Ideally, psychotherapy and pharmacotherapy are complementary and synergistic.1,2 They are inseparable because all clinical encounters, even those limited to medication management, contain at least informal psychotherapeutic elements and opportunities. However, not all patients can or will participate in explicitly combined treatment. Some will not tolerate psychotropic drugs, either physiologically or as a matter of personal choice. Other patients cannot overcome a sense of stigma associated with mental health services, or they lack sufficient ability to trust, to introspect, to communicate, or to learn, all traits important for effective psychotherapy.
Given this complexity of individual presentation and response, what should a primary care physician do? In this issue of American Family Physician, Rupke and colleagues3 reasonably suggest that for mild to moderate depression, most patients may choose their treatment. Patients unfamiliar with psychological treatments may make more informed decisions if they understand from the beginning that psychotherapy is not “just talking” but involves becoming stronger and wiser through effortful change and learning.
As part of a balanced approach to treatment selection, it can be helpful to present medication in the same light (i.e., not as a stand-alone “cure” but as a tool to help patients actively examine and improve their lives). When discussing patient choices, it also is helpful to remember that sometimes treatment preferences can be part of the problem, such as when victims of domestic violence request medication with the dysfunctional expectation that they will no longer need to face their life problems, or when a patient’s request for counseling stems from a desire to influence or have a special relationship with the physician.
Once a patient is interested in psychotherapy as a treatment option, or when clinical factors mandate its consideration, the physician must decide which patients may receive treatment from the physician and which patients need referral to a mental health subspecialist.
For physicians considering counseling in the office setting, the following are issues to consider:
• Does the patient have a sufficiently positive relationship with you, one that is characterized by warmth, trust, and willingness to openly disclose information? The most robust finding in psychotherapy research over one half century is that the quality of the therapeutic alliance is the best predictor of treatment outcome.
• Does the patient’s insurance restrict mental health treatment or impose special managed-care requirements for patients with psychiatric diagnoses? Clarification of these issues is an essential element of treatment planning, because a plan that does not match available resources cannot be implemented.
• Does the patient have any concerns about relationships that you may have with other persons? Although a family physician’s knowledge of and access to other family members is a potentially valuable clinical asset, it cannot always be therapeutically deployed without risk to the therapeutic alliance.
• Does the patient have a need for the enhanced confidentiality often available in mental health settings? The Health Insurance Portability and Accountability Act made special provisions for the separate physical and legal treatment of psychotherapy notes. Other laws in many jurisdictions, as well as in federal courts, provide a legal privilege for specialist mental health treatment that may not apply to counseling by a primary care physician. Any patient whose mental health and treatment may become an ▴ issue in litigation (including disability determination) may be better served by a subspecialist.
• Does the patient have complex comorbidities, a personality disorder, or a history of significant interpersonal difficulties or early trauma affecting his or her capacity for healthy attachment? In these cases, referral to a subspecialist may be more desirable because such patients are at greater risk of complicated treatment courses and of re-enacting their interpersonal difficulties in the physician-patient counseling relationship. Patients with a history of physical or sexual abuse are at particular risk and may have difficulty establishing a useful psychotherapeutic relationship with a physician who also performs invasive procedures or genital examinations.
For physicians considering referral to a psychotherapist, the following are issues to consider:
• Do you have adequate information about the therapist’s track record? Unlike medications, which have highly controlled chemical compositions, psychotherapy varies greatly according to the skill of the individual practitioner. Paper credentials are a reasonable place to start, but the best way to find skilled therapists is to keep track of patient experiences. Therapists to recommend are those who successfully engage and retain even difficult patients; therapists to avoid are those who have high rates of patient drop-out, noncompliance, and hospitalization, or those who fail to collaborate with other health professionals. Listening to your patients’ post-referral experiences will help you develop knowledge of the therapists in your community and also may allow you to assist patients in extricating themselves from an unfortunate experience.
• Is the patient willing or able to tolerate the possibility that he or she will need to meet more than one therapist before finding a good match? Some trial and error in finding the right therapist is inevitable.
• Are the patient and therapist willing to collaborate with you? Therapists who insist on overly rigid interprofessional boundaries, or patients who will not allow their therapists to talk with their physicians, are exhibiting signs of potential trouble. Monitoring referral outcomes is important because poor-quality psychotherapy may cause serious harm, exacerbate presenting symptoms, or produce new symptoms as a result of defining unrealistic goals or tasks (psychotic decompensation or suicide would be extreme examples). A patient may lose trust in the physician or may even become disillusioned to the point of not obtaining necessary treatment in the future.4
Following these few principles will help patients get the most benefit from brief office counseling and from formal psychotherapy.