Table Of ContentCompetency in
Combining
Pharmacotherapy
and Psychotherapy
Integrated and Split Treatment
Competency in
Combining
Pharmacotherapy
and Psychotherapy
Integrated and Split Treatment
By
Michelle B. Riba, M.D., M.S.
Clinical Professor of Psychiatry, Department of Psychiatry,
University of Michigan, Ann Arbor, Michigan
Richard Balon, M.D.
Professor of Psychiatry, Department of Psychiatry and
Behavioral Neurosciences, Wayne State University, Detroit,
Michigan
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is ac-
curate at the time of publication and consistent with general psychiatric and med-
ical standards, and that information concerning drug dosages, schedules, and
routes of administration is accurate at the time of publication and consistent with
standards set by the U.S. Food and Drug Administration and the general medical
community. As medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific situations may require a
specific therapeutic response not included in this book. For these reasons and be-
cause human and mechanical errors sometimes occur, we recommend that read-
ers follow the advice of physicians directly involved in their care or the care of a
member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views
and opinions of the individual authors and do not necessarily represent the poli-
cies and opinions of APPI or the American Psychiatric Association.
Copyright © 2005 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
09 08 07 06 05 5 4 3 2 1
First Edition
Typeset in Adobe’s Berling Roman and Frutiger.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Riba, Michelle B.
Competency in combining pharmacotherapy and psychotherapy: integrated
and split treatment / by Michelle B. Riba, Richard Balon. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-143-9 (alk. paper)
1. Mental illness—Chemotherapy. 2. Combined modality therapy. 3. Psycho-
therapy.
[DNLM: 1. Mental Disorders—therapy. 2. Clinical Competence. 3. Combined
Modality Therapy—methods. 4. Drug Therapy—methods. 5. Psychotherapy—
methods. WM 140 R482c 2005] I. Balon, Richard. II. Title.
RC483.R465 2005
616.89'18—dc22
2004026974
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction to the CoreCompetencies in
Psychotherapy Series. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
1 Introduction to Integrated and Split Treatment. . . . . . . . . . . 1
Part I
Integrated Treatment
2 Selection of Medication and Psychotherapy in
Integrated Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3 Evaluation and Opening in Integrated Treatment . . . . . . . . 31
4 Sequencing in Integrated Treatment. . . . . . . . . . . . . . . . . . . 49
5 Termination in Integrated Treatment . . . . . . . . . . . . . . . . . . 61
Part II
Split Treatment
6 Selection of Medication, Psychotherapy, and
Clinicians in Split Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . 75
7 Evaluation and Opening in Split Treatment. . . . . . . . . . . . . .83
8 Sequencing and Maintenance in Split Treatment . . . . . . . .109
9 Termination in Split Treatment. . . . . . . . . . . . . . . . . . . . . . .123
Part III
Evaluation, Monitoring, and Supervision
10 Evaluation, Monitoring, and Supervision of
Integrated and Split Treatment . . . . . . . . . . . . . . . . . . . . . .139
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153
Preface
T
he practice of combining pharmacotherapy and psychotherapy for
mental disorders has become the most frequently used approach to the
treatment of these disorders. Most clinicians would agree that the com-
bination of these two modalities is more efficacious and beneficial than
each modality alone for a wide range of disorders.
Combining pharmacotherapy with psychotherapy may seem like a
simple affair. However, it is a fairly complex process with many variations
and permutations. Pharmacotherapy could be combined with brief psy-
chotherapy, cognitive-behavioral therapy, psychodynamic psychother-
apy, supportive therapy, interpersonal therapy, and many others. The
combination of pharmacotherapy and psychotherapy could be delivered
by one person (integrated treatment) or by two or more persons (collab-
orative or split treatment). The combination of these two modalities
could begin with either pharmacotherapy or psychotherapy, with the
second modality starting later. All these issues need to be factored in
when considering combining pharmacotherapy and psychotherapy. The
Residency Review Committee for Psychiatry appropriately decided that
psychiatry residents must be able to demonstrate competency in combin-
ing psychotherapy with pharmacotherapy.
This book is intended to be a basic text for residents and teaching fac-
ulty in addressing competency in combining psychotherapy and pharma-
We thank Linda Gacioch for her invaluable help with the preparation of this
book.
vii
viii Combining Pharmacotherapy and Psychotherapy
cotherapy. It is meant to be simple, straightforward, clinically oriented,
and easy to read.
We feel that each psychiatry resident should become competent in
and master both major approaches to combining psychotherapy and
pharmacotherapy—integrated and split treatment—because these are
common clinical practices.
Therefore, this book is divided into two major parts, the first dealing
with integrated treatment and the second focused on split treatment.
Some parts of the text in these two sections could, in fact, be similar if
not identical, because they deal with similar problems. The resident,
however, should read both sections of the book separately to familiarize
and educate himself or herself with each particular treatment modality
(i.e., integrated and split treatment). Each section is a separate unit stand-
ing on its own, and therefore should be read as such.
We hope that this book will help all residents in psychiatry to master
and become competent in combining pharmacotherapy and psychother-
apy. Ultimately, their mastery of and competency in this crucial thera-
peutic area will help to improve the lives of patients.
Richard Balon, M.D.
Michelle B. Riba, M.D., M.S.
Introduction to the
Core Competencies in
Psychotherapy Series
W
ith the extraordinary progress in the neurosciences and psychophar-
macology in recent years, some psychiatric training programs have de-
emphasized psychotherapy education. Many residents and educators
have decried the loss of the “mind” in the increasing emphasis on the bio-
logical basis of mental illness and the shift toward somatic treatments as the
central therapeutic strategy in psychiatry. This shift in emphasis has been
compounded by the common practice in our managed care era of “split
treatment,” meaning that psychiatrists are often relegated to seeing the
patient for a brief medication management session, while the psychother-
apy is conducted by a mental health professional from another discipline.
This shift in emphasis has created considerable concern among both psy-
chiatric educators and the consumers of psychiatric education—the resi-
dents themselves.
The importance of psychotherapy in the training of psychiatrists has re-
cently been reaffirmed, however, as a result of the widespread movement
toward the establishment of core competencies throughout all medical
specialties. In 1999 both the Accreditation Council for Graduate Medical
Education (ACGME) and the American Board of Medical Specialties
(ABMS) recognized that a set of organizing principles was necessary to
measure competence in medical education. These six principles—patient
ix
