On therapist-prescriber collaboration in mental health care

If you have not seen Shrinking on Apple TV, stop reading and go watch it. I'll wait.

Back? Good. Now let's talk about what is missing.

The show has Jimmy, a therapist who is also quietly falling apart from grief, and decides the best way to handle that is to just say exactly what he thinks to his patients. No filter. Ethically complicated. Extremely entertaining.

It has Gaby, warm and funny and somehow giving the best advice while her own life is held together with sarcasm and very good outfits. And it has Paul, played by Harrison Ford, who is gruff and brilliant and secretly the most caring person in the room. Which alone is worth the Apple TV subscription.

What the show does not have is a prescriber. Not one. Not in the background. Nobody is managing medications. Nobody's clients are apparently on anything. Which, if you work in mental health, you know is not exactly realistic.

I notice this the way you notice when someone forgets to invite you to a party you did not know you wanted to attend.

Here is the thing about the therapist-prescriber relationship in real life. It is either really good or it basically does not exist. There is not much in between.

The version that does not work looks like this. A therapist refers a client to a prescriber. The client comes back to therapy on a new medication. The therapist has no idea what was prescribed or why. The prescriber has no idea what is happening in therapy. The client is stuck in the middle trying to explain both sides to both people.

Nobody planned it this way. It just happens because the system was built for referrals, not for relationships.

The version that works looks more like Shrinking. Except with a prescriber at the table and slightly fewer boundary violations.

It looks like this. I know your client's therapist. We have talked. I know what they are working on in therapy, and they know what I am thinking. When something changes, we just talk. Like colleagues who work together.

Jimmy would have called me at 11pm. I would have picked up. Paul would have been quietly impressed and said nothing. Gaby would have already known.

Ideally we would grab coffee between sessions or talk through a case on a walk. We may not share an office. But we can still show up like we do.

-Jamie