Dr Robert London

Making Dual Therapy Work

Clinical Psychiatry News - Volume 33, Issue 2, Page 19 (February 2005)

We're in the midst of a crisis in psychiatry. Why? Partly because much of our world has been turned over to a group of caregivers called “psychotherapists.”

Many of these psychotherapists are fine at what they do. And given the shortages of psychiatrists and our tendency to focus on psychopharmacology, these people are needed. But who are they?

Of course, we know about Ph.D. psychologists, mental health social workers, and psychiatric nurse-practitioners. Their education, training, and clinical experience can be extremely varied, but they do have knowledge about mental health and psychotherapeutic intervention.

In addition to those trained professionals are other psychotherapists who have been taking correspondence courses and participating in weekend or summer seminars.

Finally, add practitioners of various subspecialties or varieties of techniques, including family and couples therapy. Some refer to themselves as behaviorists, hypnotists, analysts, cognitivists—and the list goes on and on.

For the mental health consumer, this variety of therapists and therapies presents a maze of confusion. Much has been written in dozens of books about ways to negotiate this complicated area. I do not propose to solve this problem here.

Rather, I would like to address something more concrete and specific. The more psychiatrists turn their attention to medication and give up on talking strategies and theories, the more these patients need to find someone with whom to talk.

Psychopharmacology articles most often conclude that combining medication with talk therapy is best. If that's the case, and if the psychiatrist believes this, then whom does the psychiatrist pick to do this kind of work? What communication exists between the psychiatrist and the talk psychotherapist? From my experience, it is rare that regular codified communication occurs. The patient or consumer of mental health services is not even shopping in the same store.

These issues bring to mind a patient I saw in consultation a few years ago who was seeing a psychiatrist for medication and a psychotherapist for talk therapy. The patient was in a complete quandary. Like many people in talk therapy, this 30-year-old patient had some confused ideas and conflicts. She had made some poor life choices, was anxiety ridden with mood fluctuations, and was ambivalent in her ability to sort out her life issues.

Medications helped control her moods, and talk therapy gave her good intellectual perspectives on how to avoid repetitive behaviors that caused her difficulties. On a routine visit, her primary care physician sensed the patient's confusion and started talking with her. She thought that the patient needed a new opinion to get a better perspective on a situation that was causing her emotional distress, based on therapeutic confusion. The primary care physician referred the patient to me.

To realize her career goal of additional education, the patient could have accepted money from her father plus a car to attend a college 40 miles from home. Not borrowing the money from him would have forced her to finance the loan. And without a car, getting to the college would have extended her commute by about an hour each way. During monthly 20-minute psychopharmacology visits with the psychiatrist, the patient raised this issue. The psychiatrist was clear: “You want this career; your mood is well balanced; your father is making you an offer. Take it.”

The psychiatrist was using clear thinking in seeing the stability of the patient's mood and her wanting to achieve a goal, but was not paying attention to the ghosts of the patient's past. The patient placed great value in the psychiatrist's thinking and believed she should move forward. But she wasn't.

The patient's psychotherapist, on the other hand, was concentrating on the patient's past by focusing on understanding the controlling, enabling father who would need to be ignored if the patient was to move forward in life. The patient placed great value in the psychotherapist, too, and believed she should pay close attention to what the therapist was suggesting. Confusing? Indeed.

In this situation, my consulting job was easy. With the patient's permission, I called both treating parties, explained my role and how I got there, and—believe it or not—started a communication between the psychiatrist and psychotherapist that didn't exist previously. The result was that both treating parties respected the other's point of view, began a working relationship based on the patient's welfare, and were better able to integrate goals into the patient's ongoing psychotherapy.

The woman did go on to that college, and her father helped pay for it. She got the car and better understood how to integrate her poor past life experiences and choices with the current, well-intentioned offers from her family. What a happy ending.

In my experience of hearing about other dual therapeutic approaches, the results are often not as successful. Communication between treating therapists may be poor. Theories and ideas of psychotherapy may be rigid and dogmatically ingrained. Intellectual insularity and a lack of humility often cloud psychotherapeutic communication as well.

But we must understand that the age of dual therapy is upon us. And as the leaders in mental health care, we psychiatrists need to bridge this communication gap.

First, we need to know who else is treating the patient we are medicating or advising, and for whom we are responsible. Then, we need to have regular communication with that therapist to share ideas, prognoses, and treatment plans. This can be done in the context of an extended first visit with a psychiatrist who sets in motion a medication regimen. A therapist recommended by the psychiatrist is always a good start. If a therapist is in place, communication should begin before the patient's second visit with the psychiatrist. Furthermore, ongoing therapist communications, other than crisis intervention, should be a must.

Contemporary psychotropic medications have helped make great improvements in patients' recovery and quality of life. Talk therapy also makes tremendous changes in a person's behavior and improves the patient's level of functioning. As more psychiatrists move away from the field of talk therapy, we still need to keep track of what the patient talks about in order to fulfill our role as leaders in mental health.

Let me know your thoughts on this important topic by e-mailing me at cpnews@elsevier.com, and I'll try to share them with my readers.

PII: S0270-6644(05)70669-X