While communication is probably the most important factor in successful split treatment, it is rarely done well (Hansen-Grant and Riba, 1995). Without a systematic way for clinicians and the patient to have regular, documented communication, there often arise misunderstandings and misconceptions. Further, patients are sometimes put in the middle of having to be the messenger between the clinicians. Needing to communicate puts additional burdens and stress on busy clinicians with the telephone or in-person time not usually reimbursable. Poor communication leads to misinter-pretation of what should be attributable to psychodynamic issues or medication side effects, or both – a poorly constructed treat-ment plan, ill-defined plans for discharge from treatment, lack of coordination with family members, neither the clinician nor pa-tient fully understanding vacation or coverage issues, and so on.
The literature demonstrates that when clinicians know one an-other, they are more comfortable with split treatment (Goldberg et al., 1991; Weiner and Riba, 1997). Unfortunately, often the clinicians do not know one another, which leads to basic mis-trust, competition, or inequality in the relationship (Baggs and Schmitt, 1988). Further, this devaluation can be displaced onto the patient during critical treatment decisions, with certain pa-tients exploiting this competition even further (Kelly, 1991). The psychotherapy skills of psychiatrists and nonmedical therapists and the psychopharmacologic education of social workers and psychologists are all highly variable, contributing to mistrust (Neal and Calarco, 1999). In such circumstances, the patient may actually be seen more often by both clinicians and have ill-defined treatment goals.
When patients are referred by their therapists for medication evaluations, the reactions are variable, but often negative. Such reactions include feeling abandoned or rejected, as if the therapist has lost interest or given up, like a failure because therapy did not work, devaluation of the psychotherapy and the therapist, ideali-zation of the physician, shame, resistance to further psychody-namic exploration of issues and a narcissistic injury (Busch and Gould, 1993). Busch and Gould note the difficulties for the thera-pist who needs to make the referral: shame that help is needed and anger towards the patient for needing additional help. The psychiatrist could then collude with the patient’s negative trans-ference towards the therapist and the psychodynamic process.
Results of such negative transference could lead to premature closure within the therapeutic process (Bradley, 1990). There may be a flight into health by the patient when the medication is first prescribed. The patient and physician may then realize too late that there was an overreliance on biologic interventions. The dyadic relationship between the therapist and patient is changed with the addition of a physician and medication (see Figure 87.1) leading to distortions and transference changes in all the relationships.