Mental health articles

With the rise in drug treatments and fi nancial pressures from managed-care programs, it has become increasingly common practice in the past 10 to 15 years for mental health treatments to be split—with social workers, counselors, or psychologists doing talk therapy, and psychiatrists (or health service providers) managing medication. While this arrangement may be effi cient and cost eff ective, it also presents challenges to the treating clinicians. Changing the treatment from a dyadic to a triadic relationship has profound psychological impact on the patient. Further, the therapist’s role is relatively passive, while the provider’s role is to do or give something. Making this collaboration work requires thoughtfulness, tact, and a certain degree of artistry. Th e decision to request a consultation is not a simple event. While the patient’s serious symptoms are the most obvious precipitant, oft en the patient is also making the therapist anxious or frustrated. Sometimes there is a desire,
perhaps not fully recognized, to have someone else take a look at the student.
In any case, the therapist should avoid communicating a sense of therapeutic
nihilism to the student. Th e message needs to be, “Medication might help the
therapy to help you better,” not, “Th ere’s nothing I can do for you, so you’d
better take medicine.” At the same time, the therapist needs to avoid overselling
the medicine as the solution to all of the patient’s problems. Th e therapist
needs to carefully listen for patients’ reactions and responses to the suggestion
of consultation. Are students pleased that their complaints are being taken
seriously? Do they fear that this means that they are sick and not just worried
or sad? Th ese reactions should be thoroughly discussed.
Th e psychiatrist must avoid the temptation to be the powerful helper who
is actually doing something, while the therapist is portrayed as passive and
peripheral. Both the therapist and the medicating psychiatrist need to be
aware of the more obvious transference and countertransference problems
that tend to emerge in shared treatments. If medication is to be prescribed,
there should be a mechanism for regular communication between the clinicians
involved in the treatment. Th ere must also be clear lines drawn as to who
is responsible for which aspect of treatment and planning. Will the therapist
manage the full referral plan, or will the psychiatrist take care of the medication
follow-up plans? Th ere are probably strategic advantages to having one
clinician manage the total referral plan, since one person can carefully track
and clarify the cost of ongoing treatment. In some services, the therapist and
psychiatrist may work at diff erent hours or sites, which requires an organized
system of communications. Voice mail or written messages allow for frank
discussions of planning, goals, and medication strategies between therapist
and psychiatrist, limiting the problems inherent in split treatments.
While clinical charts should refl ect that all clinicians are aware of treatment
plans and are in contact, charts can be requested by patients, insurance
companies, and potentially by other parties as well, and so are best treated as not completely private. In light of this, the clinical chart is not the best place for thorough discussion of all clinical and planning issues. It goes without
saying that the clinical chart is not the place to record disagreements between
clinicians regarding the treatment plans.
Finally, many students now request that college mental health services
provide medication management alone or medicate them while they pursue
therapy from a private practitioner. Th e service needs to consider the burden
that this may place on its resources. A college counseling service must have
adequate psychiatric staffi ng to promptly see new students needing evaluation
for medicine. Since many students do present to college services in fairly acute
distress, it seems sensible to have the greatest resources set aside for acute care. Of course, the school’s location and availability of aff ordable psychiatric care
in the community must also be considered in setting policy.

Tags: psychiatrist