. Some authors (e.g., Foulks and Pena 1995) have advocated that matching a patient with a therapist or physician of a similar ethnic or cultural background may facilitate the process of psychotherapy or pharmacotherapy. Others (Yamamato et al. 1993) have warned that this matching could have its pitfalls and could be discriminatory at times. Nadelson and Zimmerman (1993) have recommended that a patient’s request for a therapist or psychiatrist of a specific gender, ethnicity, or race or a patient’s uneasiness with a particular therapist’s or psychiatrist’s gender, ethnicity, or race should be an issue explored and addressed in therapy.

2.1.4 Increased Time And Resources Available For Patients. The combination of a 20-minute medication review and 50-minute therapy session represent more resources than just one of these modalities and is an unquestionable benefit. The combination of resources is also advantageous during the temporary absence of a psychiatrist or therapist.

2.1.5 Increased Amount Of Clinical Information. There may be information that the patient feels more comfortable sharing with their therapist and vice versa. Thus, psychiatrist and therapist should set time aside to share information, impressions, and concerns and to support each other in their efforts to help patients (Pilette 1988).

2.1.6 Enhancement Of Compliance. As Paykel (1995) pointed out, psychotherapy may assist or possibly hinder, medication compliance. Similarly, collaborative treatment may also increase compliance with psychotherapy.

2.1.7 Professional And Emotional Support For Both Therapist And Psychiatrist. As Pilette (1988) pointed out, such support is especially important when the patient is difficult to treat and also during times of crisis.

2.2 Negative Aspects Of Collaborative Treatment

2.2.1 Inappropriate Prescribing Decisions Without Knowledge Of The Content Of Therapy. The prescribing psychiatrist may not always be aware of all the inner conflicts or external pressures felt by the patient. For instance, the psychiatrist may prescribe medication for anxiety that arose after an important intrapsychic conflict was addressed in therapy with the nonmedical therapist.

2.2.2 Potentially Discrepant Information Given By The Patient To Each Clinician. Frequently, the discrepant information provided by the patient to both treating professionals could lead to decisions with serious consequences. This issue is directly related to the next one—splitting.

2.2.3 Splitting Of Clinicians. This is probably the most frequently discussed negative aspect of collaborative treatment. Treatment provided by two persons provides a fertile ground for a patient to develop negative transference, to introduce problematic countertransference and to split the prescribing psychiatrist and therapist. Splitting may lead to noncompliance with any of the treatments.

2.2.4 Unclear Confidentiality. As Pilette (1988) pointed out, is the collaborative treatment an occasion for free communication between a therapist and psychiatrist without the patient’s consent? What if the patient asks that some important information not be related to the other treating professional? These issues are complicated and need to be discussed and resolved.

2.2.5 Clouded Legal And Clinical Responsibility. It is not always clear who is legally responsible for various aspects of collaborative treatment. It is rather safe to assume, however, that the psychiatrist will most likely be found legally responsible for all aspects of clinical care including inappropriate or negligent supervision (Balon 1999).

2.2.6 Lack Of Reimbursement For Collaboration. The fact that third party payors do not reimburse for collaboration somewhat hinders the collaborative treatment.

2.2.7 Various Misconceptions Of Patient, Therapist, And Psychiatrist. These include issues such as therapists and psychiatrists ignoring the psychological meaning of medication, psychiatrists’ belief that therapists should always agree with and support physicians’ decisions, and patients’ common perception that psychiatrists are only interested in prescribing medication (Goldsmith et al. 1999).

This is only a brief summary of positive and negative aspects of collaborative treatment. More thorough discussion of both positive and negative aspects is provided in the two introductory chapters of Psychopharmacology and Psychotherapy. A Collaborative Approach (Goldsmith et al. 1999, Riba and Balon 1999).

3. Legal And Ethical Issues

3.1 Legal

The major worry in collaborative treatment is that with two clinicians delivering the care, there will be a loss of information or understanding of what may be occurring for the patient. There are currently no standards in place for how frequently or for how long patients should be seen by physicians if collaborative treatment is provided. There is, therefore, a broad range of frequency of visits and communication patterns between the patient, therapist, and physician, which range from ideal to inadequate. Because medications are involved in collaborative treatment and historically have been the source of significant legal exposure, the issue of medical practice is an important topic for discussion. Negligence underlying malpractice liability is of two types: (a) carelessness in gathering necessary data about a patient and (b) negligence in assessing that information in determining appropriate treatment modalities, interventions, providing precautions, etc. (Macbeth 1999). Psychiatric medications, like all medications, are associated with side effects. Physicians who prescribe medications become liable if there is a deviation in the accepted uses of the medications and there results harm to the patient. It is critical for physicians to obtain informed consent from patients when prescribing medication and also to ascertain liability for patient suicide.

