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

Toward Successful Split Treatment

The following suggestions are offered as organizing principles for these three stages :

Toward Successful Split Treatment


The following suggestions are offered as organizing principles for these three stages (with permission from American Psychiatric Press, Riba and Balon, 2001):


A key aspect of split treatment is how complex and dif-ficult such treatment is for the clinicians, the patient and the pa-tient’s family. Unless one works in a clinic or organized setting where relationships between clinicians are well-delineated (e.g., one psychiatrist works with a specific group of nonmedical thera-pists), much thought must go into managing safe and effective split treatment.


It may be helpful to think of split therapy having a begin-ning, middle course, and end (Table 87.1). In order to avoid or minimize the pitfalls associated with split treatment, the follow-ing clinical suggestions are provided as organizing principles for its three stages (Rand, 1999; Tasman and Riba, 2000):



Beginning of Treatment


·                 Communication is key to providing excellent care in split treatment. At the beginning, both clinicians should obtain a signed release-of-information form from the patient. Commu-nication must be regular and frequent between the clinicians and the patient should be made aware of these discussions. The forms of regular communication should be decided at the onset – routine telephone calls, faxes, emails, follow-up letters and the like. The patient should not be a messenger between the clinicians.


·                 Issues of confidentiality should be discussed and reviewed at the beginning of treatment. Confidentiality should not be used as a cover to hide from taking the time to make telephone calls, to send copies of evaluations and follow-up notes, to send emails or faxes, or to have joint sessions with both clini-cians and the patient.


·                 Diagnostic impressions should be independently arrived at, then discussed and agreed upon. If there is a difference of opinion, an understanding must be reached before treatment proceeds.


·                 The clinicians must work with each other and with the patient to determine the treatment plan. The treatment plan should specify how often each of the clinicians expects to see the pa-tient and what process to pursue if the patient does not follow-up or if there is a missed appointment. If the patient wishes to end either the therapy, the medications, or both, it has to be un-derstood that all parties will discuss this important decision. It is desirable for a written contract to be drawn up between the clinicians and the patient so that all parties understand what the agreement for services will entail. Included in the contract should be a delineation of the clinicians’ roles and responsi-bilities, as well as those of the patient.


·                 Clinicians vacation schedules and other on-call and cover-age issues must be discussed regularly and documented. The patient needs to know whom to call in an emergency. At the beginning of split treatment, both clinicians and the patient should be aware of their respective beliefs regarding medica-tion and psychotherapy.


·                 There must be a discussion about what type of care would be optimal for the patient and if there are barriers to such care. The patient should be informed of this review; if possible, he or she should participate in it.


·                 The clinicians should discuss their professional backgrounds and training with each other at the beginning of the patient’s treatment. Issues such as licensure, ethics, violations, mal-practice claims, hospital privileges, coverage of professional liability insurance, participation on managed care panels and commitment to split treatment should all be made clear.


·                 The clinicians need to agree who will communicate with third parties regarding the patient’s care. Further, each clinician should know the patient’s mental health benefits and means of payment. There needs to be an agreement by all parties as to the use of such benefits.


·                 The clinicians need to understand how best to interface with the patient’s family or significant others.


·                 If the patient has health providers other than the psychiatrist and therapist (e.g., primary care physician, cardiologist a physical therapist), it should be decided which clinician will be the designated communicator or coordinator with those other providers.


·                 At the beginning of treatment there should be a review of how each clinician will assess and manage the patient’s thoughts regarding or attempts at suicide, homicide, violence and domestic abuse.


·                 It should be made clear to the patient what symptoms or types of issues should be brought to the attention of which clinician.


·                 It is helpful for the clinicians to decide how problems will be handled as the need arises.


·                 The clinicians should discuss differences in fee schedules, cancellation policies, length of visits and frequency of visits.


Middle Course


·                 Special attention must be paid to transference and counter-transference in this type of system of care. Disparaging and negative remarks made by the patient concerning either clini-cian, therapy, or medication must be understood and managed in the context of this complex type of treatment.


·                 Clinicians should review how many cases of split treatment they have in their practices and whether or not this is a safe mix. Factors to consider include the clinical complexity of the cases, how busy the practice is, the influence of third-party payers and the hassle factor, the number of different clini-cians one is working with, the psychiatric disorders of one’s patients, and so on. It may be prudent to determine the risks involved in having a large patient population in split treatment and to weed the number of such patients down to an accept-able level. Further, clinicians should minimize the number of collaborators, since it is virtually impossible to keep track of a large number of clinicians’ credentials, vacation schedules, communication patterns, and so on.


·                 Adherence to medications and to psychotherapy should be ad-dressed equally.


·                 Treatment plans should be regularly reviewed and updated be-tween the clinicians and the patient.


·                 Use of the patient’s mental health benefits should be regularly reviewed and discussed between the clinicians and the patient when appropriate.


·                 There must be an agreement that either clinician can terminate the split therapy but that the patient must be provided adequate and appropriate warning and referrals to other clinicians. In other words, the patient cannot be abandoned.



Ending Split Treatment


·                 After reviewing the treatment plan, both clinicians and the pa-tient will decide together on the goals that have been met or have not been realized and the best time for termination. They should decide how to stagger the discontinuation of therapy and of medication.


·                 It is important to consider how to manage follow-up and recur-rence of symptoms.


The clinicians must have a system for giving each other feedback on the care each is providing to the patient. Ideally, after the treatment is complete, the clinicians should review any aspects of the case that could have been managed or handled differently. Ideally, the patient should be part of this evaluation process as a way of assuring continuous quality improvement. Most importantly, throughout all stages of the split treatment process, clinicians need to respect both the patient and each other’s professional understanding.


Although the challenges of split treatment are great, there are many reasons for clinicians and patients to try to surmount the obstacles. Good communication patterns between clinicians and many of the suggestions noted here may be guideposts on the path toward successful split treatment.


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