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In many treatment settings, including academic and community mental health centers, the psychiatrist's role often includes providing psychopharmacologic evaluation and management for patients whose psychotherapy is carried out by a nonmedical allied mental health professional. The writing of a prescription for a patient does not take place in a vacuum. The psychiatrist is not a medicine-dispensing machine.
Managed care policies usually finance only 15-minute sessions for medication management. Despite the brevity of these contacts between physician and patient, an attentive psychiatrist can obtain a quick—although limited and sometimes blurred—view of the patient's underlying problems during these meetings. These contacts also present opportunities for the emergence of transference and countertransference reactions and, in that context, psychotherapeutic interactions. The conscious and unconscious reactions in both parties usually remain unanalyzed unless they loom as resistance to the treatment.
At a recent conference I attended, a psychiatrist described a crisis that dramatically demonstrated the intensity of feelings the interaction can generate. The subject of the symposium was countertransference. One of the issues I discussed was split treatment and the psychiatrist's countertransference when patients have idealized positive or negative transference reactions to the prescribing psychiatrist. These reactions evoke a special challenge when the patient's feelings toward the psychiatrist are the reverse of those toward the nonphysician psychotherapist.
During the question-and-answer period a member of the audience rose to describe an alarming clinical situation she had experienced in the context of split treatment. She was providing medication management for a patient who had begun to make subtle—and not-so-subtle—threats. Speaking with great hostility directed at the psychiatrist, the patient described her sister's violence toward her own psychiatrist. The patient then made allusions to her own potential for violence. She hinted that she had learned a great deal about the psychiatrist's personal life, including where she lived. In contrast, she was mild mannered, pleasant, and agreeable with her psychotherapist.
The psychiatrist said that because of managed care restrictions, she could spend only the allowable 15 minutes with the patient. Thus she felt constrained from exploring and dealing psychotherapeutically with this ominous development. Her supervisor's response to the problem was to suggest transferring the patient to another medicating psychiatrist. The psychiatrist asked me: "What should I do?"
The emergent crisis needed to be dealt with directly and effectively. There was major exploratory, confrontational, and psychotherapeutic work to be done to understand and defuse a situation that was potentially threatening to both psychiatrist and patient. This situation was also a potential therapeutic opportunity. If the therapeutic work was successful, it could enable the patient to alter her psychologically destructive perception of interpersonal relationships.
To proceed effectively, the two treaters had to talk. One possible course of action would be to initiate a meeting between the patient, the psychiatrist, and the psychotherapist to decrease the splitting, find a therapeutic resolution for the patient, and ensure the safety of the caretakers. Whatever process was decided on, this was not a time to be silent, transfer the patient, or simply walk away. Split treatment demands that those involved recognize and attend to what Busch and Gould (1) have labeled the "therapeutic triangle" and to achieve what Kahn (2) described as a "triadic therapeutic alliance."
Inherent in the split-treatment setting is a replication of the parent-child relationship, with all of its pleasures, pain, rivalries, and potential transferences. Parenting works well when parents interact with recognizable mutual respect and with good communication. In this climate the children are not able to pit one parent against the other. Both parents attend to the children with care and concern and work together to develop what is most advantageous for the child.
Parenting suffers in conditions of competition, lack of respect, and failures of communication. This atmosphere provides opportunities for the child to act out unconscious—or not-so-unconscious—wishes to have a special, idealized relationship with one or the other parent. For the young child with an immature ego structure, the wish to have the perfect idealized parent is an expected part of the developmental process. The successful resolution of this maturational struggle involves relinquishing the fantasy and being able to integrate the good and bad aspects of the parent and find value in people who are neither all good nor all bad. Patients who suffer from developmental crises reflect their early lives in their transference to their clinicians in split treatment. In this situation the collaborative work of the two "treater-parents" can be invaluable in helping patients achieve internal unity and rework related developmental issues.
A number of forces work against this unity and can be destructive if they are not carefully monitored. In 1984 Beitman and colleagues (3) observed that most psychiatrists are accustomed to being the primary therapist. The transition from being the primary person in the patient's therapeutic life to being part of a team requires containment of the usual role that we achieved through training and clinical experience. Newly trained psychiatrists may be more familiar with and more comfortable working as part of a team, but the same issues will arise as they deal with the patient's primary attachment to another member of the team.
The importance of the patient to the psychiatrist is not eliminated because of the triangular treatment situation. As the psychiatrist spends time with the patient, his or her interest and sense of caring naturally evolve, as does the patient's attachment and reaction to the psychiatrist. Immunity from this process is not conferred just because someone else is the designated psychotherapist. Recently I heard a young psychiatrist express surprise that her patients were upset when they learned that she was taking a three-month leave of absence for personal reasons. As she described it, she was "only" doing medication management, not psychotherapy. Of course, there is no such thing as "only" writing prescriptions: she had become an important force in her patients' search for psychological stability.
