Academic Psychiatry 29:195-202, June 2005
© 2005 Academic Psychiatry
Teaching Collaboration Between Pharmacotherapist and Psychotherapist
James M. Ellison, M.D., MPH
Dr. Ellison is Clinical Director of the Geriatric Psychiatry Program of McLean Hospital Belmont, Massachusetts. Address correspondence to Dr. Ellison, McLean Hospital, 115 Mill St., Belmont, MA 02478; ellisonj{at}mcleanpo.mclean.org (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: Collaborative treatment, in which psychotherapy provided by one clinician is integrated with pharmacotherapy provided by another clinician, has been explored from various angles. This article addresses the teaching of collaborative pharmacotherapy to psychiatric residents. METHOD: The author’s observations derive from a selective review of the literature and from conclusions drawn from practicing and teaching collaborative therapy in a psychiatric residency program. RESULTS: Limited formal attention has been given to defining the skills psychiatrists should acquire in order to collaborate effectively. The author describes the rationale for providing collaborative treatment, identifies the skill set that facilitates collaborative treatment, and outlines an approach to teaching and assessing these skills. CONCLUSION: The practice of collaborative treatment is an important psychiatric role. The core skills of collaborative treatment should be explicitly taught and residents’ competency in these skills should be evaluated in psychiatric training programs.
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INTRODUCTION
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Psychiatrists often take pride in being comprehensively trained mental health professionals, equipped to address a broad range of clinical issues and to provide multiple forms of treatment. Residency training programs employ lectures, clinical experience, and supervision to build skills in the delivery of both pharmacotherapy and psychotherapy. During the course of training, a resident is exposed to a variety of patient populations and to diverse clinical settings. In this way, a psychiatrist is prepared to deliver the full range of mental health services from diagnostic assessment and differential diagnosis to multimodal treatment using psychosocial and somatic therapies.
Beyond the training years, however, many, if not most, psychiatrists assume a circumscribed prescribing role rather than a comprehensive treatment role in the care of at least some patients (1). This occurs commonly when a psychiatrist prescribes medications for a patient and monitors their effects while one or more additional clinicians, often nonpsychiatrists, administer psychosocial treatments ranging from individual to group therapies. When the provision of psychosocial and pharmacotherapeutic treatments is contemporaneous but unintegrated, as is too often the case, this is called "split treatment." This unintegrated combination of treatments is prone to complications of transference and countertransference as well as to various types of miscommunications between patient and clinicians or between clinicians.
In contrast to "split treatment," "collaborative treatment" refers to a treatment framework in which pharmacotherapy and psychotherapy are provided by different clinicians who actively attempt to coordinate and integrate these treatment modalities. Collaboration, which implies at least partial independence of the separate clinicians and their approaches with a shared patient, adds dimensions to treatment that are not present when only one clinician is involved (2). In the training of psychiatrists, limited attention has been paid to defining and imparting the skills required for optimally effective collaborative treatment.
Collaboration draws upon a set of skills distinct from the standard diagnostic and treatment skills necessary to provide either psychotherapy or pharmacotherapy. Though many residency training programs ask their residents to engage in collaborative treatment (3), residents may actually finish their training without having received specific guidance in how to work collaboratively with psychotherapists. In discussing how to prepare residents for effective collaborative work, I will review the knowledge base and practical skills required and recommend training approaches that can facilitate their acquisition. For the purpose of this discussion, I will focus on psychiatric residents. Related comments, of course, could be made about trainees from other disciplines. In particular, a collaborative pharmacotherapist can be an advanced practice nurse, a physician’s assistant, or a primary care physician. A psychologist or social worker often delivers the psychotherapy in a collaborative treatment.
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What Should a Psychiatric Resident Know About Collaborative Treatment?
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There is now ample support for combining psychotherapy with pharmacotherapy in the treatment of patients with many different classes of mental disorders (4). As a broad generalization, pharmacotherapy is regarded as a standard treatment component for several specific disorders and as a potentially valuable adjunct for many others (5). Medications often serve to reduce presenting symptoms rapidly and significantly. Patients who view their symptoms in a medical rather than psychosocial context or wish to avoid the commitment of time and money required for engagement in psychotherapy may specifically request medication as an initial treatment approach.
The addition of psychotherapy to pharmacotherapy has been reported, in various conditions, to increase adherence to a prescribed medication regimen and to offer much that may be of even greater value over time. Psychotherapeutic interventions can increase patients’ awareness of cognitive, emotional, life style, and interpersonal factors that affect their symptoms. Psychotherapy can enhance the degree of symptom resolution achieved through pharmacotherapy, address a complementary set of symptoms less amenable to somatic approaches, increase the degree of response in some treatment resistant patients, reinforce the stability of remission, and allow a patient a greater sense of agency in attaining and sustaining treatment goals (5).
