Psychiatric Annals

IMPROVING THE PRACTICE OF SPLIT TREATMENT 

Positive and Negative Aspects of Split Treatment

Richard Balon, MD

Abstract

Split treatment, for the purpose of this article, is defined as the practice of psychiatrists prescribing medication for patients who are in therapy with nonphysician clinicians, or therapists, such as psychologists, social workers, nurses, and counselors. As Goldberg et al.1 pointed out, split treatment is not new - as early as 1947, Fromm-Reichman described this practice as a standard analytic procedure in both inpatient and outpatient settings. The practice of split treatment was gradually used more often and became common in psychiatry, especially during the past two decades. Psychiatrists complained about split treatment, fought it, and belittled it, but finally most of them grudgingly accepted it. In the 1984 survey by Beitman et al.,2 63% of psychiatrists in Washington state acknowledged being involved in this practice.

There are various possible explanations for the expansion of split treatment, including advances in clinical psychopharmacology, such as the advent of new antidepressants and their use for less severe conditions; expansion of a nonphysician clinician force; lack of training in psychotherapy and lack of time among primary care physicians; and increased pressure to reduce health care costs, combined with the arrival of managed "behavioral" care.3

The main argument for using split treatment - its lower cost - has recently been challenged.4,5 Goldman et al.4 found that integrated treatment (ie, treatment in which psychotherapy and pharmacotherapy are provided by a psychiatrist) is not more costly than split treatment. Dewan5 thought that the integrated biopsychosocial model practiced by psychiatry is both theoretically and economically the preferred model when combined treatment is needed.

Split treatment is always going to be an uneasy and controversial issue because it involves diminished control, decreased revenues, increased and complex legal and ethical responsibilities, differences in education between psychiatrists and therapists, and complicated interpersonal relationships. In addition, psychiatrists and other physicians remain clinically, ethically and legally responsible for a patient's care as long as the treatment continues under their supervision. Split treatment also involves the demedicalization of health care. Although split treatment elicits an array of feelings and attitudes and its alleged cost-saving value is not clear, it appears to be here to stay, at least for now. Thus, acknowledging, becoming familiar with, and mastering all aspects of split treatment, positive and negative, seems to be a prudent approach to this practice.

POSITIVE ASPECTS OF SPLIT TREATMENT

There are several positive aspects of split treatment, including the use of special talents of both therapists and psychiatrists; the cost-effective use of all available resources; increased time and resources available for patients; an increased amount of clinical information; more opportunity for patients to select a therapist with an ethnic background similar to theirs; enhanced patient compliance; and, according to Pilette,6 much professional and emotional support for both therapists and psychiatrists.

Use of Special Talents of Both Therapists and Psychiatrists

Special talents of both the therapist and the psychiatrist in various areas, such as mood disorders, dual diagnosis, or mental retardation, could be of benefit to the patient. This aspect of split treatment does not need to be related to a psychiatrist's expertise only; it could also be related to his or her role as a second therapist working with the patient.7 In addition, the psychiatrist may help to resolve a conflict between the patient and the therapist and vice versa. The second, or "outsider" (managerial), party can also serve as a negative split object, on whom the patient focuses many of his or her own disowned negative features.7

The use of special talents could also be helpful in training programs. McNutt et al.8 pointed out that assignment to a member of a permanent, nonmedical…

Split treatment, for the purpose of this article, is defined as the practice of psychiatrists prescribing medication for patients who are in therapy with nonphysician clinicians, or therapists, such as psychologists, social workers, nurses, and counselors. As Goldberg et al.1 pointed out, split treatment is not new - as early as 1947, Fromm-Reichman described this practice as a standard analytic procedure in both inpatient and outpatient settings. The practice of split treatment was gradually used more often and became common in psychiatry, especially during the past two decades. Psychiatrists complained about split treatment, fought it, and belittled it, but finally most of them grudgingly accepted it. In the 1984 survey by Beitman et al.,2 63% of psychiatrists in Washington state acknowledged being involved in this practice.

There are various possible explanations for the expansion of split treatment, including advances in clinical psychopharmacology, such as the advent of new antidepressants and their use for less severe conditions; expansion of a nonphysician clinician force; lack of training in psychotherapy and lack of time among primary care physicians; and increased pressure to reduce health care costs, combined with the arrival of managed "behavioral" care.3

The main argument for using split treatment - its lower cost - has recently been challenged.4,5 Goldman et al.4 found that integrated treatment (ie, treatment in which psychotherapy and pharmacotherapy are provided by a psychiatrist) is not more costly than split treatment. Dewan5 thought that the integrated biopsychosocial model practiced by psychiatry is both theoretically and economically the preferred model when combined treatment is needed.

