Question By Jennifer Weinstein

Currently, there is a push for people to be on medication, and clients often come in stating that they want medication. This is especially true in multidisciplinary environments where psychiatrists and APRNs work alongside psychotherapists. However, some people do not have this mindset. For therapists who believe that medication only needs to be used as a last resort or in obvious serious situations, is it ethical to not refer everyone to a med provider, and instead of offering medication right off the bat, to wait and try and achieve success in therapy first, in the hopes that medication will not be needed?

Response By Dr. Jeffrey Barnett

This is a great question and one that all psychologists and psychotherapists should carefully consider.  It is true that some mental health patients must have medication included as a part of their treatment. These may include those suffering from Bipolar Disorder, Schizophrenia, and other serious mental illnesses. But, even for these patients, we know that medication alone does not provide the best treatment outcomes. Even for these patients, psychotherapy and psychoeducation are important components of their treatment. Many of these patients struggle with medication compliance for a variety of reasons to include side effects of their medication. We also know that for many mental health patients, even those for whom medication may be of help, that many of them will also benefit from psychotherapy alone or a combination of psychotherapy and medication. Fairly recent data demonstrate that psychotherapy can result in many of the same changes in the brain that medication causes, and without the significant side effect potential or the potential for drug-drug interactions.

It is unfortunate that we live in a time where pharmaceutical companies directly market their products directly to consumers and the health insurance and managed care industries often take a myopic view due to fiscally motivated treatment decisions. Some patients may not be allowed to see a psychotherapist under their insurance plan until they have tried and failed with two or three medications. That’s really tragic, especially with all we know about the effectiveness of psychotherapy.

Informed consent about treatment options and competence about psychopharmacology

I believe your question brings up several important ethics issues. The first is informed consent. It is important to share all reasonably available information with your clients to assist them in their decision making. While we shouldn’t overwhelm them with information, it is important to ensure that they understand the reasonably available options and alternatives for their treatment along with their relative risks and benefits. This will then assist them to make more thoughtful and informed treatment decisions. The second important issue is that of competence. If we aren’t sufficiently knowledgeable about psychopharmacology and psychotherapy we can’t provide the relevant information and can’t effectively assist patients to make the most informed decisions possible.  We should also explore with patients their motivations for wanting medication. They may be seeking a quick and easy ‘fix’ for their difficulties. Again, providing them with relevant information will assist them to have realistic expectations of treatment whether psychotherapy alone, medication alone, or a combination of the two. Finally, when our psychotherapy patients are being treated with medication it is important that we address confidentiality and consultation issues with regard to coordinating treatment with their prescribing physician (or other professional). We should ensure that we have appropriate consent from our patients before sharing information with others, but should stress the importance of coordinating care with our patients. We can monitor for side effects, positive effects, and the like. The prescribing professional may only meet with the patient for 15 minutes every 6 months whereas we may meet with the patient for 50 to 60 minutes each week.  For those patients taking medication in addition to our psychotherapy we can play a valuable role in monitoring their functioning and progress.

Interdisciplinary collaboration with prescribing professionals

We can also work to educate prescribing professionals about the short and long term benefits of psychotherapy for a wide range of presenting problems. In the multidisciplinary environment it can be very important to provide inservice training on psychotherapy. You could also provide consultations on patients at intake and explain treatment options then.

There is not obligation to refer all patients to a prescribing professional right away, but this goes back to the points raised about informed consent. One thing you can do is in your practice literature (as well as on your website if you have one) you can describe the services you offer along with your treatment approach and practice philosophy. That may be a good way to let patients and potential patients know how you approach treatment for a range of presenting problems. Then, if they still want to meet with you could go through the informed process as described earlier. But, you should endeavor to provide patients with accurate information, not just personal opinion. Also, it is important to ensure that all patients are medically cleared for treatment and if medical conditions exist that may impact their treatment referral for appropriate medical care is essential (e.g., diabetes, hypertension, etc.).

What you ask about is a true ethics dilemma; that is, there is no clearly correct or incorrect course of action. The best course of action depends on a number of issues and factors as described above. What makes your practices ethical or unethical is the actions you take, the actions you choose not to take, and the rationale for doing so (along with following the dictates of the ethics code and relevant state laws).

I hope this is of help. Thanks for seeking this consultation. I hope others can benefit from reading it and will respond as well.

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