Pharmacotherapy and psychotherapy can be offered by a single care provider or by one or more collaborating clinicians. Each approach has advantages and disadvantages for all parties. Some patients may prefer the convenience and privacy of dealing with only one clinician and resist the inclusion of an additional person, which brings with it the incremental expense of additional fees and ambiguity about who is responsible for providing help in specific problematic situations. Other patients appreciate the opportunity to draw upon the complementary skills of two clinicians and to take advantage of a larger safety net of available coverage. Some prescribing clinicians appreciate the opportunity to specialize, build a referral base, and share the management of patients while others resent a narrowed scope of professional activity and fear an increase in liability exposure through sharing treatment responsibility with other clinicians. Some psychotherapists who are not physicians or advanced practice nurses, especially those who engage in treatment of more severely ill patients, welcome the opportunity to enhance treatment by offering an additional modality. Others dislike the loss of autonomy, the implication that biological interventions will address a problem formulated in psychosocial terms, and the need to open up an intimate and dyadic treatment relationship to an additional clinician (5). For the patient and for both clinicians, collaboration can relieve some of the stress associated with feeling solely responsible for a patient’s treatment. It does so at a cost, however, by necessitating a level of attention to communication that is more complex than that required by a dyadic treatment relationship (6). The communication on which effective collaboration is built requires extra time—which is, by and large, not remimbursed—and this communication most likely occurs less frequently than it should in practice (7).
Collaborative treatment, as we know it today, has evolved in response to both theoretical considerations and practical exigencies. At the dawn of psychiatric chemotherapy, some psychoanalysts preferred that their medicated patients receive prescriptions from a separate clinician to avoid the introduction of nonpsychotherapeutic elements into the analytic relationship (8). During the growth of community psychiatry, nonphysician psychotherapists’ treatment of chronically and severely ill patients was facilitated by prescribing psychiatrists who provided diagnostic assessments and pharmacotherapy but were, by necessity, deployed in this specialized role in order to serve the needs of a large patient population. As the scope of psychiatric pharmacotherapy became increasingly complex and specialized, some psychiatrists focused their postgraduate training and activity in this area and welcomed collaboration as a means of promoting more efficient specialization. Other psychiatrists with clinical practices, even those deeply identified with their psychotherapeutic expertise, often accept collaborative treatment referrals as a means of increasing their case load, networking, and maintaining prescribing skills. Some clinicians, by interest or temperament, gravitate toward a specialized pharmacotherapy practice and prefer to work with medical and pharmacotherapeutic aspects of care while relying on a collaborating psychotherapist to address patients’ psychosocial concerns more fully. In many agencies that struggle to control their costs, relegation of psychiatrists to a specialized prescribing role has been considered a means of limiting expense.
It remains unknown whether collaborative therapy is more or less clinically effective than multimodal treatment from one clinician. Supporters of collaborative treatment point out that the clinician who specializes in pharmacotherapy may have greater command of the available medications and more expertise in their use. The specialized pharmacotherapist may have greater skill in predicting or diagnosing drug interactions or recognizing and treating adverse effects. Furthermore, a skilled pharmacotherapist may lack specialized training or experience in providing specialized forms of psychotherapy, such as cognitive behavior therapy, interpersonal therapy, dialectical behavior therapy, or other approaches with possible specific benefits to defined patient subpopulations. On the other hand, as supporters of multimodal therapy from a single clinician will note, the limited pharmacotherapy treatment role usually implies diminished individual patient contact, which can mean that the pharmacotherapist possesses less knowledge about a specific patient’s baseline level of functioning, symptoms of concern, attitudes toward treatment, and psychosocial support system. These deficits may detract from treatment adherence and effectiveness (5).
In addition, debate continues over the questions of cost and cost-effectiveness. Although many institutional programs limit psychiatrists’ clinical roles to pharmacotherapy in the belief that psychotherapy provided by them will drain their budgets, some evidence supports the notion that a psychiatrist providing both psychotherapy and pharmacotherapy is surprisingly cost-effective (9, 10). Preliminary findings suggest that the psychiatrist who provides both modes of intervention is in a position to use a smaller number of sessions per treatment episode since both medications and psychosocial treatment are delivered during the same visit (10). Combined therapy from one clinician, too, may allow fine tuning of the pharmacotherapy in a way that reduces duration of treatment, employment of polypharmacy, overall cost of prescriptions, and occurrence of adverse effects associated with medication interactions and/or excessive dosing.
