Being explicit about psychotherapy

[SmallBird]

I'm interested in hearing about how different people approach the issue of choosing a psychotherapy modality for a particular patient, and to what extent that process involves the patient and is made explicit. In our local practice environment, it seems that this decision is in the majority of cases made before the first visit, simply by virtue of whom the patient will be seeing. Whatever your underlying diagnosis, if you contact a psychiatrist in private practice you will likely receive exploratory therapy, which will most often be dominated by psycho-dynamic therapy but occasionally involve other approaches. On the other hand, if you happen to schedule an appointment with a psychologist who graduated in the last ~10 years you are more likely to receive CBT. I guess I had imagined that these decisions would have more to do with the underlying diagnosis, and an explicit process where the patient and provider have decided together what they will be doing - and my sense is its a bit more like this at the VA. I wonder what other people have noticed in their practice environments?

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[slappy]

From what I've seen, most of the time it ends up true to the saying, "if all you have is a hammer, everything will look like nails". Most psychiatrists in the community (who do psychotherapy) are more comfortable with (and sometimes better-versed in) one form of psychotherapy over another, and attempt to treat all treatable "abnormalities" with the same approach. An ideal approach would be a qualifying psychiatrist assessing a patient thoroughly to determine the best form of therapy (based on the patient's condition, and the patient's tolerability and suitability for that form of therapy), referring the patient to an expert in that form of psychotherapy, and that expert doing another complete initial evaluation to confirm all of the above followed by explaining the process and what he/she should expect over the next few weeks-to-months, before commencing the actual treatment phase. But, like with all things in medicine, ideal isn't always real.

 

[nitemagi]

I begin with a diagnostic interview and assess to what degree the patient is interested in psychotherapy. During that interview you can also test out different simplistic interventions and "treatment philosophies" and see pretty quickly which modality might be more effective. In general the first modality is always maintaining the relationship - namely rapport. IMO everything else is just strategies. While the idea of "schemas" seems interesting, I find the techniques of CBT more useful than the cognitive model for focusing on depression, though it can be helpful for some patients. Basically I'll use anything that the patient is open to trying that I believe I can use effectively. If I test out using some CBT approaches and hit a stone wall, I'm not going to put in more effort to shove it down their throats (pardon the mixed metaphor). So in that way the patient dictates the approach based on what they respond to, which you should know pretty quickly (in less than a session). When I say "respond," I mean be open and interested in. I'm sure many depressed patients won't experience the benefits of CBT until session 10 or 12 for many, but that presumes their participation.

 

[F0nzie]

If therapy is indicated I tell the pt I offer Psychodynamic and CBT and also collaborate with a psychologist if they would rather be referred. I describe the process for both types of therapy and let the patient choose. I also let them know we can always switch or mix the two if necessary. I feel giving pts the choice at the beginning helps spark their sense of agency for the hard work ahead.

 

[billypilgrim37]

For better or worse, I think most of us settle into that eclectic position where we offer a supportive psychotherapy that is heavily informed by our cbt, dbt, psychodynamic, ipt, MI, lmnopqrstuv training. I do more CPS for kiddos more than anything else any more though. My analytic supervisor was very thoughtful in the way he saw all therapies as psychodynamic (or should be psychodynamic informed), and that you could pull in techniques as needed.

Of course, at that point, you're no longer practicing an evidence based modality, except that the active ingredient in therapy that appears to be the most important is therapeutic alliance, so maybe you are.

Some people really hate this idea, but it has its merits.

 

[notdeadyet]

Once I get a handle on the patient's diagnostic picture and goals, I make therapy modality recommendations if there are particular ones that would be especially helpful. If I practice them, I offer up my services, if I do not, I refer out.

There are some times that I feel a particular modality is called for (e.g.: PE/CPT for PTSD, DBT for BPD, etc.) but often there is room to play to the therapists strengths and patient's desires. And if psychiatrists are well-trained, they'll be able to use both cognitive behavioral and psychodynamic techniques and purely using one or the other is less of a thing.

 

[nitemagi]

Once I get a handle on the patient's diagnostic picture and goals, I make therapy modality recommendations if there are particular ones that would be especially helpful. If I practice them, I offer up my services, if I do not, I refer out.

There are some times that I feel a particular modality is called for (e.g.: PE/CPT for PTSD, DBT for BPD, etc.) but often there is room to play to the therapists strengths and patient's desires. And if psychiatrists are well-trained, they'll be able to use both cognitive behavioral and psychodynamic techniques and purely using one or the other is less of a thing.

