SAN FRANCISCO – In psychiatry, the thinking has changed on working with psychotherapists who lack medical degrees, according to Dr. John Q. Young.
Dr. Young, a psychiatrist with the University of California, San Francisco, said knowing how to collaborate with doctorate- or masters-level psychotherapists is an increasingly important skill.
Years ago, not only was the emphasis on treatment by the medical doctor, but the physician often showed undisguised hostility to other clinicians, Dr. Young said at a meeting on depression research and treatment sponsored by the university. Some psychiatrists framed these issues in ethical terms. For example, a survey of psychiatrists in the 1980s showed that fully two-thirds believed that it was unethical to collaborate with non-MD therapists, he said.
More recent models of interactions between psychiatrists and psychotherapists emphasize relationships that are supervisory, consultative, or collaborative.
In a typical collaborative scenario, the psychiatrist manages the patient's medications while the other clinician–a psychologist, a clinical social worker, or a marriage and family therapist–provides psychotherapy.
Other, more complex scenarios also are possible. For example, while the psychiatrist provides pharmacotherapy, one therapist might provide group dialectical-behavior therapy, another therapist might provide individual therapy, a neurologist might treat the patient's complicated migraines, and a primary care physician or specialist might treat the patient's chronic fibromyalgia pain.
Even the typical scenario sets up complicated triangular patterns of transference and countertransference. Still, Dr. Young offered several tips aimed at making such collaborations pleasant and therapeutically fruitful.
Dr. Young recommended establishing a written or oral contract with the patient and the other clinician at the beginning of therapy. At the Langley Porter Psychiatric Hospital and Clinics, where Dr. Young serves as associate director of the adult psychiatry clinic, psychiatrists use a standard form called “Collaborative Treatment Notice to Patients.” This form emphasizes that there is no supervisory relationship between the psychiatrist and the therapist, but that the two will be communicating as necessary about the patient's case.
The notice clarifies that medication-related problems or questions should go to the psychiatrist and that other concerns about treatment should go to the therapist.
One step the psychiatrist can take is to telephone or meet with the psychotherapist early in the patient's treatment, when it's critical to discuss and agree on a diagnosis. In Dr. Young's experience, the psychiatrist gains useful information–and the psychotherapist is pleasantly surprised–if the psychiatrist inquires about the therapist's working diagnosis.
It also is helpful for the psychiatrist and psychotherapist to learn and appreciate each other's focus. “This goes to developing ways of relating beyond our historic tribal conflicts,” Dr. Young said. Furthermore, it is in everyone's best interests for the collaborators to understand each other's approach and training, elucidate belief systems around risk management, and be explicit about goals for psychotherapy and pharmacotherapy.
Agreeing on the type and frequency of routine and emergent communication is an important part of the collaborative process. “Our minimum standard for our clinicians is to call when there's any change in clinical status or treatment and to ask that the other collaborators do the same,” Dr. Young said. “Some of us practice what I call 'turbo-collaboration,' where a psychiatrist tries to call after each visit with a message summarizing what the patient's status was and any change in meds.”
Dr. Young stated that he had no conflicts of interest related to his presentation.