Split treatment is always going to be an uneasy and controversial issue because it involves diminished control, decreased revenues, increased and complex legal and ethical responsibilities, differences in education between psychiatrists and therapists, and complicated interpersonal relationships. In addition, psychiatrists and other physicians remain clinically, ethically and legally responsible for a patient's care as long as the treatment continues under their supervision. Split treatment also involves the demedicalization of health care. Although split treatment elicits an array of feelings and attitudes and its alleged cost-saving value is not clear, it appears to be here to stay, at least for now. Thus, acknowledging, becoming familiar with, and mastering all aspects of split treatment, positive and negative, seems to be a prudent approach to this practice.

POSITIVE ASPECTS OF SPLIT TREATMENT

There are several positive aspects of split treatment, including the use of special talents of both therapists and psychiatrists; the cost-effective use of all available resources; increased time and resources available for patients; an increased amount of clinical information; more opportunity for patients to select a therapist with an ethnic background similar to theirs; enhanced patient compliance; and, according to Pilette,6 much professional and emotional support for both therapists and psychiatrists.

Use of Special Talents of Both Therapists and Psychiatrists

Special talents of both the therapist and the psychiatrist in various areas, such as mood disorders, dual diagnosis, or mental retardation, could be of benefit to the patient. This aspect of split treatment does not need to be related to a psychiatrist's expertise only; it could also be related to his or her role as a second therapist working with the patient.7 In addition, the psychiatrist may help to resolve a conflict between the patient and the therapist and vice versa. The second, or "outsider" (managerial), party can also serve as a negative split object, on whom the patient focuses many of his or her own disowned negative features.7

The use of special talents could also be helpful in training programs. McNutt et al.8 pointed out that assignment to a member of a permanent, nonmedical staff offered a group of troubled patients an opportunity for optimum continuity of care with a familiar, "seasoned" therapist. McNutt et al. also thought that a sizable portion of these patients would not have done as well if they had been subjected to the traditional medical trainee rotation.

Cost-Effective Use of All Available Resources

This aspect is especially important to patients and third-party payers. Due to various economic pressures and insurance restrictions, most patients cannot afford psychotherapy by psychiatrists, and especially by psychoanalysts, anymore. Frequently insurance companies either do not cover psychotherapy provided by psychiatrists or pay an amount that is not acceptable or economically feasible to psychiatrists. Psychotherapy provided by therapists is less expensive and is frequently covered by insurance carriers. Most patients can still benefit from the combination of pharmacotherapy and psychotherapy.

As mentioned before, there have been recent challenges to the prevailing assumption that split treatment is less expensive.4,5 Goldman et al.4 analyzed data from managed mental health care organizations. These data indicated that the costs of treatment for depression were lower when medication management and psychotherapy were delivered by a single psychiatrist, and that this was primarily due to the reduced number of sessions used by patients in integrated treatment. Dewan5 reached a similar conclusion. There are numerous possible explanations for this finding. Further research is needed to resolve this issue.

Increased Time and Resources Available for Patients

This is an unquestionable benefit. The combination of a 20-minute medication review and a 50-minute therapy session is just one of these modalities, versus a 50-minute full session by a psychiatrist that combines medication review and therapy.

The combination of resources is advantageous during the absence (due to a vacation or a conference) of a psychiatrist or a therapist. In a properly arranged collaborative treatment, during the absence of one party, the other party is better informed and can provide better coverage. Although the coverage by a nonphysician clinician cannot provide the full value of services rendered by a psychiatrist (and vice versa), it can be of great emotional value to the patient. It could also provide invaluable information to the covering psychiatrist (eg, transferential issues). The importance of the exchange of information between the two treating parties must be emphasized prior to this coverage arrangement. An urifamiliar psychiatrist who is providing "medication and legal" coverage may easily underestimate or overestimate the suicide threat of a patient with borderline personality disorder.

An Increased Amount of Clinical Information

This is another unquestionable benefit in a properly conducted collaborative treatment. There may be information that the patient feels more comfortable sharing with his or her therapist. It is useful for the psychiatrist to carefully read the referral note or the whole evaluation written by the referring therapist. The psychiatrist and the therapist should set aside time to share clinical information, impressions, and concerns and to support each other in their attempts to help their patients.6 The therapist and the psychiatrist could provide invaluable clinical information to each other. Patients should give informed consent for this exchange of clinical information and should be informed in detail about the scope of the information shared between the psychiatrist and the therapist.

