This is part J of a two-part series. Part 2 will appear in the June issue.
Split treatment is a clinical term in general psychiatry1 that customarily refers to the prescription of psychoactive medication by a psychiatrist while the remainder of the therapy is conducted by another psychotherapist, usually a nonphysician. The practice of split treatment is widespread in the therapy of mental illness. Split treatment can include mental health therapy in which the psychotherapist is under - or is perceived to be under - some degree of supervision and adrninistrative control by the prescribing psychiatrist.2 The role of prescribing clinician can sometimes be filled by nonpsychiatrist clinicians (eg, nurse clinical specialists or primary care physicians). The term split treatment can carry a divisive undertone, reflecting many professionals' emotional response to the frequent clinical risks, professional conflicts, and unarticulated contractual expectations that can often accompany this type of conjoint mental health treatment. These negative dimensions of split treatment are more frequent when the therapists are unfamiliar with each other's work and expectations.
In this article, we discuss the medical, demographic, and financial forces driving the increasing frequency of split treatment, focus on the types of split treatment that involve psychiatrists as primary pharmacotherapists, and then clarify the clinical problems emerging from this model that require direct resolution by the psychiatrist-therapist team. In part 2 of this article, we will present eight essential questions for a clinician embarking on a split treatment collaboration to consider and a model letter from a psychiatrist to a psychotherapist that will address the most salient of those problems of split treatment.
THE HISTORY OF SPUT TREATMENT
There are several forces that have fostered the use of split treatment. First among these has been the discovery of an ever-increasing range and number of effective pharmacologic treatments for major mental illness. This trend began in the early 1950s with the introduction of phenothiazines, tricyclic antidepressants, and lithium. Following the World Health Organization studies of schizophrenia in the late 1970s,3,4 the U.S. mental health community became aware of the true spectrum of affective illness; as a consequence, the range of indications for antidepressants and mood stabilizers increased significantly. In the years following, most serious psychiatric diagnoses were examined from the perspective that they might be variants of affective disorders with similar responsiveness to pharmacologic treatments. In turn, the research findings extended the range of indications for antidepressants and mood stabilizers. Finally, in the past 15 years there has been a marked increase in both the number of families of pharmacologic agents and the combinations of agents available, thereby continuing the expansion of the role of psychopharmacology in the treatment of mental illness.
In addition to the expanding number of medications and their indications, there has been an increasing number of nonphysician therapists who are providing mental health services. In 1995, there were 69,817 psychologists, 93,245 clinical social workers, 6,804 psychiatric nurses, 46,227 marriage and family therapists, and more than 10,000 mental health counselors in the United States.5 In contrast, the American Medical Association reported that there were 33,486 psychiatrists.5 Many patients treated by nonphysician therapists will need pharmacologic treatment in addition to their psychotherapy.
In the late 1960s, the community mental health movement emerged with strong economic, public health, and ideologic concerns that in turn fostered the use of split treatment. Because nonphysician therapists provided services at a lower hourly rate, a larger population could therefore be served within a limited government subsidy. Psychiatrists were also in insufficient supply, particularly outside large urban areas. In addition, the egalitarian, nonhierarchical ideology that was part of the community mental health movement also supported the increased use of nonphysician therapists as equal partners on the psychotherapeutic playing field. Together, these factors fostered the increased use of psychiatric colleagues as psychopharmacologists rather than as primary therapists.
Later, in the 1980s and into the present, both staff (ie, clinicians who are employees) and network (ie, clinicians who are independent contractors) model health maintenance organizations began influencing the delivery of mental health care.6 These managed care organizations (MCOs) have been attracted to split mental health treatment by the financial incentives of using lower-cost mental health providers in lieu of psychiatrists for the psychotherapy portion of the patient's treatment. Although a recent study has contradicted some of these financial assumptions/ split treatment to contain mental health costs remains a preferred policy of most MCOs.
Many MCOs have also created management policies in which the company controls the patient's entry and subsequent triage to physician and nonphysician providers within the MCO's mental health system. Many insurance plans require that the patient call a toll-free telephone number, whether for inpatient or outpatient treatment. Thus, the MCO itself, rather than the primary care physician, becomes gatekeeper and triage. One effect of these toll-free telephone access lines is that few outside the management of the MCO have access to the mental health provider directory. Access to the range of provider options within the network is thereby limited. Currently, the National Council of Quality Assurance (NCQA), an MCO oversight organization, requires an NCQA-approved MCO that provides mental health care to have a toll-free access line. Although this NCQA requirement may facilitate patient access to the mental health services, it also fosters the MCO's control over the patient's choice of provider within the network by controlling patient triage.
