When Independent Treatment Goes Dysfunctional

What does a psychiatrist, or even a primary care physician, do when she harbors doubts about the patient's psychotherapy? As I have opined previously I believe the advantages of independent psychotherapy and medication management (or other biological treatment, such as TMS) outweigh the disadvantages. But when the physician does not know the psychotherapist well because the patient chooses his psychotherapist or the physician does not know the psychotherapist well, problems can arise, for example when there is:

  • No sign of improvement after extended treatment.
  • Evidence of boundary violations or other impropriety in the relationship.
  • Failure of the psychotherapist to respond to phone calls or other attempts to establish or maintain contact for coordination of treatment.
  • Lack of evidence of effectiveness of the treatment approach for the patient's disorder.

or when:

  • The physician has a vague negative sense about the psychotherapist from past encounters.
  • The physician dislikes the psychotherapist.
  • The physician knows that the psychotherapist dislikes her.

One might expect to resolve some of these problems with a phone call, email, or other communication, but a persistently dysfunctional treatment team can ultimately harm the treatment. Which relationship should take precedence over the other, the medication management relationship in which the patient spends ten minutes with the psychiatrist every three months, or the psychotherapy relationship consisting of fifty minute meetings weekly? Medication may work the same regardless of how you feel about the person who prescribes it. This may not hold true for psychotherapy. At what point should the physician impose an ultimatum: Find a new psychotherapist, or find a new psychiatrist?


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