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What Are the Core Skills of Collaborative Pharmacotherapy?
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Effective collaboration begins with a receptive attitude toward collaborative treatment, complementary approaches, and collaborating clinicians (6). Psychiatrists must be taught that collaborative treatment is an accepted and effective practice (1). For pharmacotherapists, particularly those who are partial to a biological view of mental disorders, effective collaborative treatment requires a basic appreciation of psychotherapy’s value. The psychiatrist must learn not only to feel but also to convey an appropriately receptive attitude toward the collaborating psychotherapist or psychotherapists, even when the treatment "team" is an ad hoc cooperation constructed for practical reasons around the treatment of one or a few shared patients.
Notwithstanding the importance of conveying respect for a prospective colleague, it is also necessary for psychiatrists to learn to identify psychotherapists with whom collaboration will be excessively difficult or impossible as a result of basic differences in clinical values, treatment approaches, personality styles, or competence. One of the skills that psychiatrists are rarely taught is how to respectfully inquire about a potential collaborator’s training, experience, and approach. Though it may be difficult to ask questions that could elicit a defensive response from a peer, learning about one’s prospective colleague early in a shared treatment can reduce or prevent complications, including risk management issues, that might later occur when it becomes apparent that treatment is being affected adversely by the clinicians’ incompatible beliefs and/or professional practices (11). In turn, the psychiatrist must take the time to acquaint the psychotherapist with his or her background and approach. The two clinicians, brought together by the shared treatment of one or more patients, should then communicate adequately about the specific patients’ needs, diagnoses, and treatment plans.
Many consulting pharmacotherapists make use of a consultation request form (Appendix 2) that organizes the information to be obtained from the psychotherapist and documents the history obtained and recommendations made. Some clinicians also make use of a written "collaborative treatment contract" that delineates the roles and responsibilities of each clinician and can be shared with the patient, while others rely simply on a brief discussion to review issues such as how treatment responsibilities will be divided, under what circumstances communication between the clinicians will occur, how coverage will occur during one or both clinicians’ vacations, and who will be available for initial response to a patient during which sort of need or crisis. The substance of such a discussion should be documented in the patient’s medical record for future reference.
Whether treatment is proceeding smoothly or with difficulty, it is helpful for collaborating clinicians to communicate periodically about a patient’s progress and about any major changes in treatment approach. With the patient’s documented consent for initial and ongoing communication, events such as a major advance or setback in treatment, nonadherence to a treatment plan, or termination of one clinician should prompt one clinician to contact the other. Most patients appreciate the value of such communications and easily accept that they will occur at the clinicians’ discretion. Others, particularly those who have had painful prior experiences with previous treaters, may require that specific permission be obtained for the timing and content of each communication. Occasionally, a patient will insist on being included in any communication that occurs between pharmacotherapist and psychotherapist. This may require an inconveniently greater commitment of time from each clinician, but accommodating such a limitation usually can be accomplished through scheduling a joint meeting or a conference call. In advance of such communications, it is generally wise to discuss and agree on the timing and location of such a meeting or call and obtain agreement regarding any charges that will be made for the time of one or both therapists. The occurrence and content of significant communications between treaters about a shared patient should be documented in sufficient detail in the patient’s medical record.
Rarely, a patient forbids pharmacotherapist and psychotherapist to be in contact at all. This often indicates the presence of a complicated transference to one or both treatment providers or the existence of a highly relevant secret that has been selectively divulged to only one clinician. A patient’s refusal for communication between clinicians makes "collaborative treatment" as such an impossibility and usually indicates a severe impediment to treatment progress that should be speedily addressed.
Although I have focused on opening up communication as a support to collaboration, there is often a need to limit certain types of clinical communication. In the pharmacotherapist role with a shared patient, the psychiatrist must be mindful to keep on task and respect appropriate role boundaries. Tempting as it may be to exercise one’s broader skills on the patient’s behalf, the pharmacotherapist should refrain from deeply interpretative comments; from inappropriately detailed inquiry into highly personal areas such as a trauma history; and from excessive availability as an empathic listener when such availability might foster an expectation of continued gratification, lead to counterproductive idealization, and interfere with the alliance between patient and psychotherapist. Similarly, even a pharmacologically sophisticated psychotherapist should be expected to avoid directly advising a shared patient regarding medication choice, dosage, or treatment of side effects. The patient who divulges information to the pharmacotherapist that has not been shared with a psychotherapist—for example, an ongoing substance abuse problem or distressing transference feelings—can be gently encouraged to bring these concerns back to the psychotherapist. When a patient trustingly confides in a psychotherapist the occurrence of embarrassing medication side effects, such as sexual dysfunction or excessive flatus, or admits poor adherence to a medication regimen due to cost or fear of dependence, the psychotherapist can facilitate better treatment by guiding the patient back to the pharmacotherapist regarding these issues. In addition to referring the patient respectfully back to a collaborating therapist, a brief phone contact between clinicians or a message left in an appropriately confidential form can clarify the reason for this referral. In this way, one can avoid a potential misunderstanding on the part of a collaborator who might otherwise conclude that the other clinician is neglecting appropriate communication.