Patients who call their MCO for mental health treatment are frequently first triaged to a nonphysician therapist for evaluation, with a psychiatrist being called on secondarily only if medication may be warranted. As a result, psychiatrists in network MCOs are regularly asked to prescribe medication for patients whose psychotherapy is being performed by clinicians credentialed by the MCO but who may be professionally unknown to the psychiatrists. Managed mental health care, with its focus on cost containment, represents the newest, most financially driven force promoting the use of split treatment.
THE CONCEPT OF SPLIT TREATMENT
Although clinical collaboration in medical practice is common, the paradigm of split treatment in psychiatry presents unique clinical issues because the professional relationship is not easily delineated regarding the clinical, ethical, and administrative requirements for each clinician. The central questions underlying the role of each mental health clinician are:
1. What is the specific clinical duty of each clinician to the patient?;
2. What is the relative autonomy of each clinician?; and
3. What is the dependence or interdependence of the two clinicians?
In 1980, in an early effort to resolve interprofessional ambiguity and to address the evolution of the professional roles of the psychiatrist, the American Psychiatric Association (APA) published "Guidelines for Psychiatrists in Consultative, Supervisory or Collaborative Relationships With Nonmedical Therapists."7 Three classes of professional relationship were described and defined: consultative, supervisory, and collaborative.
In a consultative relationship, both clinicians are professionally certified for autonomous clinical activity. There is no interdependence between the clinicians. In a consultative relationship, a psychiatrist can offer an opinion without assuming responsibility for the patient's ongoing care. The psychotherapist is free to accept or reject the psychiatric opinion.
In contrast, a psychiatrist in a supervisory relationship is responsible for the oversight and direction of all aspects of the patient's mental health treatment. The psychotherapist is not authorized to act autonomously (ie, without supervision). An example of a supervisory relationship is a psychiatrist's supervision of a dependently licensed psychotherapy trainee working in an appropriately licensed clinic or hospital.
Of the three professional interrelationships, the collaborative relationship classified in these guidelines7 most often applies to split treatment in general psychiatry and is most vulnerable to a lack of interprofessional clarity.
Implicit in this [collaborativel relationship is a mutually shared responsibility [clinical dutyl for the patient's care in accordance with the qualifications and limitations of each therapist's discipline and abilities, (p. 1490)
In a collaborative relationship, both the psychiatrist and the other mental health professional have met the professional (and, if applicable, institutional) standards for independent functioning. However, because the clinicians share responsibilities for the patient's treatment, they are professionally interdependent (as opposed to being dependent, as in a supervisory relationship). Unlike a supervisory relationship, each clinician in a collaborative relationship is independently licensed and neither clinician has the professional authority to direct the conduct of the other.
Publications subsequent to the APA "Guidelines" have articulated additional concerns about the complex relationship between medical and nonmedical psychotherapist collaboration. McNutt et al.8 have discussed the role ambiguities of outpatient collaborative split treatment in a teaching hospital clinic. Noting the forces that were fostering split treatment. Pilette9 called for clarification of issues of confidentiality, clinical responsibility, and patientclinician relationships.
Bradley10 has used a historical view of the ideologic differences between pharmacotherapy and psychotherapy to clarify sources of transference and countertransference conflict in split treatment. Ellison and Smithu analyzed a series of clinical vignettes to illustrate conceptual and theoretical differences between pharmacotherapist and psychotherapist. They emphasized the importance of clarification of the underlying psychological meaning of clinical disagreements.
In a 1991 survey of Connecticut psychiatrists, Goldberg et al.12 found that only 38% of psychiatrists doing split treatment endorsed it as generally ethical. Eighty-five percent thought they might be medicolegally responsible not only for their own professional conduct, but also for that of their psychotherapist colleague. The survey found there was also ambiguity concerning the coverage responsibilities of each professional. In a commentary about these concerns, Appelbaum" outlined applicable direct and indirect liability law and called for clinician responsibilities to be clearly specified. More recently, Sederer et al.14 reported the clinical guidelines of the Harvard Risk Management Foundation task force regarding prescribing psychiatrists in consultative, collaborative, and supervisory relationships. It is evident from the work of Sederer et al., as well as their predecessors, that collaborative relationships have the greatest potential ambiguity for clinical duties and interprofessional responsibilities.