Moie Opportunity foi Patients to Select a Therapist With an Ethnic Background Similar to Theirs

Some patients may not feel comfortable discussing certain issues with a therapist or a psychiatrist who has a different ethnic background or gender. Nadelson and Zimmerman9 pointed out that female patients may not candidly discuss issues of rape, abortion, or sexual abuse and other "female" concerns with a male therapist. According to Ruiz et al.,10 ethnic minorities have a low rate of use of and limited access to health and mental health services, probably, in part, due to cultural and language barriers. Intuitively, selecting a therapist or a psychiatrist of the same gender, ethnic background, or both may help to facilitate the process of psychotherapy or pharmacotherapy. The possibility of this "matching" selection is increased in split treatment.

However, there are no studies confirming an advantage when the therapist and the patient are of the same ethnic background or gender. Yamamoto et al.n warned that a random procedure of matching patients with therapists of the same background has many pitfalls. Patients may, for instance, place undue expectations of empathy and similitude on therapists because they are of the same race, and patients can be disappointed if therapists have not had experiences that enable easy identification with them.11 Yamamoto et al.11 also thought that unless patients are asked whether they prefer this matching, the practice may be construed as discriminatory. Foulks and Pena12 also pointed out various pros and cons of "culturally responsive" psychotherapy.

Thus, although matching patients with therapists or psychiatrists on the basis of ethnicity, gender, or racial background seems logical and understandable, it should be done at the request of patients, sensitively, on an individual basis, and with the consent of patients. A patient's uneasiness with the ethnicity, gender, or race of his or her therapist or psychiatrist should be explored in the therapy. Thus, this seemingly logical positive aspect of split treatment could be a much more complicated issue.

Enhanced Patient Compliance

Compliance means the extent to which a patient takes medication as prescribed or adheres to a treatment regimen. It is an important issue, but one that is difficult to study. There are surprisingly little data on the effects of combination treatment on compliance with psychotropic medication, and even less on the effects of collaborative treatment on compliance.

Paykel13 discussed the original Merman's listing of possible deleterious and beneficial effects of combining drugs and psychotherapy and mentioned positive effects of drugs on psychotherapy (eg, facilitation of psychotherapeutic accessibility) and positive effects of psychotherapy on drugs (eg, facilitation of drug treatment, including improvement of compliance). He thought that psychotherapy may positively facilitate drug treatment by helping to establish the physician-patient relationship and improving attendance at therapy sessions and compliance. However, Paykel also thought that psychotherapy might reduce drug compliance. Jamison et al.14 found that patients regard psychotherapy as important in ktrdum compliance.

Pilette6 suggested that the therapist should be interested in pharmacotherapy and should be supporting the psychiatrist. According to Pilette, at times that means taking a more active stand, such as reminding a patient of the need for faithful compliance, and noting both the objective and the subjective responses of a patient to medication. Balon15 suggested that enhancement of compliance in collaborative treatment should always be a two-way process, with the two treating parties working together to enhance the patient's compliance with both treatment modalities.

Professional and Emotional Support for Both Therapists and Psychiatrists

The benefit of this aspect to patients is only secondary. Pilette6 pointed out that much professional and emotional support could be obtained from the three-party (ie, the therapist, the psychiatrist, and the patient) treatment relationship and that such support is especially important if the patient is difficult to treat and when there are times of crisis. Trainees and experienced psychiatrists may benefit from the support of a mature or seasoned therapist.

NEGATIVE ASPECTS OF SPIJT TREATMENT

There are several negative aspects of split treatment, such as the inappropriate prescribing decision without knowledge of the content of therapy; potentially discrepant information given by a patient to each of the treating parties; splitting of the treating parties; unclear confidentiality; clouded legal and clinical responsibility; therapist, psychiatrist, and patient misperceptions; and no reimbursement for collaboration.

Inappropriate Prescribing Decision Without Knowledge of the Content of Therapy

A psychiatrist may not be aware of all the inner conflicts or external pressures felt by a patient. He or she may prescribe medication for anxiety that arose after an important intrapsychic conflict was addressed with a therapist. The antianxiety medication works, but the patient subsequently does not deal with the issue that caused the anxiety and, therefore, therapy does not progress.

On the other hand, a psychiatrist may decide to discontinue an antidepressant for a patient who has been denying depression for several months and is complaining about various side effects of medication. However, the patient has mentioned feelings of hopelessness and helplessness, with fleeting suicidal ideation, in therapy and this information has not been related to the psychiatrist. The consequences are not difficult to imagine, and the benefits of sharing this information are obvious.

Another example could be a patient who complains about sexual dysfunction after starting a medication and thus the psychiatrist switches him to another, perhaps less effective, medication. However, it became obvious in therapy that the patient had had serious marital difficulties and could not relate sexually to his spouse and that the medication probably has nothing to do with his inability to have intercourse.