Here's the thing - most patients barely understand what therapy is at all. So they're not going to understand at the outset what their options are. If you can explain it to them, great. But it's kinda like sitting down with them and saying "Well which antidepressant do you want to start" without them knowing anything about them. They might pick one based on a friend or a commercial. Really it's YOUR job as the psychiatrist to make treatment recommendations, and use what you believe will help. They should have a choice, but make sure it's an informed choice.

I have had that conversation where I lay out all the different treatment options and do my best to explain the differences within the frame of the diagnostic interview, and most of the time I get shrugged shoulders.

 

[F0nzie]

I have not had the issue of patients feeling confused with choosing psychodynamic vs cbt. What it typically boils down to is whether they feel they can commit to the homework involved with CBT. Some patients also do not jive with the open endedness of Psychodynamic therapy and prefer more structure. I would rather know these specifics in advance than spend 3 sessions addressing their incompletion of the homework which may or may not even be related to their issue. I prefer to lay out the options for treatments that have similar evidence. Like a dentist offering invisalign vs. braces for mild misalignment.

 

[notdeadyet]

Here's the thing - most patients barely understand what therapy is at all. So they're not going to understand at the outset what their options are. If you can explain it to them, great.

It's not that hard. I'm not going into great detail here. But I find patient buy-in is pretty critical, so making sure someone is on board with logs for CBT, writing about trauma for CPT, and the like is important.


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[Shikima]

FWIW Smallbird, the practice environment I'm coming from has more of disjointed blob to create a treatment plan which is acceptable for the Pt. Often I'm struck how Pt's are not wanting medications but want immediate relief from symptoms. I often express that there isn't a magic pill to make all the problems go away, however, I can mitigate a majority of the symptoms with medications. The real cure, as I explain, is in them engaging with talk therapy for the real cure which may provide the stage for weaning off of medications. I'm often rebutted citing that they've been down that walk before and didn't find it helpful; I reply citing it could have been the type of therapy and/or relationship which interfered with them gaining the full potentials from the sessions and that consideration for returning back with a different therapist to learn skills where they then can practice could lead to reduction in medication needed. This usually is accepted and I do find that they take a more proactive approach in their care by pushing the therapist to push them with homework to practice.

 

[nitemagi]

Tis not that hard. I'm not going into great detail here. But I find patient buy-in is pretty critical, so making sure someone is on board with logs for CBT, writing about trauma for CPT, and the like is important.


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I'd say there's an inverse relationship between the number of options offered and the ability to comprehend them with depth. Maybe like an inverted U-curve.

 

[smalltownpsych]

FWIW Smallbird, the practice environment I'm coming from has more of disjointed blob to create a treatment plan which is acceptable for the Pt. Often I'm struck how Pt's are not wanting medications but want immediate relief from symptoms. I often express that there isn't a magic pill to make all the problems go away, however, I can mitigate a majority of the symptoms with medications. The real cure, as I explain, is in them engaging with talk therapy for the real cure which may provide the stage for weaning off of medications. I'm often rebutted citing that they've been down that walk before and didn't find it helpful; I reply citing it could have been the type of therapy and/or relationship which interfered with them gaining the full potentials from the sessions and that consideration for returning back with a different therapist to learn skills where they then can practice could lead to reduction in medication needed. This usually is accepted and I do find that they take a more proactive approach in their care by pushing the therapist to push them with homework to practice.

There are unfortunately a lot of people who don't really want to do the work that psychotherapy requires. The marketing for the medications is effective at promoting the medications as a solution for all, too. All I see are happy smiling and active people in the commercials. It is interesting how the patients who benefit the most from medications such as Bipolar I and Schizophrenia also resist them the most. The patients who have the least benefit from medications, PTSD, Substance Abuse, Anxiety Disorders want the meds the most.

As far as the original topic, I am more explicit or less explicit based on the patient's needs as well as the issue being treated. For example, when treating a phobia I tend to be pretty specific. When treating BPD, pretty specific about the DBT stuff and the interpersonal work that we do is more implicit and uncovered as we work. Also, I almost never throw out terms like CBT or DBT or Psychodynamic to patients unless they bring them up and then I usually ask them what their understanding of it is first. That will tell me what they think will work or won't work for them and I have found that people usually have a pretty good idea of that. If they say they had a therapist who gave them lots of homework and it didn't help, then I know not to make that same mistake.

My favorite type of psychotherapy patient to work with are the ones who want to improve their interpersonal functioning and try out new ways of relating to others based on our work and then come back saying things like, "I really thought a lot about how I always say yes to people regardless of how I really feel so I did something different and this is what happened". That's when some real change can happen!