CLINICAL DILEMMAS AND CLINICAL DUTIES IN SPLIT TREATMENT
On the surface, a collaborative relationship in mental health might seem to approximate the medical paradigm of two physicians (eg, the internist and the cardiologist) working together in a single patient's treatment. However, in split treatment, separable psychological arenas that are one clinician's sole, independent responsibility cannot be defined: a patient's psychopathology and individual mental health treatment cannot be unambiguously sorted into medical and nonmedical components.
Psychopharmacology inevitably involves psychotherapy,15 and the clinical focus and responsibilities of therapist and psychopharmacologist have multiple overlaps. As a result, it is never implicitly clear who, if anyone, has ultimate clinical responsibility for certain facets of the patient's illness and overall care. Although medication side effects, drug interactions, and prescription refills are medical, a patient's worsening depressive symptoms fall into both the therapeutic and the pharmacologic realm. The same dual nature is true of symptoms of mania, psychosis, severe anxiety, eating disorders, character pathology, and, in fact, virtually all psychiatric diagnoses that are treated with both verbal and drug therapy.
The same professional overlap is true of clinical risk assessment of and intervention with a patient's potential for suidde, violence, or impulsive behavior that might endanger third parties. The APA's definition of collaborative treatment calls for "a mutually shared responsibility [clinical duty] for the patient's care in accordance with the qualifications and limitations of each therapist's discipline and abilities" (p. 1490).7 However, neither the nature of mental illness nor the stages of its treatment lends itself to being easily separated into medical and nonmedical components. As a result, the clarification of certain roles and responsibilities for each mental health clinician in spHt treatment must be created de novo between the clinicians involved.
In reality, the clarification is often done ineffectively or not at all. At times the collaborative relationship of split treatment has been a clinical shotgun wedding - a product of clinical and economic forces rather than the two mental health clinicians wanting to work together. Clinicians' exposure to litigation for the other clinicians' actions has produced a chronic erosive anxiety that undermines wanting to "be in it together." Clinician attempts to clarify the clinical roles have left an enormous legacy of interdisciplinary resentment and anxiety. Many nonphysician colleagues feel they have received unwanted oversight from hierarchically minded medical colleagues who are not sufficiently knowledgeable about either the patient or the psychotherapy. Many psychiatrists feel they have medical and legal responsibility for patient care in the absence of either adequate authority or ongoing clinical oversight.
Nevertheless, the APA has articulated a broad professional standard for roles and responsibilities to which psychiatrists should adhere.7 The interaction between psychiatrist and nonphysician therapist must be:
sufficient to assure that their [psychiatrists'] ethical, medical, and legal responsibilities toward the patient are met.... Because of the wide range of competence and training that exists among non physician therapists, it is difficult to specify precisely what an optimum number and frequency of contacts between a psychiatrist and a non physician therapist should be. However, it is incumbent upon psychiatrists to satisfy themselves as to the level of competence, level of training and, where required, the licensure of the therapist, (p. 1490)
Psychiatrists often think that because they meet with the patient infrequently, their clinical responsibility for the patient can be proportionally circumscribed. This is a serious clinical misunderstanding that can result in disastrous failures in patient care and risk management. Psychiatrists have clinical and ethical duties to their patients that are unassignable, irrespective of the number of minutes spent with them. It is those duties in the setting of split treatment that must be clarified and performed.
Fundamental to a successful collaboration is agreement on certain basic, clinical issues: the competence, licensure, and insurance status of the psychotherapist; the patient's informed consent to the psychiatrist and the therapist sharing information on an ongoing basis; what portion of the patient's treatment the clinicians are independently or interdependently responsible for; the two clinicians' responsibility to inform each other of significant changes in the treatment; the right, and even obligation, to terminate participation in an unworkable split treatment as long as there is sufficient notice and a treatment alternative for the patient and the other therapist; the issue of responsibility for the supervision and oversight of the other clinician's work; the required frequency of contact with both the patient and the other clinician; and routine and emergency availability or coverage during nights, weekends, and vacations.
Part 2 of this article will address the implications of these issues and will include a model letter from a psychiatrist to a psychotherapist that outlines these clinical concerns to facilitate a successful split treatment collaboration.
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