Naturally, the development of a good doctor-patient relationship is essential, even when the physician's role on the treatment team is that of the prescribing psychiatrist. Medication management requires that the patient be trusting; otherwise the prescribing psychiatrist will not obtain a valid picture of the medication's efficacy or side effects or the patient's compliance. Compliance with medication regimens, as we know, can be a major stumbling block in every realm of medical treatment. Appreciating the nuances of transference that interfere with compliance and recognizing the characterological conflicts that impede treatment progress are fundamental to the success of our work.
Inherent in supportive therapy are clarifications, empathically framed confrontations, and interpretations given as explanations as well as praise, reassurance, and appropriate encouragement. It is not possible to work as the provider of medication without using these resources at one time or another. Sometimes the prescribing psychiatrist also may provide psychoeducation and cognitive reframing, techniques usually associated with cognitive-behavioral therapy. Occasionally, given sufficient familiarity with the patient and a collaborative relationship with the psychotherapist, a psychodynamic interpretation of resistance or defense can prove helpful. The challenge is to achieve a therapeutic result that enhances the overall treatment and supports the work of the other member of the treatment team.
Negative outcomes are most likely when the evidence of transference and countertransference are not recognized or addressed. What is a common scenario? The psychiatrist may be experienced as the authoritarian parent, the longed-for good parent that never existed, or an intruder in a previously private relationship. The first two cases may be comfortable and rewarding for the psychiatrist, but a countertransference wish to be the favorite parent may encourage a therapeutically destructive power struggle with the collaborating psychotherapist.
Busch and Gould (3) believe that the major countertransference stumbling block is the temptation to collude with the patient's negative transference to the psychotherapist. This development may have two possible sources. The prescribing psychiatrist may feel narcissistically injured by having to share power with the psychotherapist and may harbor the competitive belief that his or her approach would be the superior one. Alternatively, the psychiatrist may feel anxious about having to share control of the patient's treatment.
Kahn notes that in the worst scenario the countertransference struggle may reduce the patient to a narcissistic object while the two therapists struggle for power. Intergenerational differences can generate additional tensions. In teams composed of an older therapist and a younger psychiatrist or vice versa, both clinicians must be alert to the possibility of negative or competitive feelings.
Several valuable strategies may be used to keep these problems from occurring.
• Know and have professional regard for the referring psychotherapist with whom you work.
• Talk together about cases, and learn how the therapist thinks about clinical issues.
• Be continually alert to the manifestations of transference and countertransference phenomena.
• If the therapist is unfamiliar with the prescribed medication, explain the expected amount of time for it to take effect, possible side effects, and drug interactions. If the psychotherapist is familiar with the medication's strengths and limitations, he or she can be alert to possible complicating side effects.
• Communication is essential. Patients must be informed that you will talk with each other, and they must be informed of the nature of that discussion. Reporting back to the patient is essential. Familiarize yourself with the relevant confidentiality requirements and obtain informed consent as appropriate.
These features of split treatment will affect the psychotherapy, and they need to be addressed in the therapeutic work. When the treaters' relationship is characterized by mutual respect and open communication, the triangular transferences can be anticipated and understood—and the triangular countertransferences acknowledged—without embarrassment or damage to the treatment.
Unfortunately, collaborative discussions by treating clinicians are not generally reimbursed by third-party payers. Those who pay for the treatment need to be educated about the importance of this time and how it affects the treaters' ability to provide high-quality care. They should know that it ultimately reduces treatment cost. However, as clinicians we cannot afford to wait for approved reimbursement before we proceed with communication. To wait is detrimental to our work as well as potentially dangerous.
The prescribing psychiatrist has a psychotherapeutic involvement with the patient that is at times supportive, cognitive-behavioral, and occasionally psychodynamic. In every case it is essential that the psychiatrist be psychodynamically informed and aware of transference and countertransference issues. As Basch (4) has reminded us, "to say nothing is not to do nothing." Silence creates the sense of a "blank screen" on which patients will project their conflicts, hopes, and fears. The challenge and reward in this situation is in figuring out how doing "something" will be therapeutically rewarding for the patient and supportive to the overall treatment process.
Dr. Goin, who is editor of this column, is clinical professor of psychiatry and behavioral sciences at the University of Southern California School of Medicine in Los Angeles. Send correspondence to her at 1127 Wilshire Boulevard, Suite 1115, Los Angeles, California 90017 (e-mail, firstname.lastname@example.org).
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