 

[billypilgrim37]

I think what you're seeing though is that therapy, like any intervention (definitely including medications), DOESN'T work for everyone. The ones who engage in it well are likely the ones for whom it works well, and it may not be very helpful for the ones that don't. Sure, there are definitely patients that after long convincing do engage and do extremely well, but there are plenty who just don't. And there are some who can only participate in therapy once medications have improved things somewhat. And this is all assuming there are quality therapists available, which can be a real issue. It's (hopefully) less of an issue when you're able to offer therapy yourself.

And there isn't great evidence that somehow therapy fixes the "real" problem while medications just cover things up. Talk to someone who is depressed with tons of cognitive distortions about how they were before they were depressed, and often the cognitive distortions weren't there (or were much more manageable) almost by definition. Even if they don't engage with therapy OR take medications, the natural course of the illness is that they'll probably feel better. Six months later there's a good chance those distortions have much abated. Obviously this varies a lot on patient population.

I typically tell people the point of treatment for mild-moderate depression/anxiety isn't necessarily because they NEED treatment (because that's what a lot of people see it as... they either NEED it, or they don't, and that's a really silly distinction), but because we know treatment (therapy or meds) are designed to keep the episodes from getting worse, make episodes last less long, and lower the risk of episodes coming back.

Therapy can be awesome and lifesaving/changing and extremely valuable, but that doesn't make it magical, which is how some of us present it to our patients. We sometimes set them up for grave disappointment that way.

 

[OldPsychDoc]

There are unfortunately a lot of people who don't really want to do the work that psychotherapy requires. The marketing for the medications is effective at promoting the medications as a solution for all, too. All I see are happy smiling and active people in the commercials. It is interesting how the patients who benefit the most from medications such as Bipolar I and Schizophrenia also resist them the most. The patients who have the least benefit from medications, PTSD, Substance Abuse, Anxiety Disorders want the meds the most.

Keep in mind too that there are a LOT of these patients who simply aren't ready to do that work--and need some "Therapy lite" (and yes, medication) to get going. Taking someone from say, an inpatient hospitalization in which they finally realized that their problems of the past 15 years were in part due to poor choices of coping strategies for the untreated depression and PTSD they've had for that time, into "doing work" is akin to signing up an obese diabetic with osteoarthritis for a 10K. Yeah, they need to get moving, but let's start with some walking and stretching, shall we?

 

[Zenman1]

If we consider that the therapist/patient relationship is more effective than any particular type of therapy then it helps to present the patient with options. I know all the therapists at my location so if the patient prefers a male or female or wants CBT, someone to hold their hand and guide them, or someone to rip them apart and put them back together, then that's who I connect them with. The most effective therapist I ever had shook me by the shoulders and called me an a**hole, BTW.

 

[Shikima]

Keep in mind too that there are a LOT of these patients who simply aren't ready to do that work--and need some "Therapy lite" (and yes, medication) to get going. Taking someone from say, an inpatient hospitalization in which they finally realized that their problems of the past 15 years were in part due to poor choices of coping strategies for the untreated depression and PTSD they've had for that time, into "doing work" is akin to signing up an obese diabetic with osteoarthritis for a 10K. Yeah, they need to get moving, but let's start with some walking and stretching, shall we?

Often re-framing the cognition that this is an easy cure which will take place in a matter of moments is often helpful. I ask how long did it take for them to arrive to the point where they are now in seeking out help, and often the answer will be some lengthy period of time. This often opens up their eyes momentarily and I'm able to counter citing that it'll take that period of time to return through the practicing of the skills while backing off on the medications slowly. There is some hope I see in their eyes when I tell them they can learn new ways in managing stressors while being on minimal or no medications.

 

[SmallBird]

Great responses, thanks everyone!

And yet there is a super interesting tension between the approach framed by slappy (which emphasizes making a thorough assessment and then a specific treatment recommendation for a certain type of therapy) and the approach described by billypilgrim (which emphasizes drawing on a variety of techniques in the context of a strong doctor patient relationship). These approaches both seem sensible but are really quite different.

In my limited experience working on CBT for eating disorders, or social skills training for HFASD, as two examples, patients seem to find it a lot more satisfying to have an elastic frame to the session and it can become quite exploratory. I've never thought to tell them that by preventing us from completing all the excercises in the manual we are applying a less evidenced based treatment - somehow that sounds crazy. But on the other hand if they were seeing someone who was very focused on this type of treatment (or indeed were receiving it in a group setting) there would be more enforcement of sticking to protocol.

