On a bright and crisp Saturday morning last October, Liam Oberman* went to the emergency room. He wrung his hands as he waited to be seen, and when asked why he was there, he said, “I’ve been thinking about suicide.” He was whisked into a back room, where his clothes, shoes, and belt were confiscated. Later that day, he voluntarily checked himself into the in-patient psychiatric ward of the hospital, to access medical attention and medication as soon as possible.
Liam’s therapist had strongly recommended that he start medication for his severe depression and anxiety, which had turned into a month-long battle with intrusive thoughts that finally veered toward suicidal ideation. However, since his therapist was a licensed social worker but not a psychiatrist, she could not prescribe him any medication, and did not work closely with any psychiatrists.
Without ready access to a psychiatrist referral, Liam felt stuck. “I just wasn’t sure what else to do,” he said. “It would have been really hard to just find someone and start outpatient therapy, since I was in such a crisis.” While it was an extreme step to get medical attention via an in-patient hospital, “in the end, it was probably the best way to get medication and medical treatment immediately,” he said. “My therapist said that she thought my life was in danger, and that really struck me. Going to the hospital was worth it.”
When Liam was discharged four days later, with a prescription for Lexapro (Escitalopram) in his pocket, his belt and clothes returned him in large paper bags, he was assigned to see a psychiatrist in the neighborhood where he lived (who we’ll call Dr. Roberts*). For the next six months, Liam dreaded going to see Dr. Roberts, even though appointments were as sporadic as once a month. “I felt like he was trying to be my therapist,” Liam said, “when I already have a therapist who I have a great relationship with. I was just seeing Dr. Roberts because I had to, for my meds. I couldn’t get my monthly refill if I didn’t see him.”
The Divided Care of Split Treatment
Liam isn’t the only patient frustrated by the “split-treatment” model of mental health. Split-treatment is the standard practice in which therapists have to refer clients to psychiatrists or primary care physicians for prescriptions, and psychiatrists are increasingly unable to see clients for long-term talk therapy.
Yet there is a strong mutual need for collaboration between mental health providers — therapists need psychiatrists, and vice versa, since psychiatric practices are becoming increasingly focused on evaluation, diagnosis, and managing pharmaceutical regimens. But as providers remain split into specialized niches, where does this leave patients?
In a landscape whose rules of engagement are often dictated by insurance claims, liability issues, and an ever-narrowing specialization of providers, linking these separate pieces to integrate mental health care can be a daunting challenge. It could feel like we need a map to navigate the complexities of this split-treatment world.
Integrating the Split-Treatment Mental Health Care Landscape
Elka Goldstein* is a licensed social worker who created a potentially optimal scenario in the face of split treatment: she developed a joint collaborative practice with a psychiatrist. Initially, this partnership offered the opportunity to build her private practice and see more clients, while closely coordinating with a psychiatric provider to monitor diagnoses and medication plans for patients.
“The best thing about this is that the client only has to go to one place, and we talk to one another behind the scenes — so they don’t need to reiterate how things are going with each provider,” Elka said. “I can see how a patient is doing with a given prescription drug — like a particular antidepressant or a combination of therapies — and can recommend an adjustment in drug dosages. It’s an amazing way to be involved in all facets of a client’s care, because I see how they respond to medications on a day-to-day basis.”
While this scenario sounds ideal — just find a psychiatrist and a therapist who are partners — few of these integrated practices seem to exist. Why is that?
The Origins of Split Treatment
Looking at the evolution of both psychiatric care and outpatient talk therapy over the last few decades, some answers can be found in the division of training between therapists, psychiatrists, and psychologists, and in the increasing reliance on pharmaceuticals to support talk therapy.
According to the most recent clinical practice guidelines for treating depression by the American Psychiatric Association, a combination of both talk therapy and medication is recommended to provide the most comprehensive long-term treatment for patients. Additionally, an article in World Psychiatry in 2014 reported the discovery that psychotherapy and pharmaceuticals combined were twice as effective as drugs alone. Moreover, the study in World Psychiatry demonstrated that the benefits of talk therapy and pharmaceuticals were primarily independent, meaning that each therapy helped patients in a different way.
