There are today two completely different perceptions of the clinical
psychiatrist's activities. Ours is that the psychiatrist is the captain of the
ship, the best diagnostician, the leader in psychotherapy, the expert in
differential diagnosis and in the differential use of psychotropic
medications, and the best judge of the allocation of mental health
The opposite perception has the psychiatrist accepting the practive of
medicating a patient diagnosed and treated elsewhere. For several years a
number of financial intermediaries in health care have tried to teach us that
psychiatrists should mostly devote themselves to signing prescriptions. The
main evidence in favor of this distortion is that some psychiatrists may be
better paid for signing three prescriptions in one hour than talking with a
patient during the same time.
The mutilated perception of psychiatry has unfortunately advanced even
among those who believe they are protecting psychiatry. I have several
A company hired by a patient's employer asked a psychiatrist to evaluate a
colleague's work. The consultant was active in organized psychiatry. He wrote
in his opinion that the patient's social problems were probably due to the
patient's early upbringing, that the prescribed medications might not be
enough, that the psychotherapy given by the psychiatrist was insufficient, and
that the patient should be referred to a psychologist for further therapy.
The treating psychiatrist stood his ground. Both the social problems and
the symptoms responded to his therapy, and the patient became fully
functional. The psychiatrist thought the split therapy proposed by the
consultant would have been less effective.
A second case illustrates the lack of communication common in split
therapy. A psychiatrist was asked for his opinion about the treatment of a
patient who had been in treatment for one year and was still complaining about
the same symptoms. The treatment plan called for a psychologist to see the
patient two to four times a month and a psychiatrist to conduct"
medication management" as needed. The psychologist had seen the
patient four times in five months, and the psychiatrist twice in the same
time. The patient was not aware of any communication between the psychiatrist
and the psychologist. She was working with the psychologist on her
self-esteem, while taking 300 mg of trazodone most nights.
Refusal to participate in split therapy is an ethical position for those
who do not believe in it and are prepared to provide both psychotherapy and
psychopharmacologic treatment. Split therapy may be a poor second choice when
the psychiatrist is prepared to give both treatments. If the psychiatrist
doubts his or her own ability as a psychotherapist, which is regrettable but
likely in the current environment, there are excellent remedial courses that
may help correct the problem.
The financial incentives proposed by intermediaries that favor split
therapy should not deter most psychiatrists from the full practice of their
profession. These incentives create quicksand in which many may drown. The
temporary financial benefit does not compensate for the mutilation of