Also, the treatment goals of the psychiatrist and the therapist may be different. If the differences in goals are not discussed at least between the psychiatrist and the therapist, serious problems may arise.

Potentially Discrepant Information Given by a Patient to Each of the Treating Parties

Information provided by a patient to each of the treating parties could be different or could be interpreted differently by each party. A patient may talk about suicidal ideation only with his or her therapist or only with his or her psychiatrist. Frequently, the discrepant information could lead to decisions with serious consequences or to conflicts. For instance, one of the treating parties may push for discharge without the knowledge of the other treating party (who may not be present at the time of the decision), and this decision may be based on only a patient's denial of active symptomatology. The level of experience of each party in interpreting information and in being able to deal with crisis issues frequently differs. This issue is directly related to the next one - spk'tting of the treating parties.

Splitting of the Treating Parties

Treatment provided by two individuals creates fertile ground for a patient to develop negative transference, for problematic countertransference to be introduced,16 and for the psychiatrist and the therapist to be split. SpHtting is probably the most frequent and best-known negative aspect of split treatment. It could lead to noncompliance with any of the treatments. The patient may assume that medication is not the "real" treatment and he or she and the therapist will band together and press for more, or only, psychotherapy.

On the other hand, a patient can use idealization of medication to resist exploration of painful transference issues arising in therapy.16 Bush and Gould16 pointed out that gender issues may play an important role in these resistances. For example, a male patient in therapy with a female therapist may be warding off maternal transference longings and erotic desires and may use idealization of a male psychiatrist as a resistance to these wishes and fears. Occasionally, one or both treatments could be derailed and terminated due to splitting.

Psychiatrists and therapists could contribute to the splitting or could consciously or unconsciously participate in it. Some therapists may question the value of psychotropic medication and may call it a crutch. Some psychiatrists do not believe that psychotherapy is efficacious. More than 20 years ago. Brill17 pointed out that increasing numbers of therapists were beginning to resist and resent working under the direction of psychiatrists. They believed, and continue to believe, that their own professions and therapeutic skills had advanced to the point that independence was justified. As Balon3 has suggested, the two treating parties, if suspicious of or aware of spk'tting, should try to resolve the issue by themselves or by seeking advice or consultation from an independent colleague or supervisor.

Unclear Confidentiality

As Pilette6 has asked, is the collaborative treatment an occasion for free communication between a therapist and a psychiatrist without the patient's consent? Should the patient give blanket permission for all communication between the two, or should the patient be asked for consent each time? What if a patient asks that some important information not be related to the therapist or to the psychiatrist? These questions are complicated and have not been fully answered.

Clouded Legal and Clinical Responsibility

It is not always clear who is responsible for what clinical decision in collaborative treatment, but it is almost always safe to assume that the psychiatrist will ultimately be found liable not only for his or her own mistakes, but also for mistakes resulting from inappropriate or negligent supervision or poorly arranged collaborative treatment.1819 Who decides whether and when to hospitalize a chronically suicidal patient? Ultimately, this should be the psychiatrist, but is that clear to the therapist and to the patient? Should every patient seen in a clinic have an initial psychiatric evaluation, or should the clinic rely on the diagnosis made by the therapist? Who is responsible for an inappropriate diagnosis made by an unskilled therapist participating in collaborative treatment? There is a perception among psychiatrists that there is an increased risk of being sued by patients who are in collaborative treatment.

Usually, courts consider the psychiatrist to be the "captain of the ship" and take expansive views of the psychiatrist's responsibilities.20 Other complicated legal and ethical issues in split treatment include unethical fee splitting, inappropriate delegation by a psychiatrist to a therapist, and unethical delivery system arrangements.3 The articles by Macbeth and Lazarus in this issue are devoted to these important topics.

Therapist, Psychiatrist, and Patient Mlsperceptlons

Goldsmith et al.21 delineated some of the misperceptions in collaborative treatment, including the ubiquitous misperceptions of overvaluing the pharmacotherapy, psychotherapy, psychiatrist, or therapist; thinking that each treating party is working independently with the patient toward a separate goal; and believing that only the psychiatrist knows about the medication.

Therapist misperceptions include ignorance of the psychological meaning of medication, believing that all questions about medication should be answered by the psychiatrist, believing that the psychiatrist will try to push the therapist aside, and thinking that the patient is too sick for help.

Psychiatrist misperceptions include thinking that the therapist should always agree with and support the psychiatrist's decision, believing that the therapist feels free to discuss disagreements, and thinking that the psychiatrist will take over if the patient's condition worsens or if the therapist takes a vacation or is temporarily unavailable.

