- Collaborative treatment between prescribers and therapists is a staple of today’s treatment model. I believe we can do it better.
- Medication therapy is a superior idea to medication management. It incorporates the best of therapy with the best medication.
- Here are some thoughts about better co-joint work between prescribers and therapists.
For years, as an outpatient psychiatrist, I have been providing co-joint treatment with many wonderful non-physicians, mostly social workers and psychologists. Much of my practice is managed solely by myself (therapy and medication), but I enjoy the camaraderie of working with others who do psychotherapy in a different role.
There are incredibly talented therapists out there, many of whom do interventions that are truly inspiring. Sometimes I watch in awe.
Medicine and Therapy
When working in tandem with a therapist, I call it "medication therapy" rather than "medication management."
Years ago, many of us can remember the development of "managed care," with its focus on cost-effectiveness co-joint treatments. Also, having worked on inpatient services, it is entirely sensible to embrace collaborating with non-physician clinicians.
The question is: how do you do it right?
This is very important work. When done correctly, it is teamwork at its best.
"Med Management" Must Go
The term, "med management" came along around the same time as the term "provider," which replaced the more appropriate term, "professional." This is not the space to start critiquing insurance companies, but when we are no longer professionals (psychiatrists, psychologists, social workers, and nurses all get clumped together in this category) quality of care may become a concern.
Sometimes, non-physician clinicians might think of the “medical manager,” perhaps unconsciously, as somebody who is just “providing” medicine. Some physicians and nurse practitioners may fall into this role. Or, the prescriber, in turn, sees the therapist as someone who just “provides” psychotherapy. This is a non-integrated treatment mindset. These are mistakes. There’s nothing that can be further from the truth that care is not integrated, and most social workers and psychologists would readily agree. Unless medication management is done with great professionalism, incorporating the collaborative zeitgeist of medication therapy, it will necessarily be flawed.
The Basics of Collaborative Medication Therapy
When the non-physician clinician decides a patient may benefit from medication they make a referral. Part of that referral needs to include an understanding that a release is to be signed to enable a free flow of information.
As a medical prescriber, I don’t need to know every detail of the psychotherapeutic work, but I do need to know how the patient is doing, if there are problems with compliance. I need to know if a new medication that had been introduced or changed is causing a noticeable shift as seen by the clinician on the case.
The non-physician must keep good notes about which medications the patient is on. Since they are seeing the patient with greater regularity, I rely on their expertise in making sure that the patient is compliant, whether the patient is responding, if any questions have come up that are to be referred to me for a consultation, or for a medical evaluation in another specialty.
From my point of view, the treating therapist is my eyes and ears. If something comes up between myself and the patient, that material could be useful for the therapist, as well. It should be a full collaboration.
Medication and Meaning
Medication carries meaning. Some people are highly resistant and frightened about dependency, others worry about side effects. Some see doctors or medication as vehicles of control. Still others depend on medicine when they should be working harder in psychotherapy. None of these are satisfactory situations.
It is important that the patient work on whatever resistance they have regarding taking medicine (or not). At least from the start, this is important work for the primary therapist. For some patients, compliance can be part of truly meaningful therapeutic work with the non-physician. Resistance to compliance can be a missed opportunity for growth.
In my work, patients are invited to let me know when new refills are required. I’m usually generous with refills. But sometimes there are controlled substances that need attention. If the patient waits until the last minute for these things, it’s likely I will not be able to provide. This is an important therapeutic issue that has to do with executive functioning among other things. The patient may be testing me or themselves, "Will I be saved?" The patient may have self-contempt because they keep avoiding dealing with parts of treatment that matter. Such reactions are important to explore in psychotherapy work.
The Magic of Collaboration
Sometimes, consultations need to happen in a more intense way, where the psychiatrist works with the patent in psychotherapy. If this happens beyond an occasional conversation, the patient needs to be aware that they may be charged. Often, it will be useful to set up a session or two to discuss the case objectively. These would not be as in-depth as psychotherapy, but rather as medication therapy, to ascertain:
- Are there issues in our therapeutic alliance?
- What can we do to strengthen this alliance?
Sometimes the clinician may educate me about how the patient perceives pharmacology services, or that the fit may not be quite right. These are important conversations that can increase compliance and decrease unnecessary stress for all parties involved in a treatment.
Finally, having a healthy alliance with the patient regarding their medications provides a sense of agency, that another person in their life respects their efforts to get better.
It can be hard to struggle with a psychiatric issue, and being part of a collaborative team can make a difference. Our common humanity is one of the most basic aspects of healing. It is not to be underestimated.
Think about the value of medication therapy. There’s nothing new here. It’s about setting up a therapeutic alliance from the start with intention, kindness, and common purpose.
It may be somewhat more expensive and it may require a set of healthy understandings right from the beginning, but outcomes, I believe can only be better if we are all in it together.