If patients are going to be seen infrequently by the prescribing physician, there must be a way for the physician to set up a communication pattern where side effects and suicidality are made known, to the extent possible, to the physician, on a regular basis. For example, if a patient were being seen by the physician every six months but the therapist is seeing the patient weekly, then the therapist and physician must discuss how issues and developments about the patient can be communicated.

In collaborative treatment, it must be determined how the treatment plan is shared between the clinicians; how emergencies including hospitalization will be managed; and who is directing the psychotherapy. The setting may play a large role in the extent to which the physician, therapist, and patient communicate. In many public settings, for example, the psychiatrist only sees the patient infrequently. The patient, however, has a case manager whose job it is to communicate to the various clinicians about the patient. In managed care settings, psychiatrists may find themselves in relationships with therapists whom they don’t know and who are unaware of their skills, talents, experience, etc. There may be disincentives for the physician to see the patient often, even when more psychosocial problems accumulate for the patient. In collaborative treatment in certain settings, patients sometimes don’t even know who the doctor is and often the physician has not had the chance or taken the opportunity to meet with the patient’s family, since others (therapists, case managers, nurses, a previous physician) might have already done so.

There is, therefore, a range of potential legal problems for physicians who engage in collaborative treatment. Physicians are usually viewed as ‘the deep pocket’ when there is a lawsuit regarding a patient’s treatment. The physician usually carries more insurance than the nonphysician therapist and is viewed by juries as ‘being in charge’ by virtue of education and experience. Even if the plaintiff’s attorney does not believe that the psychiatrist was central to the matter, it is often likely that the psychiatrist will be part of the suit to extend the limits of insurance and to try to reach ‘the deep pocket.’ There is also the problem that occurs when there is more than one defendant. One defendant can try to make their case stronger by blaming the other defendant, thereby turning against one another. Another problem is that even if medications or the medical management provided by the physician is of minor importance to the reason for the suit, regardless of the realities, the physician is often viewed as being in charge while the therapist is viewed as subordinate to the physician.

Finally, physicians are increasingly signing contracts to provide services for patients in managed care. These contracts are usually written by the companies themselves and the fine print is not read carefully by the physician, causing them to be implicitly involved in relationships with therapists that are not collaborative in nature but more supervisory. This practice, therefore, often puts the physician at further risk.

There are some suggestions for clinicians to heed in order to decrease legal risk in collaborative treatment:

(a) Clinicians should understand the settings they are practicing in, including its operations and routines.

(b) Care should not be compromised because of the setting or because the patient is being treated in a collaborative model.

(c) Use good communication techniques with professionals with whom you are sharing responsibility for the patient. Document these discussions.

(d) If supervision is part of the collaborative relationship, then set regular supervision times and amend depending on the patient’s condition and needs.

(e) Read the fine print in all managed care and other contracts that are signed.

For a more thorough discussion of these issues, please see the work of Macbeth (1999).

3.2 Ethical

When patients receive collaborative treatment because that is what is deemed best for their care, then there is not an ethical problem. An ethical and clinical dilemma however, may exist if such care is provided because of cost considerations (Lazarus 1999). While some patients clearly benefit from team approaches to care, others do not. Research is starting to help us discriminate between such patients and determine mental health outcomes in different practice and fee arrangements (Rogers et al.1993, Wells et al. 1992). Goldman et al. (1998), for example, has shown that for many patients, psychotherapy and psychopharmacology provided by a psychiatrist alone is as effective and less costly than collaborative treatment.

There are four bioethical principles that need to be considered when one is providing collaborative treatment (Beauchamp and Childress 1994):

(a) Beneficence: the covenant between professional and patient to do what is in the patient’s best interest;

(b) Nonmaleficence: the principle of doing no harm;

(c) Autonomy: respect for the individual rights of patients, especially in the area of informed consent and treatment refusal; and

(d) Justice: the fair treatment of patients.

As noted by Lazarus, when determining ethical dilemmas related to collaborative treatment, any two or more of the above principles may be compromised or in conflict (Lazarus 1999). In this era of cost containment and lack of standards regarding collaborative treatment, all of these principles are being tested. The American Psychiatric Association (APA 1993) and the American Medical Association (AMA 1994) have addressed ethical principles and have recognized the importance of collaborative treatment. Section 5 of the AMA principles states: ‘A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated’ (AMA 1994).

It is a complex area where psychiatrists and other mental health professionals engaged in collaborative treatment can find themselves in ethical dilemmas. Some of this has to do with the settings and the rules within those settings; physician–therapist relation-ships that should be modified because of the patient’s condition but may not be; need for differential types of supervision and monitoring between therapist and physician but which are not taken into consideration; fee schedules that cause disincentives for providers to see patients more often, even when needed; lack of understanding by the patient of the nature of the collaborative relationship between the providers; etc.

In order for health professionals to provide psychotherapy and psychopharmacology in an ethical manner, Lazarus (1999) suggests:

(a) The physician and therapist keep themselves adequately and appropriately informed of the nature of the treatment and the progress of those patients cared for in this type of treatment.