The mental health field is becoming increasingly open to combining medication with therapy in treating a number of mental health issues, but this can lead to individual providers treating individual patients as if in a vacuum. To complicate matters, according to a study published in 2013 in the Yale Journal of Biology and Medicine, primary care physicians now prescribe the majority of antidepressants and see the majority of patients with depression — many of whom have never seen a psychiatrist for evaluation or support. With this increased stratification, it is now possible to see a therapist for your emotions, see your primary care doctor for antidepressants, and skip the psychiatrist evaluation altogether.
This is not necessarily for the best. As noted by Dr. Michelle Riba in “Can a Split-Treatment Model Work?” in Psychiatric Times, “One of the problems for patients is deciding who is in charge. Who should they see for which problems?” While patients often do not know who to call in emergencies, a split treatment model of therapy can be equally befuddling for providers. Dr. Riba notes that “clinicians often do not work out communication patterns that lead to successful split treatment arrangements or articulate the implicit and explicit responsibilities of the clinicians.”
Bringing Providers Together
So what can you do to ensure that if you see more than one mental health provider, you can get both safe and effective integrated mental health care?
Liam expressed his frustration with having to be the liaison between his providers: “I had a lot of resistance to seeing Dr. Roberts just to get my meds. I didn’t want to talk with him about my issues; I had been seeing my therapist for a few years before I started Lexapro, so she and I speak the same language.”
He talked with his therapist about his resistance to seeing Dr. Roberts, and she thought he should explore the resistance more. Perhaps he felt powerless at the office of the psychiatrist, and didn’t want to open up or get to know him because it was exhausting or embarrassing to rehash details he had already discussed at length in therapy. “In some ways,” Liam said, “I’d prefer it if he was more clinical — I feel like by attempting to do mini-therapy with me he is patronizing me — and the only reason that I’m there is because he has control over my meds.”
To create more successful split-treatment therapy arrangements, Dr. Seth Mandel offered some advice for patients and providers alike. He noted that when a patient was referred to him for psychiatric evaluation by a therapist or via Talkspace, he immediately reaches out to the primary therapist after his consultation, “so that they know the patient has been seen and so they can review my findings and recommendations.”
Dr. Mandel also emphasized the importance of having a note or referral from the therapist so that both providers can be on the same page about what the most important issues are for a patient. He said, “I am a firm believer that our patients do best when the therapist and the prescriber are in regular contact. It is always best to collaborate because patients may give different information to each provide and may under report symptoms to one or the other due to their particular comfort level.” Moreover, “the patient looks to us for the correct answers. If we cannot agree on the approach, the patient loses confidence in the whole process and inevitably will not do as well as if the providers were on the same page.”
Dr. Mandel notes that he “always asks a patient who their therapist is, and therapists should ask their patient who is prescribing their medication.” In order to help foster communication and collaboration between providers, Dr. Mandel suggested that “a patient should make this information known if it is not explicitly asked for.” But “from that point on, it is really the providers’ responsibility to communicate because it is the standard of care. The patient already has enough to worry about.”
This sentiment could be a relief for patients, since there is a pervasive sense that you are on your own with your doctor, or at the mercy of your insurance company. It can be great to hear that these two providers should be talking with one another because it’s the medically responsible thing to do. Simply knowing this can be powerful encouragement to ask your providers to discuss your treatment with one another!
How Patients Can Advocate for Themselves
Since integrated collaboration is not yet the norm, here are a few suggestions to advocate for the best possible mental health care between several providers:
- Share each provider’s contact information with the other, and encourage them to be in regular communication.
- Ask for active referrals or personal recommendations from one trusted provider, or seek out therapist-psychiatric teams, clinics, or partnerships that offer an integrated model.
- Seek out a psychiatrist who also provides talk therapy, integrating care within a single provider.
- Touch base with each provider about the other, and let both know if there are changes, or if you have questions. What is their comprehensive plan for your care?
- Don’t be afraid to seek out a different psychiatrist or therapist if one provider is not addressing your needs or helping you in the way you want.
Finally, Liam decided to tell Dr. Roberts how he felt. “I just told him that it was hard for me to talk to him, and I really just wanted him to help me regulate my meds and not get involved in that emotional way. It was like unloading a big emotional burden, telling him how I really felt. We agreed to see each other a bit less often, and now we’re in a more honest place.”
Ultimately, while split treatment can muddy the waters of therapy by introducing additional providers, relationships, and judgments, the goal is to feel better. And good relationships help us feel better faster. As informed clients, we get to take control of our own care. When all of these pieces fit together, the picture of healing can be that much clearer for everyone involved.
* Names have been changed to protect privacy.