When Physician-Patients Push Back Against “Split Treatment”
I don’t have the data but the word on the street is that many physicians do not like undergoing split treatment when they become the patient. I have heard this from doctor friends and colleagues, my residents and a couple of medical students. Here is a disguised story about a friend of mine, a cardiologist in another state, who called me to complain:
“I don’t get it. Why should I have to see both a psychiatrist and psychologist? I really like my psychiatrist. He did a very thorough assessment of me when I first saw him. He picked up that I need both medication and psychotherapy and explained that clearly to me. I agreed. He knows what he’s doing. He prescribed the right drug for me. It’s working. And he’s more than a ‘pill-pusher’. He’s kind. But he says because insurance pays so poorly he doesn’t do psychotherapy anymore. I challenged him and I could see he was getting defensive so I backed off.
Now I go to a psychologist for weekly psychotherapy. And I like him too. He’s also good at what he does. But when I asked him how often he and my psychiatrist discuss my case, he hesitated and never gave me a straight answer. So I asked him ‘Would you call him if you thought I was getting worse?’ You know what he said? He told me that it depends. If I get really bad, like suicidal, he’d call him because my psychiatrist has more training and experience and he might want to change my medication or put me in the hospital. He was honest and told me that he hasn’t had a lot of suicidal clients and ‘they kind of make me nervous.’ I guess I was supposed to feel comforted by that but I wasn’t really.
I find it hard to really open up, especially to talk about something as intimate and private as suicide. So this seems like a dilemma to me. If I really open up to my psychologist, he’s going to freak out and dump me back to my psychiatrist. Then my psychiatrist who I never really shared that with – and whom I hardly know - is now going to jump in and take some action. But what if I need something different than ‘action?’ Anyway I just find the whole model of care kind of weird. I thought that you guys got training in psychotherapy during your residency, no?”
Split treatment is also called collaborative treatment. Coordination of care in split treatment is the standard of care of the American Psychiatric Association but in one study, albeit dated, only 36% of psychiatrists adhered to this (1). This piece is not intended to debate the pros and cons of split treatment. Others have done this with finesse (2). In fact, I am of the school of thought that some psychiatrists practicing split treatment are actually doing a fair amount of brief or supportive psychotherapy in addition to prescribing and monitoring medication.
The above example is not just about this. It is about two of the fundamental premises of the therapeutic alliance and those are trust and constancy. Knowing that you can be completely honest with your caretaker and expect that he/she is comfortable with your dark and frightening side is foundational. I am wondering if there are situations in which exceptions should be made to recommending split treatment.
Given how difficult it is for physicians to seek help when they are ill and given that physicians have a higher rate of depression and death by suicide than the general public, is it possible that a split treatment approach is less than optimal? Or upping the ante even higher, could it be dangerous? Are we asking the impossible of a frightened and embarrassed medical colleague, expecting him to put his total trust in two mental health professionals? And unlike the example above, even if the psychologist is fully trained and experienced with treating suicidal patients using evidence-based treatments, can the patient count on his two mental health professionals to practice collaborative therapy without having to ask?
I put this out to the reader. Should psychiatrists who are given the privilege of treating a physician colleague forgo split treatment and practice good old-fashioned biopsychosocial psychiatry?
References
2. Pies, R. (2011). Has Psychiatry Really Abandoned Psychotherapy? Behind the New York Times Story. Psych Central. Retrieved on February 29, 2016, from https://psychcentral.com/blog/archives/2011/04/03/has-psychiatry-really-abandoned-psychotherapy-the-story-behind-the-new-york-times-story
Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.