(b) The physician and therapist assure themselves that the treatment is being carried out competently and adequately.

(c) The physician and therapist provide enough supervision, consultation, or collaboration to ensure that their ethical, medical, and legal responsibilities towards the patient are satisfied.

(d) The collaborative treatment is consistent with any local, state or national guidelines outlining psychiatrists’ responsibilities to patients and in conformity with licensure requirements and the scope of practice of all the healthcare professionals involved.

4. Maximizing The Collaborative Relationship

Providing combined psychopharmacology and psychotherapy is a complex enterprise, much more difficult than a single therapist providing either the psychotherapy; psychotherapy and pharmacotherapy; or pharmacotherapy. There are, therefore, some general suggestions offered that might be useful.

It is incumbent upon the clinicians and patients involved in such treatment to be aware of the complicated nature of this form of care. While combining psychopharmacology and psychotherapy offers distinct and unique advantages, there are problems, as noted in the above section. Time and attention must, therefore, be given to the process of treatment as well as the content. Written contracts between clinicians have even been suggested as a way to delineate the specific duties and responsibilities of providers (Appelbaum 1991). Other authors have suggested that the patient be part of the three way contract and so be asked to sign such agreements for care (Chiles et al. 1984, Woodward et al. 1993). Specific guidelines for combined care based on the phases of treatment (initial, mid, termination) have been described by Rand (1999). Kahn (1990) has delineated the ideological differences that the psychotherapist and psychopharmacologist often have and the identified roles they must play in order to provide such treatment.

It is probably prudent for clinicians, both physicians and nonphysician therapists, to review their case mix from time to time. Goals would be to limit the numbers of such collaborative treatments based on the amount of time it takes to speak with other therapists; review and develop joint treatment plans; read other clinicians’ notes; determine the background and treatment orientation of the clinicians who are collaborating on patient care; work with patients’ families and significant others; develop vacation and coverage schedules with collaborating clinicians; discuss such arrangements with patients; etc. Such thoughtful processes may lead to a decrease in malpractice exposure and ultimately more efficient and useful clinical care.

Attention must be paid carefully to the issue of confidentiality and communication between clinicians and with the patient. Consent to discuss treatment plans as well as content of sessions must be clarified. Since it is impossible to initially predict what will be important or relevant, the patient must be cognizant of these communication patterns and provide consent to clinicians at the beginning of treatment. Any barriers to such communication should be discussed with the patient as well as any relevant family members. It should be determined how the information will be transmitted, that is by telephone, electronic communication, mail, in person, etc. and how often. Communication must be regular, not just when there is a crisis (Vasile and Gutheil 1979). It is critical that the patient understands which type of problems should be discussed with which clinician. Further, patients should not be placed in the position of needing to relay information between clinician and the other.

Even with that said, it will sometimes be difficult to sort out. As an example, often what seems like uncomfortable medication side effects could be resistance to taking medications. What seems like a dynamic issue in therapy could in fact be a medical problem. Clinicians need to be supportive of the treatment plan; listen for resistances to either psychotherapy or pharmacotherapy; try to delineate the boundary of the treatment being provided by the individual clinician; and talk regularly with one another about the patient’s progress. Because of financial remuneration patterns and modern contractual agreements between clinicians and payers, it is easier than ever for a clinician to find themselves responsible for large numbers of patients, many of whom are not being seen frequently or regularly. This can lead to problems with the inherent doctor–patient relationship that is the hallmark of providing care, whether it is pharmacotherapy, psychotherapy, or both. The clinician is well advised to review the ethical boundaries of the work situation and the nature of the tasks required.

Certain patient populations may be at higher risk in such combined therapies. For example, patients with personality disorders are notoriously difficult to treat given their problems with interpersonal relationships. As summarized by Silk (1999) and others, patients with Cluster B diagnoses are prone to splitting (Kernberg 1975); often do not tell the entire story equally to all clinicians (Main 1957); and tend to externalize problems (Silk et al. 1995). When there is concomitant substance abuse, emotional lability, and self-mutilating behaviors, combined treatment with more than one clinician can be enormously difficult and complex.

Finally, psychiatry residency training programs and graduate programs in social work and psychology must develop education and training in the specific area of combined treatment. Teaching psychopharmacology alone or psychotherapy without integrated pharmacotherapy is no longer sufficient. There needs to be curricula developed and teachers who are trained themselves in how to deliver such care with emphasis on learning to communicate clearly with other professionals; thinking clearly about diagnosis and treatment strategies; and developing leadership abilities (Spitz et al. 1999).

5. Conclusion

Providing combined pharmacotherapy and psychotherapy is a growing and important part of psychiatric care. It is a complex dynamic treatment, fraught with potential pitfalls but offering many advantages. Importantly, it offers a unique opportunity for a biopsychosocial and fiscal model of care and interesting areas for future research and clinical development.

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