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Pearls


Sharing a patient’s care: Secrets for success

Split treatment relationships create opportunities and challenges for both clinicians and patients

Vol. 9, No. 8 / August 2010

Split treatment occurs when a psychiatrist and psychotherapist share a patient’s care. These relationships create opportunities and challenges for both clinicians and patients. Some patients may experience positive transference, such as nurturing and idealization, whereas others may have negative transference, including narcissistic wounds and devaluation of 1 or both clinicians.1 This article will help you navigate split treatment relationships.

Types of relationships

Duplicative services involve a patient receiving psychotherapy or psychopharmacology from ≥2 clinicians; the latter is more common. Duplicative psychopharmacology can occur inadvertently when drugs prescribed by a nonpsychiatrist overlap with psychotropics in their effects.

Duplicative opinions. When sought with the knowledge of all parties, second opinions can strengthen the doctor-patient relationship and improve outcomes. Duplicative opinions may be pathologic when patients do not disclose their opinion-seeking to both clinicians. This form of “doctor shopping” is common among patients with personality disorders, especially borderline personality disorder, and those who seek drugs from multiple providers to abuse, stockpile, or sell them.

Strategies for split treatment

During the first session, discuss the patient’s expectations. Establish a treatment plan, setting forth what you are and are not responsible for managing. If the patient is transferring treatment to you, ask if he or she has terminated treatment with the prior clinician.

If psychotropics are indicated, ask the patient to agree that only you will manage medications for mood, attention, cognition, energy, and sleep, except in an emergency such as an allergic reaction. Inform your patient that having multiple physicians managing these symptoms puts him or her at risk for drug-drug interactions and ineffective treatment. Ask your patient to notify you about any new medications.

A patient’s psychodynamic issues with medications can complicate pharmacotherapy. For example, a patient may experience transference reactions to medications, such as issues relating to control of the treatment process or psychogenic side effects. Ideally, the psychotherapist and psychiatrist work together to determine which clinician could better address these issues.

If a patient reports that another clinician devalued your treatment, don’t react immediately. Explore with your patient how the discussion with the other clinician came about. Patients can misinterpret what other clinicians say or lie in an attempt to create conflict between you and your colleagues. Give the other clinician the benefit of the doubt and if possible, speak to him or her before commenting about the alleged statements. Look at these situations as an opportunity to set limits with patients.

References

1. Bradley SS. Non-physician psychotherapist-physician pharmacotherapists: a new model for concurrent treatment. Psychiatr Clin North Am. 1990;13(2):307-322.

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