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Chapter: Essentials of Psychiatry: Combined Therapies: Psychotherapy and Pharmacotherapy

Positive Aspects

There are several positive aspects of split treatment, including the increased time that patients have with more than one clinician;

Positive Aspects


There are several positive aspects of split treatment, including the increased time that patients have with more than one clinician; better utilization of resources; enhanced opportunity for align-ment of gender, ethnicity between patient and clinician; more professional support for each clinician; and, perhaps, better ad-herence of the overall treatment plan by the patient and family.


Increased Time with Clinicians


Within the structure of split treatment, patients actually meet with at least two different clinicians: one for psychotropic medi-cation or other somatic treatment and the other clinician for psychotherapy. Under ideal circumstances, the patient is seen by the nonmedical therapist at appointed intervals between the physician appointments. This could then allow for the patient to get longitudinal care by two clinicians and to therefore be seen on a continuum by both. Under this type of arrangement, there would not be too long an interval in which the patient is not seen by a mental health professional. With good communication, the therapist relays all important information to the physician in a timely manner. If there are planned vacations by either clinician, the other clinician is aware and can make different plans accord-ingly to see the patient. The patient may be able to provide more useful information in this treatment approach, given that she has more time to spend in overall treatment.


Better Utilization of Resources


With the growing realization of the importance of evaluating for emotional problems in the primary care setting, there is better recognition of psychiatric symptoms and disorders. In rural areas where there may not be enough mental health clinicians to serve the needed population, splitting the duties of the various clini-cians might be a cost-effective way to ensure allocation of care. Similarly, there are certain types of psychotherapeutic treat-ments with documented efficacy, such as cognitive–behavioral treatment of depression and behavioral treatment of obsessive– compulsive disorder, panic disorder and phobias, which must be delivered by knowledgeable clinicians (Fawcett, 2001).


Greater Choice of Clinicians


Split treatment allows for more choices in the selection of clini-cians based on gender, race or ethnicity, and religion or cultural values. Such matching may help the patient and clinician avoid certain difficulties that arise in psychotherapy when there is not a full appreciation of cultural issues (Foulks and Pena, 1995).


Improved Adherence to the Treatment Plan


Patients attribute certain meanings to the prescription and taking of medication, depending on their illness-belief system (Rolland, 1994; Winer and Andriukatis, 1989). Some patients hear an ex-planation of the need to take medications as having a “chemical imbalance” and embrace the idea that there is a biochemical rea-son for the problem. Other patients feel ashamed or guilty over having a defect and develop a strong resistance to taking their medication as prescribed (Paykel, 1995).


It is important for the clinicians involved in split treatment to appreciate how the patient understands the need for medica-tion. Similarly, it is valuable for the physician to be aware of how the nonphysician therapist understands the role of medication in the overall treatment. The physician and therapist must help support medication and psychotherapy so as to help the patient succeed in having a good outcome. In this way, the patient will receive support from both treaters with neither the medication nor the therapy undermined.


Enhanced Support for Clinicians


There are several levels of support that accrue to clinicians involved in split treatment. With particularly difficult patients, such as those with severe personality disorders or hard-to-treat depressions or psychoses, it is very valuable for clinicians to be able to feel a mutual caring for one another and an empathy for the difficult clinical situations that can arise. Split treatment allows for a sharing of information that can help clinicians help patients through crises. As Silk points out, patients with borderline personality disorder, for example, are noted for fueling strong countertransferential feelings of anger, fear, and worry in clinicians (Silk et al., 1995). It is very helpful when clinicians in split treatment can present a unified front to the patient, acknowledging that they are capable of handling the patient’s affective storms but also provide support to one another to diminish feelings of burn-out. Balon (1999) has noted that psychiatry residents, in particular, value the teaching and support they receive from seasoned, mature social workers and psychologists while providing split treatment.


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