Yesterday I was called by a psychotherapist who had referred a few of her clients to me in the past (she provided the therapy while I prescribed medication for the same people). This call was not about a typical referral, though. The therapist sought a medication evaluation for herself.
Most of the medical field accepts without question that colleagues can treat one another. A dermatologist looks at an internist’s rash, the internist treats the dermatologist’s high blood pressure. It doesn’t matter that they share some of the same patients. The perception is that the dual roles of patient and professional colleague do not conflict.
Psychiatry has been different, particularly during the era when traditional (“psychodynamic”) psychotherapy was the field’s main tool. In such therapy, the relationship is not incidental to the treatment provided. It is the treatment provided. The relationship-in-the-room takes the place of blood tests and brain scans in collecting data, and the place of medications and surgery in helping a person change. Mixing this essential relationship with other types of roles — colleague, family member, golf buddy, or worst of all, lover — simply ruins it. It also opens the door to unethical exploitation, as the therapist may unduly influence the patient in this other role. Professional codes of ethics for psychiatrists and other therapists condemn dual-role relationships for this reason.
But what about medication management? Most psychiatrists do little, if any, psychotherapy anymore, leaving that to psychologists, social workers, marital and family therapists (MFTs), and others. When psychiatric treatment is medication and not the relationship itself, then the usual situation in medicine seems to apply. Couldn’t my colleague, the psychotherapist who called, see me for a medication evaluation just as she could a dermatologist or internist with whom she shared patients?
Although she only sought medication services from me, I can’t help but think like a therapist. I imagined the awkwardness of later speaking with her about a shared case if she divulged strong feelings related to her job. I imagined I might expect less of her as a colleague if I knew her inner pain, yet this could shortchange the patients we shared. I was concerned I might treat her differently as a patient, since I already knew her as a colleague.
I politely declined, and suggested ways for her to find a psychiatrist she doesn’t work with professionally.
The reverse situation of “patient first, colleague second” has also come up. A few patients of mine are themselves therapists, and occasionally ask to collaborate on a case. I invariably decline, citing the dual-role concerns above. It feels less clear when ex-patients later become therapists, and then refer their own clients to me. Any word-of-mouth referral is a compliment, and the truth is, I have accepted such referrals. But I still wonder about the potential clash of roles.
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