Even when collaborating providers of care are dedicated, skillful, open-minded clinicians, the shared treatment of a patient will occasionally end in irreconcilable conflict. Ideological differences about a patient or treatment approaches or goals, uncomfortably mismatched personal styles of work or communication, or doubts about the co-treater’s actual competence or ethics are important reasons for the failure of a collaborative treatment (6). In almost no other aspect of collaborative treatment is communication between clinicians so vital as when conflict between clinicians threatens a treatment’s integrity and continuity. When such conflict is initiated by a patient’s description of the other clinician’s inappropriate behavior, however, acceptance of the description at face value must be tentative until the patient’s report can be adequately investigated and verified. Sometimes a brief conversation between care providers will clarify a simple misunderstanding or error. If a more serious problem is verified, consultation with a mutually acceptable, objective third party can be helpful. When serious ethical breaches are identified, a clinician may be faced with the difficult decision of whether to involve regulatory agencies such as licensing boards. In such a situation, it is generally wise to review the situation with a trusted colleague and to seek legal advice before taking any other actions. In many cases, it is also necessary for clinicians to examine their attitudes toward their collaborators in order to distinguish reasonable from inappropriate expectations or countertransference projections.
Interruption of a treatment is an unfortunate and disruptive experience for a patient, but a psychiatrist with intolerable reservations about a collaborating psychotherapist (or vice versa) should strongly consider, with appropriate consultation, whether to disengage himself or herself and the patient from a treatment that might otherwise result in harm to the patient or unacceptable risk for the clinician (6). Termination, when necessary, must be handled appropriately so as not to constitute an abandonment of a patient in crisis (12).
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How Should Training Directors Increase Residents’ Skill as Collaborative Pharmacotherapists?
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Psychiatric training programs have devoted little attention to instructing residents in the techniques of collaborative pharmacotherapy and even less attention to evaluating their success in this important clinical role, though this has been recognized as an important area for training (13). Appendix 1 lists some ways in which residency programs can incorporate specific training and evaluation on collaborative pharmacotherapy into a psychiatric resident’s professional training.
Pharmacotherapy curricula for residents should address not only the basics of diagnosis and treatment, but these curricula should also address the broader professional and social contexts that include related issues such as pharmacoeconomic implications of prescribing patterns; research and data analysis methods from which evidence-based treatment recommendations can be derived; informed consent procedures and documentation; appropriate precautions for off-label treatment approaches; risk management; patient education; psychodynamics of pharmacotherapy; and collaborative treatment. The successful conduct of collaborative treatment is important to master, since it has practical implications for clinicians who hope to establish either a private or institutional practice. Effective collaboration can increase patient satisfaction and improve clinical outcomes, encourage a greater volume of referrals, and reduce liability exposure that might result from poorly managed collaborative treatments.
Specific content within pharmacotherapy seminars, therefore, should address the psychiatrist’s role in collaborative treatment. Clinical and risk management issues (2, 11), including standards for documentation and recognition of liability concerns associated with shared clinical responsibility, should be included and can be reviewed in one or two dedicated lectures and revisited in the course of teaching on related topics. Lectures can be supplemented with readings from one or more of the informative publications on this topic (14–18).
In addition to attending didactic sessions about collaboration, each resident should treat a specified number of patients collaboratively. Supervision of the resident’s work should focus not only on the patients but also on the collaborative treatment process and integration of treatment modalities. The precise number of patients is less important than the associated teaching and supervision, but I’d suggest an expectation that a resident treat at least 12 patients collaboratively over the course of several years of residency training. These patients should span a diagnostic range that includes adjustment and personality disorders as well as mood, anxiety, and psychotic disorders. Supervisors should be encouraged to address collaborative treatment interactions and processes, paying particular attention to helping residents develop comfort in sharing responsibility for care while maintaining clarity of role definitions and awareness of risk management issues. By discussing not only the trainee’s interaction with a patient but also the working relationship with a co-treating psychotherapist, a supervisor can work toward these goals and make a trainee’s appropriate or inappropriate attitudes and expectations of collaborators and collaboration explicit. Interdisciplinary case conferences can provide an opportunity for discussing the process of collaborative treatment with additional input from clinicians in the psychotherapist role. In such a setting, the distinct contributions of complementary treatment approaches can be considered, and the roles and interactions of the clinicians can be explored. Finally, a resident’s skill and effectiveness in collaboration can be evaluated in part by obtaining input from psychotherapists who have cotreated patients. Though infrequently done, such a "360°" assessment process can equip the trainee with valuable information difficult to obtain in any other way.