Patient misperceptions include worrying that the psychiatrist may precipitously stop medication or force hospitalization, believing that psychiatrists are only interested in prescribing medication, and assuming that all uncomfortable feelings can be attributed to the side effects of medication.

No Reimbursement for Collaboration

The fact that third-party payers do not always reimburse for collaboration does not help to improve the practice of split treatment. This is an ethically legally, and otherwise complicated issue. Perhaps there is time to set up payment scales for consultations and phone calls with therapists.

CONCLUSION

The practice of split treatment is a complicated matter with many positive and negative aspects. Although it is not clear whether collaborative treatment is less expensive than integrated treatment by a psychiatrist, it is clear that this practice is here to stay at least for now. Thus, a consideration of all of the positive and negative aspects of split treatment, together with a careful selection of the collaborators and a comprehensive collaboration strategy as delineated by Macbeth,18 seems to be a prudent approach to this practice.

REFERENCES

1. Goldberg RS, Riba M, Tasman A. Psychiatrists' attitudes toward prescribing medication for patients treated by nonmedica] psychotherapists. Hospital and Community Psychiatry. 1991;42:276-280.

2. Beitman BD, Chiles J, Carlin A. The pharmacotherapy-psychotherapy triangle: psychiatrist, nonmedical psychotherapist, and patient. J Clin Psychiatry. 1984;45:458-459.

3. Balon R. Collaborative treatment: the practice of medication backup. Primary Psychiatry. 1999;6:41-49.

4. Goldman W, McCulloch J, Cuffel B, Zarin DA, Suarez A, Burns BJ. Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Serv. 1998;49:477-482.

5. Dewan M. Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry. 1999;156:324-326.

6. Pilette WL. The rise of three-party treatment relationships. Psychotherapy. 1988;25:420-423.

7. Firman GJ. The psychiatrist-npnmedical psychotherapy team: opportunities for a therapeutic synergy, journal of Operational Psychiatry. 1982;13:32-36.

8. McNutt ER, Severino SK, Schomer J. Dilemmas in interdisciplinary outpatient care: an approach towards their ameliorarion. Journal of Psychiatric Education. 1987;11:59-65.

9. Nadelson CC, Zimmerman V. Culture and psychiatric care of women. In: Gaw AC, ed. Culture, Ethnicity, and Mental Illness. Washington, DC: American Psychiatric Press; 1993:501-515.

10. Ruiz P, Venegas-Samuels K, Alarcon RD. The economics of pain: mental health care costs among minorities. Psychiatr Clin North Am. 1995;18:659-670.

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12. Foulks EF, Pena JM. Ethnicity and psychotherapy: a component in the treatment of cocaine addiction in African Americans. Psychiatr Clin North Am. 1995;18:607-620.

13. Paykel ES. Psychotherapy, medication combinations, and compliance. J Clin Psychiatry. 1995;56(suppl 1):24-30.

14. Jamison KR, Gerner RH, Goodwin FK. Patient and physician attitudes toward lithium: relationship to compliance. Arch Gen Psychiatry. 1979;36:866-869.

15. Balon R. Positive aspects of collaborative treatment. In: Riba MB, Balon R, eds. Psychopharmacology and Psychotherapy: A Collaborative Approach. Washington, DC: American Psychiatric Press; 1999:1-31.

16. Bush FN, Gould E. Treatment by a psychotherapist and psychopharmacologist: transference and countertransference issues. Hospital and Community Psychiatry. 1993; 44:772-774.

17. Brill NQ. Delineating the role of the psychiatrist on the psychiatric team. Hospital and Community Psychiatry. 1977;28:542-544.

18. Macbeth JA. Divided treatment: legal implications and risks. In: Riba MB, Balon R, eds. Psychopharmacology and Psychotherapy: A Collaborative Approach. Washington, DC: American Psychiatric Press; 1999:111-158.

19. American Psychiatric Association. Guidelines for psychiatrists in consultative, supervisory, or collaborative relationships with nonmedical therapists. Am J Psychiatry. 1980,137:1489-1491.

20. Appelbaum PS. General guidelines for psychiatrists who prescribe medication for patients treated by nonmedical psychotherapists. Hospital and Community Psychiatry. 1991;42:281-282.

21. Goldsmith RJ, Paris M, Riba MB. Negative aspects of collaborative treatment. In: Riba MB, Balon R, eds. Psychopharmacology and Psychotherapy: A Collaborative Approach. Washington, DC: American Psychiatric Press; 1999:33-63.

10.3928/0048-5713-20011001-07

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