How Many Therapists Does It Take to Change a Light Bulb? The answer to this old joke was “None, if the light bulb really wants to change it will change itself.”
Today the question could be rephrased to how many therapists does a person really need? Or perhaps how many therapists can a person really tolerate. We live in the era of “more is better.” We don’t just want medicine, we want the “maximum strength formula.” Comedian Jerry Seinfeld says, what we are really saying is “Find the dosage that will kill me and then back off a little bit.”
Recently we've been running into a situation that is becoming more and more common. We will get patients referred to us, who are already in treatment with other community-based providers. These other providers usually do not have a full continuum of care, and in particular lack psychiatric services. The patient is usually being referred to us, just to receive medications. In order to assure continuity it has been our policy that patients seeing our psychiatrists must also be in therapy with us. Some providers try to circumvent this policy by referring their patients to us for both therapy and psychiatric services, but at the same maintaining them as their own therapy clients. In effect this gives the patients two therapists. Often the therapy they provide is in the context of intense in-home therapy or in the guise of “case management” which, looks exact like therapy, only that it is provided by an unlicensed clinician.
This is problematic for us on two fronts: financially and clinically. First, we have limited psychiatric services and those that we do provide are nowhere close to paying for themselves and contribute significantly to our annual financial loss in our psychiatry program. We can certainly understand why other community-based providers do not provide their own psychiatric services, since it would be extremely expensive for them to do so.
We feel that this constitutes “cherry picking” in which other providers take the easy and more lucrative services, leaving us to provide the more difficult to staff and financially challenging psychiatric services.
The other issue is clinical. In regards to medication, the question is: “Is the best approach for the client to be seen by a therapist and doctor who are working together from a shared medical record and who meet regularly to communicate and coordinate services? Or can a patchwork approach with multiple therapists and numerous clinicians from different organizations be more effective?"
I suppose that a highly effective “systems of care” approach could address some of these continuity issues, if clinical staff had the time and capacity to attend such meetings regularly. Financially I am not sure this is very realistic, however.
In general I have felt that such duplication of therapy services is overly time-consuming, confusing, and counter-therapeutic for client care. I also believe it can be overly intrusive, wasteful, and place an unreasonable burden on the parents. I have seen families that I believe were over-treated. With a constant slew of outpatient appointments to keep and multitudes of people coming in and out of their houses, the stress was high and there was little chance at normalizing to any degree.
Therapy like medicine may have toxic levels where too much can do more harm than good. Also, there may be significant interaction effects in which different clinicians or types of therapy may adversely interact.
What’s your opinion or experience in this area?