I agree with the idea that the underlying diagnosis is important to consider. But on the other hand, I had a patient complete an 8 week program for a specific anxiety disorder. He came back after with significant reduction in symptoms - more than I would have achieved alone - but somehow his marriage had fallen apart in this time. Not saying I could have prevented that but I wish I'd been there to talk to him about it.

 

[SmallBird]

If we consider that the therapist/patient relationship is more effective than any particular type of therapy then it helps to present the patient with options. I know all the therapists at my location so if the patient prefers a male or female or wants CBT, someone to hold their hand and guide them, or someone to rip them apart and put them back together, then that's who I connect them with. The most effective therapist I ever had shook me by the shoulders and called me an a**hole, BTW.

Interesting - it sounds like descriptions I have heard of the consult service at MGH where fellows will ask patients 'how the fu*k are you today?' to make sure they aren't faking catatonia. I guess I feel the such extreme interventions require extremes of confidence that I don't possess at this point!

 

[splik]

I think the reality is, the greatest predictor of what diagnosis you will receive and the treatment you get will be the psychiatrist you see. People do what they are most comfortable with and in PP may not refer out cases that would be better managed by others if they need to earn their crusts. This is not just about psychotherapy either. You are much more likely to end up on a TCA or MAOI or lithium if you see me than anyone else in my clinic, and much less likely to end up on antipsychotics. You are probably never going to have ECT if you see me, whereas there are other psychiatrists who shock everyone. I offer hypnosis but other people here do not. We do what we've learnt, what we feel comfortable with, and what we think works. There are also racial differences and other patient factors even within the VA system (so can't be explained by insurance factors) - white people are more likely to get therapy and more likely to get more evidence based treatments for depression.

Even within therapeutic modalities there are differences in what you might get. For example if you have PTSD and see me, you will get CPT (because that's what I've learnt and have been told not to do an PE until I've treated 4 patients with CPT), whereas most people do PE and not CPT. Some of the psychologists here are radical behaviorists and use functional analytic psychotherapy, whereas others use more ACT based approach. It's all CBT but these are on the surface strikingly different foci of treatment and orientations. Similarly with psychodynamic approaches - one of my supervisors conceptualizes everyone in ego-psychology psychobabble, while another sees everyone from a self-psychological perspective. There approaches to psychotherapy beyond formulation are strikingly different.

Despite these differences and the wooliness of the theory, I really do believe that those so-called common factors have much to answer for. I am increasingly convinced that the relationships we have with patients make the greatest impact on their recovery quite beyond using this therapy or that med. I have also noted patients who like me (or love me) seem to do much better, and those that don't like me just get worse. One of my patients I was convinced hated me and got worse and worse. After some months I brought up the topic of whether there was something about me he didn't like, and he admitted he felt forced to see me and wanted to sabotage the therapy from the beginning. We worked through it, he likes me now, and after almost a year, he's no longer depressed! Also I started seeing him for CBT and then when that didn't work shifted to psychodynamic therapy. But really it wasn't the kind of therapy that mattered I don't think, but the relationship. Similarly, I have a patient with panic disorder who I have been seeing for psychodynamic psychotherapy. CBT/exposure is of course the treatment of choice. Within 2 sessions her panic disorder went away and we are left tackling deeper issues now. I felt somewhat fraudulent not offering her CBT or referring her for it but ultimately she has much improved and it seems more to do with the attachment she has formed with me then any specific technique (though our early work was certainly informed by behavioral principles and psychoeducation about the nature of panic).

I think alot of this is true for drug therapy too. Outside of acute control of mania/psychosis I have yet to convince myself that any of the drugs have been responsible for any improvement (though the patients will often say so) and it seems to be very predictable by factors such as whether there is an idealizing or positive transference, and whether they are an immigrant (the placebo response rates seem to phenomenal in certain ethnic groups).

 

[F0nzie]

Splik, while I agree with you in many areas your lack of feeling convinced that meds are responsible for improvement may have to do with the fact that you are probably not seeing any "real" psychopathology in an academic setting.

Try working at an SMI clinic for a year with court ordered patients that want to kill you and you will see that medications work wonders. I am not just talking about giving sedation either. I am talking about patients on the severe end of the spectrum with depression, mania, and psychosis who also have significant degrees of cognitive impairment that do miraculously respond to medications and have zero interest in their relationship with you.

But still, I think your own perceptions of medications are having an influence even as you treat more stable patients. Try some samples of antidepressants and antipsychotics for yourself. I have... they're are not sugar pills.

 

[notdeadyet]

Agree with F0nzie on this one. Ruling out classes of medications is bad juju in my book and seems linked to education or exposure. The same holds true for psychotherapy modalities.

