Just take a long, hard look at what has become of the profession of psychiatry. Today, approximately ninety-percent of psychiatrists no longer provide psychotherapy--once the mainstay of traditional psychiatric treatment--to their patients. Why is that? For a few reasons. First, psychiatrists and their patients were disillusioned and frustrated with psychotherapy, its expense, duration, and limitations, especially in the treatment of more severe mental disorders such as bipolar illness, schizophrenia and major depression. Hopeful advances in the development of more efficacious pharmacological therapies fueled the biological revolution in psychiatry. The seminal contributions of Freud, Adler, Rank and Jung to depth psychology have sadly lost favor among most psychiatrists today. And the dubious benefits of Ellis and Beck's cognitive-behavioral therapy, while more medically accepted, are rather condescendingly perceived by most as, at worst, innocuous, and at best, merely a minor adjunct to pharmacological treatment.

Second, it's a turf war: Prescribing psychotropic drugs places psychiatry in a unique, lucrative and powerful position. Right now, with the exceptions of Oregon, Guam, Louisiana, New Mexico, and pending legislation to grant clinical psychologists obtaining one to three years additional pharmacological training prescription privileges in several other states, psychiatrists are the only mental health professionals licensed to prescribe such medications in the U.S. The American Psychological Association has taken a stand supporting prescriptive authority for properly educated clinical psychologists. Organized psychiatry vehemently protests such a trend.

How, readers might wonder, with this professional and political tension between the American Psychiatric Association and American Psychological Association, do psychologists and psychiatrists currently work together in treatment? Most (but not all) clinical psychologists today are fairly well-versed about psychiatric medications, via both experience treating such patients and having taken at least one course in graduate school and/or post-doctorally in this area. In my own practice of clinical and forensic psychology, when I believe that one of my patients could likely benefit from psychiatric medication of some sort, I refer them for a medication consultation to one of several psychiatric colleagues with whom I have established a professional relationship over the years. While I may have some suggestions regarding the type of medication to be taken, the psychiatrist (many of whom today see themselves exclusively as "psychopharmacologists") makes the final decision on whether or not to medicate and what type of drug to prescribe at what dosage, based on his or her own independent evaluation of the patient. Psychotropic medication can be tricky, and, while any physician is legally permitted to prescribe them (and many do), psychiatrists have, by far, the most hands-on clinical experience and expertise in dealing with these potentially dangerous and sometimes life-saving drugs. But, unfortunately, both medical psychiatry and the general public tend to overestimate the power and importance of biochemistry, neurology and psychotropic drugs in mental health while minimizing the basic role of psychology in both causing and healing mental disorders.

Once patients have consulted with the psychopharmacologist, something that can occur at the start of treatment or at any point later on as needed, they typically continue to see me for psychotherapy. As part of their therapy, we discuss how the psychiatric consultation went, whether they intend to take the recommended medication as prescribed, and review what might be expected regarding their symptoms as a result of doing so or not doing so. Many patients are quite fearful of, reticent or resistant to taking any medications in general, let alone psychiatric medications, and require a sometimes prolonged opportunity in therapy to voice their concerns, doubts and anxieties before being willing to even consider a psychiatric consultation or trying medication. If they do decide to follow the prescribed drug regimen, patients require regular and consistent support in staying the course long enough to start feeling some benefit. This is especially true of the antidepressant medications, whose sometimes unpleasant side-effects (e.g., dry mouth, constipation and diarrhea) typically precede any therapeutic effects by several weeks. Part of psychotherapy in such cases involves encouraging the patient to continue taking the medication despite those side-effects long enough for it to fully kick in. Of course, it is primarily the prescribing physician's responsibility to address severe side-effects, to adjust dosing when needed, and to try different or additional drugs if the first aren't adequately alleviating the patient's symptoms. Consultation between the prescribing psychopharmacologist and psychologist can be essential in sharing information regarding the patient's progress or problems, especially since the treating psychologist typically has more regular contact with the patient, and can more closely monitor his or her mental status.

Currently, the California Board of Psychology's official public position is that clinical psychologists (a highly specialized type of training that not all generic psychologists share) are legally and ethically within their scope of practice when discussing psychiatric medications and their possible utilization with their patients and other health professionals: "Psychologists may discuss medications with a patient . . . , suggest to a physician a particular medication to be prescribed . . . , may engage in a collegial discussion with a patient's physician regarding the appropriateness of a medication for the condition being treated . . . , [and] has primary responsibility to monitor the patient‘s progress in psychotherapy, which includes assisting in monitoring the changes which may be attributable to the medication in the patient." This has become an important and routine part of the practice of clinical psychology, since so many patients either have previously taken, presently take, or could potentially benefit from psychiatric medications as part of their therapeutic treatment plan.

However, having said all that, my own position on this matter is that psychiatric medication is seldom, if ever, a substitute for psychotherapy. Psychotherapy is not (or shouldn't be) secondary to phamacotherapy, but rather the primary mode of treatment, with pharmacotherapy supporting psychotherapy, not vice-versa. In most cases, patients who take these medications should be in concurrent psychotherapy. (Yes, even patients suffering from psychotic disorders.) For one thing, they need to be carefully monitored as to serious side-effects such as suicidality, homicidality, psychosis, mania, agitation or other untoward tendencies, something that prescribing psychiatrists or general practitioners typically do these days only on a very limited, sporadic basis, and at significantly longer intervals than once or twice-weekly therapy sessions. Indeed, most psychiatrists, psychopharmacologists and other physicians today work in tandem with psychologists and other mental health professionals, depending on the psychotherapist to see the patient more frequently and to spend more time doing so.