Caught Between Two Clinicians: Medication Advice and Communication in Split Treatment

     Timothy Lesaca MD       

    September 19, 2026


When Does Medication Advice Become an Intrusion?

The Case

A patient who is taking medication X under a psychiatrist’s care independently begins psychotherapy with a clinician unaffiliated with the psychiatrist's practice. The two clinicians have never met or spoken, and neither has established a way to coordinate care.

During a therapy session, the therapist tells the patient that medication Y would be a better choice and suggests that the patient ask the psychiatrist to make the switch at the next medication visit.

At that visit, the patient politely raises concerns about the therapist's request, saying, "My therapist told me to ask that you change my medication." The psychiatrist, aware of specific reasons why Y might be poorly suited to this patient, politely declines. The prescription stays the same, but the patient leaves with conflicting advice from two professionals they respect. Neither clinician contacts the other to discuss the recommendation.

Discussion

This case highlights a risk of split treatment, in which one clinician provides psychotherapy, and another manages medication. Communication gaps in split treatment have been documented for decades. In a study of 83 cases, Hansen-Grant and Riba found that psychiatric residents providing medication management reported contact with the patient’s therapist in 44 cases, or 53%. Only seven charts, or 8.4%, documented that contact. The authors recommended an initial conversation about roles, patient consent for communication, and regular contact about progress and treatment plans.¹ These figures come from a specific 1995 sample and should not be taken as an absolute measure of current practice. Still, the problem they describe is recognizable. Gitlin and Miklowitz later emphasized respect for the other clinician, working within one’s expertise, and efficient communication as central to successful split treatment.²

The therapist’s recommendation raises a question about expertise, but the case alone does not absolutely establish that the therapist exceeded their scope of practice. Recommending one medication over another for a particular patient does require pharmacologic judgment. Whether that judgment is appropriate depends on the clinician’s training, role, and knowledge of the patient. In their discussion of the American Psychological Association’s 2011 guidelines, Goldberg and Wagner describe ways that nonprescribing psychologists can contribute to medication discussions, with particular attention to children and adolescents and the knowledge needed to advise responsibly.³

Therapists can have good reasons to raise medication concerns. They may hear about side effects, ongoing symptoms, or frustrations that have not come up during medication visits. A patient can be stable and still find treatment difficult or unsatisfactory. Those concerns deserve attention. Here, however, the therapist presented Y as the better choice without first discussing it with the prescriber. That missed an opportunity to understand why Y might be unsuitable and to identify what, if anything, needed to change.

In a qualitative study involving 29 patients and prescribers, Díaz Crescitelli and colleagues identified “neglecting the relationship” as central to therapeutic discordance, or a breakdown in agreement about treatment.⁴ Their study does not prove that the interaction described here harms the therapeutic alliance, but it does suggest that how disagreement is handled deserves attention alongside the medication decision itself.

The patient might interpret the refusal as dismissiveness on the psychiatrist’s part, or begin to question the therapist’s judgment. Without direct communication, the patient has little way to understand why the recommendations differ. This can create a triangle in which each clinician speaks to the patient while neither speaks to the other. Everyone may remain polite, yet the uncertainty persists.

Patients should be able to discuss other medications, challenge recommendations, and seek second opinions. A therapist can help them bring concerns to a prescriber. The psychiatrist can ask what prompted the request, acknowledge the conflicting advice, and explain the specific concerns about Y. Even if Y is unsuitable, the concern behind the therapist’s suggestion may still need attention. With appropriate consent, the psychiatrist can then contact the therapist to clarify what was recommended and why, share relevant information, and agree on how to discuss future medication questions. The American Psychiatric Association’s guidance on relationships with nonphysician clinicians provides a framework for clarifying professional roles and responsibilities.⁵

The prescriber’s concern about an unnecessary intrusion is understandable. Advice from a trusted therapist carries weight. When the psychiatrist declines the suggested change, the patient may experience that refusal as a failure to listen or help, even when it rests on sound clinical reasons. The medication visit can become a test of which clinician deserves the patient’s trust.

The therapist’s own alliance with the patient may also be strained. Accepting the psychiatrist’s explanation could leave the patient questioning the therapist’s judgment; remaining loyal to the therapist’s advice could make it harder to trust the prescriber. Also, feeling caught between them may make the patient less comfortable discussing doubts with either clinician.

Direct communication can protect both alliances. Even if they continue to disagree, they can show that they will handle differences openly. The patient should not have to choose a side to feel supported.

References