Nonphysician psychotherapist-physician pharmacotherapist: a new model for concurrent treatment

In the last century the mental health field has vacillated between a biologic versus a psychologic model of the mind. Only in the last two decades have proponents of both views calmly discussed their virtues and limitations. As a result, clinicians have begun to promulgate the concept of an integrated, concurrent psychotherapy and pharmacotherapy. While this debate has raged in the psychiatric field there has been a parallel proliferation of nonphysician mental health professionals. Most of these mental health clinicians come from training programs steeped in the traditions of a psychodynamically based treatment that occurs within the interpersonal context. Today more and more of these clinicians compete for the increasing population of those seeking relief. The result of these two movements has been the introduction of a unique form of treatment in which a patient sees two therapists. In this triangular treatment, the pharmacotherapist prescribes medications and the psychotherapist provides the interpersonal therapy. In order for all practitioners to participate in this form of triadic treatment they must appraise themselves of not only the historical debates preceding this therapeutic concordance but of the transference and countertransference potentials. Some patients can have idealizing, magical, and nurturing transferences toward either therapist in the triangular relationship. Other patients can be narcissitically wounded, with a negative devaluing response toward either therapist. Paralleling the patient's transference distortions are the therapists' countertransference reactions. These can run from the omnipotent identification with the patient's idealization to the devalued, distancing response toward oneself or the patient. If these distortions are not checked they can intrude on the treatment, acting out the patient's internal split self-object representations and ultimately sabotaging treatment. Successful attention to transference and countertransference phenomena can lead to an enhanced treatment in which the biologic and psychologic treatments have a synergistic effect. Only then will we be capable of fully evaluating and researching the positive and negative effects of combined psychotherapy and pharmacotherapy with two different therapists. The outgrowth of this research will be improved patient care by enhancing our capacity to identify those patients and therapists who are good candidates for this triangular treatment relationship.