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Conclusions
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Collaborative treatment has engendered passionate support and opposition, yet both proponents and opponents agree that providing pharmacotherapy to other clinicians’ psychotherapy patients is a predominant clinical role for many psychiatrists. Collaboration’s particular skills deserve further description and clarification. The relative advantages and disadvantages of collaborative treatment with specific patient populations, the most important features of the psychiatrist’s role, the benefits and drawbacks for patients, and the risk management issues all are appropriate topics for research and professional education. A fuller understanding of collaborative treatment can work on behalf of patients, pharmacotherapists, and psychotherapists to improve treatment outcome and professional effectiveness.
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REFERENCES
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- Chiles JA, Carlin AS, Benjamin GAH, et al: A physician, a nonmedical psychotherapist, and a patient: The pharmacotherapy-psychotherapy triangle, in Integrating Pharmacotherapy and Psychotherapy. Edited by Beitman BD, Klerman GL. Washington, D.C., American Psychiatric Publishing, Inc., 1991, 105–118
- Sederer LI, Ellison JM, Keyes C: Guidelines for prescribing psychiatrists in consultative, collaborative, and supervisory relationships. Psychiatric Services 1998; 49:1197–1202[Abstract/Free Full Text]
- Riba MB, Goldberg RS, Tasman A: Medication backup in psychiatry residency programs. Acad Psychiatry 1993; 17:32–35[Abstract]
- Thase ME: Psychopharmacology in conjunction with psychotherapy. In Handbook of psychological change: Psychotherapy process and practices for the 21st century. Edited by Ingram R, Snyder RC. New York, John Wiley & Sons, 2003, pp 474–497
- Primm S, Falk WE, Grimaldi D, et al: Fundamentals of combined treatment. In The Psychotherapist’s Guide to Pharmacotherapy. Edited by Ellison JM. Chicago, Year Book Medical, 1989, pp 3–21
- Ellison JM, Smith J. Intertherapist conflict in combined treatment, in The Psychotherapist’s Guide to Pharmacotherapy. Edited by Ellison JM. Chicago, Year Book Medical, 1989, pp 96–115
- Hansen-Grant S, Riba MB: Contact between psychotherapists and psychiatric residents who provide medication backup. Psychiatr Services 1995; 46:774–777[Abstract/Free Full Text]
- Weiner HK, Riba MB: Medication backup: attitudes and practices of psychiatrists and residents. Psychiatr Services 1997; 48:536–538[Abstract/Free Full Text]
- Dewan M: Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry 1999; 156:324–326[Abstract/Free Full Text]
- Goldman W, McCulloch, Cuffel B, et al: Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Services 1998; 49:477–482[Abstract/Free Full Text]
- MacBeth JE: Divided treatment: Legal implications and risks, in Psychopharmacology and Psychotherapy. A Collaborative Approach. Edited by Riba MB, Balon R. Washington, D.C., American Psychiatric Publishing, Inc., 1999, pp 111–158
- Spitz D, Hansen-Grant S, Riba MB: Residency training issues in collaborative treatment, in Psychopharmacology and Psychotherapy: A Collaborative Approach. Edited by Riba MB, Balon R. Washington, DC, American Psychiatric Publishing, 1999, pp 279–306
- Gutheil TG, Simon RI: Abandonment of patients in split treatment. Harv Rev Psychiatry 2003; 11:175–179[CrossRef][Medline]
- Beitman BD, Klerman GL (Eds.): Integrating Pharmacotherapy and Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc., 1991
- Riba MB, Balon R (Eds.): Psychopharmacology and Psychotherapy. A Collaborative Approach. Washington, D.C., American Psychiatric Publishing, 1999
- Bradley SS: Nonphysician psychotherapist-physician pharmacotherapist: a new model for concurrent treatment. Psychiatr Clin North Am 1990; 13:307–322[Medline]
- Tasman A, Riba MG, Silk KR (Eds.): The Doctor-Patient Relationship in Pharmacotherapy. New York, Guilford, 2000
- Beitman BD (Ed.): Integrating Psychotherapy and Pharmacotherapy: Dissolving the Mind-Brain Barrier. New York, WW Norton & Company, 2002
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ABSTRACT
INTRODUCTION
