Splitting not only occurs between different members of the treatment team, but it can actually occur in the patient's mind between the physician and the medication. The physician may be idealized and the medication devalued, leading to nonadherence to the medication regimen. Conversely, the medication may be idealized and the physician devalued and seen simply as a prescription writer, a “provider” in managed care terminology, who can easily be replaced by any other provider who has a prescription pad.
Triangulation can also occur. The third party entering into a therapeutic relationship can be a stabilizing and beneficial influence or can be seen as a threat. Oedipal issues can arise in the patient or therapists, producing competitiveness, fear, anger, and rage. Projection and splitting by patients can lead to competition between the psychotherapist and physician. Patients often have fantasies about physician and psycho therapist communication. These are often eased by having the cotreaters communicate while the patient is present (eg, during phone calls).
The meaning of medication
As indicated earlier, the goals of treatment include remission of symptoms; improvement and restoration of function, quality of life, and relationships; and delay and/or prevention of recurrence of symptoms. To achieve these goals, the patient must adhere to and remain in treatment. There are many reasons for which patients discontinue treatment, and unfortunately, studies indicate that the majority of patients discontinue psychotropic medications within the first few months of their being prescribed—well before discontinuation should occur. Consequently, successful cotreatment involves the energetic and constant vigilance of all members of the treatment team to ensure the patient's use of medications and medication adherence.
An understanding of the meaning of the medication to the patient can alert the cotreaters and signal that nonadherence is likely to occur, consequently providing an opportunity for an appropriate intervention. It is essential that all members of the treatment team intervene when nonadherence occurs and not simply leave it to the prescribing physician. Patients may have unrealistic expectations of magical cures by medications, and if such cures do not happen immediately, discontinuation of the medication becomes a likely event. Patients may believe that taking a medication absolves them of personal responsibility for their own progress, growth, and recovery. They may be fearful of medication because they fear addiction; sedation; loss of control; or certain side effects, such as sexual side effects and weight gain. Alter natively, the medication may be seen as a "gift" from the physician, especially if samples are provided.
Side effects also have various meanings to patients. They may see the physician as inadequate if side effects de velop. They may believe the physician has violated their trust or is punishing them, which may precipitate frustration, anger, and discontinuation of treat ment. On the other hand, the patient may interpret side effects as evidence that he is hopeless and inadequate or that treatment has failed.
Managed care issues
Managed care issues also must be considered when constructing the shared treatment plan. One significant concern is the "dumping phenomenon." This occurs when the patient has exhausted his coverage for psychotherapy visits, but continues to require medication treatment. If the patient subsequently experiences a crisis as a result of a stressful life event, the psy chiatrist/physician may feel "dumped on" when the patient calls the psychiatrist for help, because the psychiatrist expects the psychotherapist to be the individual best able to handle this situation. Patients and therapists must re member that the end of managed care coverage does not necessarily mean the end of treatment. This, as well as the cost of possibly continuing treatment after the end of covered visits, should be discussed with the patient and by members of the treatment team. Similar situations occur when patients change insurance coverage or caregivers change accepted insurance coverage. Splitting, with idealization and de valuing, plus conscious or unconscious sabotage of the treatment team by the patient, therapist, or physician can occur in these situations.
Cotreatment can not only be successful, it can offer the patient synergistic benefits beyond those offered by the physician or psychotherapist individually.10-12 With mutual respect, close communication and cooperation, and formulation of an appropriate treatment plan that includes a plan for emergencies and challenging circumstances, physicians, therapists, and patients can successfully negotiate the potential dangers and pitfalls of the cotreatment model and benefit from its advantages.
It is essential that all members of the treatment team see each other as colleagues and not competitors and that lines of communication be maintained in a collaborative fashion. Challenging circumstances must be anticipated and addressed, including the results of triangulation with splitting, idealization, devaluing, and premature treatment discontinuation. An understanding of the psychodynamics of referral, consultation, and medication and an appreciation of the manner in which physicians and therapists are seen by patients will facilitate successful treatment and the furthering of the therapeutic alliance. While cotreatment is fraught with many dangers, these are more than compensated for by its benefits to all members of the treatment team. Careful attention to the key points outlined above can help resolve any issues or conflicts that arise and keep the patient on his planned course for recovery, remission, and functional restoration.