I sat in both chairs.
I started my career as a licensed marriage and family therapist. I did therapy for years before I went back to school to become a psychiatric nurse practitioner. And one of the most clarifying things about having held both roles is understanding, from the inside, what each side of the treatment team is actually seeing.
A prescriber sees a client for fifteen to twenty minutes, once a month. In a busy practice, sometimes less. A therapist sees that same client for an hour, every week. Over the course of a year, that’s roughly three to five hours with a prescriber — and forty-plus hours with a therapist.
Which means when a side effect shows up in week two, the therapist hears about it first. When a client quietly stops taking their medication because it made them feel nauseous and nobody told them that was temporary, the therapist is the one who finds out. When a client has been taking ibuprofen every day for their back, and they also happen to be on a medication where that interaction matters — the therapist is often the only one who knows.
The therapist holds the longitudinal narrative. They have the data. They have the relationship. And they are often the last person in the room who feels empowered to do something with it.
The training gap is real — and the research backs it up.
Ninety-one percent of therapists treat clients who are on psychiatric medications. Eighty percent report that their graduate training didn’t adequately prepare them to support those clients. I didn’t pull those numbers from obscure sources — they come from peer-reviewed research that has been sitting in the literature for nearly two decades, largely unremarked upon in how we design training programs.
What graduate programs tend to teach is pharmacology: drug classes, mechanisms of action, the fact that SSRIs act on serotonin. What clinical practice actually requires is something different. Knowing what to look for when a client says they feel “weird and electric” three days into sertraline. Knowing how to read a trend line in a client’s symptom data and understand what it means for the referral conversation. Knowing when to pick up the phone to call a prescriber, what to say when you do, and how to say it in a way that actually gets acted on.
Those are different skills. And most therapists were never taught them — not because anyone decided they shouldn’t be, but because the curriculum never got there.
Delay isn’t neutral.
One of the things I find myself most wanting clinicians to sit with is the research on what happens when psychiatric illness goes undertreated. Not undertreated in a dramatic way — just the ordinary, slow undertreating that happens when a referral gets deferred for another few months, when a client’s declining scores don’t quite get communicated to anyone who can act on them, when a medication gets abandoned at week three because the first two weeks were hard and nobody had set expectations.
The literature on this is sobering. For several of the conditions therapists treat most — depression, OCD, psychosis — duration of untreated illness isn’t just about suffering in the present. It’s associated with how the illness behaves from that point forward. How it responds to treatment. How likely it is to recur, and how much harder the next episode is to treat.
I’m not saying this to create alarm. I’m saying it because therapists, by virtue of their contact time and their clinical relationship, are often the people most positioned to shorten that window. That’s not a small thing.
What collaborative care actually looks like.
I recently delivered a training on this topic to a cohort of graduate students in counseling psychology. Smart, engaged, care-oriented clinicians-in-training who will spend their careers seeing clients who are on psychiatric medication — many of whom will have no one else actively monitoring how that medication is going.
What I tried to give them wasn’t a pharmacology course. It was a clinical framework for the specific things therapists are positioned to do: recognizing when a referral is indicated based on severity and trajectory, tracking medication response in a way that produces usable data, supporting clients through the ambivalence and confusion that often derails treatment before it has a chance to work.
I also tried to give them language. Because knowing what to do matters much less than knowing how to say it.
Here’s what I mean by the title. A therapist leaves a message for a prescriber and says: “She’s been really struggling lately. Something shifted after the medication change — she seems flat, kind of withdrawn.” That’s the poetry. It’s real. It’s clinically meaningful. And to a prescriber with twenty other callbacks that day, it’s almost impossible to act on.
The math version of the same clinical reality: “Her PHQ-9 went from 9 to 18 over the past four weeks. New adherence gap — she missed about four days during a work trip. She’s also endorsing passive SI for the first time. Requesting an earlier appointment or a phone review.”
Same client. Same week. Completely different utility.
The therapist who learns to translate — who takes the rich, narrative, relational knowledge they hold and moves it into a form a prescriber can actually use — is doing something that changes outcomes. That’s the whole thing.
If I’ve got your attention now:
I’m continuing to develop and teach in this space — including a training designed specifically for licensed therapists on medication literacy and collaborative psychiatric care. If you want to be alerted when that becomes available, subscribe to the Praxis email list below.