There are the right patients and circumstances that are best suited by SSRIs or MAOIs or nefazodone or ECT or EMDR or hypnosis. Ruling out a methodology because of lack of training or lack of personal experience is substandard care. And in psychiatry we get away with it a lot more than in other medical specialties.

 

[notdeadyet]

Incidentally, this is why I tell residency applicants to look for programs that offer a wide variety of environments/clinical exposure (private practice, county, VA, community health, acute inpatient) and teaching/practice in a wide variety of modalities. Residents are MILES better off training at programs that are strong in many modalities than in the Best Cognitive Behavioral program that emphasizes this at the detriment of others.

You don't know what you don't know. If you don't get good exposure to high acuity, you will never have a good sense of when to admit your private practice outpatients. If you don't get good exposure to the use of different medications for different conditions in different settings, you will be a psychiatrist that develops "favorites" and the expense of potentially more helpful solutions. If you don't get good exposure to a broad variety of psychotherapy, you will never know when someone is a good candidate for one that you don't regularly practice yourself. If I never used an MRI, I'm sure I'd be quite happy CTing everything, but it would come at a cost to my patients.

 

[smalltownpsych]

I think alot of this is true for drug therapy too. Outside of acute control of mania/psychosis I have yet to convince myself that any of the drugs have been responsible for any improvement (though the patients will often say so) and it seems to be very predictable by factors such as whether there is an idealizing or positive transference, and whether they are an immigrant (the placebo response rates seem to phenomenal in certain ethnic groups).

What I have found, which corresponds with what you are stating, is that the patients who look most like the clinical trials for treatments also tend to be the ones who benefit the most. That is one reason why it is crucial to diagnose accurately when making treatment decisions. Also, I agree that the relational component is vital to ongoing neurodevelopment and affect regulation and we have just begun to scratch the surface of that.

 

[splik]

But still, I think your own perceptions of medications are having an influence even as you treat more stable patients. Try some samples of antidepressants and antipsychotics for yourself. I have... they're are not sugar pills.

Apparently in the 1950s psychiatrists who try the new drugs emerging for their patients themselves and this sounds like a good idea just to see what it's like! Of course by the 60s they decided to try all the hallucinogens too and then I think it became more frowned upon.

I definitely do believe they are doing something. And yes I had been worried that my own perceptions were creeping in negatively, but have noticed that since I have become more optimistic about these things (or at least tried to), patients have also been more optimistic. But that seems to go along with my thought that expectancy has a huge role. I am obviously not talking about psychosis or mania here and like I said do see the drugs doing something more clearly here.

 

[splik]

Agree with F0nzie on this one. Ruling out classes of medications is bad juju in my book and seems linked to education or exposure. The same holds true for psychotherapy modalities..

Well I don't think people consciously rule out things, but you tend to do what you think works. I think I am a bit more conscious about some of my decisions than others. I don't rule things out, but I do think psychiatry has been prone to fads and the latest one seems to be atypical antipsychotic augmentation for depression. no one was doing this 10 years ago, now its almost a first-line thing to do as an add on (those abilify ads probably have something to do with this). I have to concede have seen some patients respond to abilify augmentation of an antidepressant, but I am extremely suspicious of this trend and tend to use other things first that are cheaper, potentially less neurotoxic etc.

 

[F0nzie]

I had a case in my pp recently. Lady with MDD, stabilized for years on Lexapro. Pt had recurrence of moderate to severe symptoms of depression in the context of mid life crisis issues. Pt did not want therapy. I augmented her with Wellbutrin XL 150mg. Symptoms went into remission after 6 weeks. Then she wanted to DC the Wellbutrin because she felt back to normal. 6 months later she's still doing fine without it.

In this case, it was clinically indicated that she stay on the Wellbutrin longer since she was early in remission and was previously having thoughts of suicide. But who really knows what happened... was it the placebo effect? Was it because she tackled her midlife crisis issues? Was it the actual medication? To what extent would maintaining her on Wellbutrin protect her against recurrence of symptoms?

I also have a handful of Schizophrenia patients that are fine without medications. They request to get off meds, I monitor their tapers and follow them. Symptoms are still present but no relapses resulting in any significant impairment. Some can do just fine for years... Not everyone can do that though.

Another example in my wife's practice. Child pt severely manic, with aggression, rapid speech, hallucinations, not sleeping, trying to jump out of car, attacking her brother. Trial of Olanzapine that worked great and parents wanted to keep her on it. Recommended taper due to long term risks. Months later kiddo is doing fine without it.

I think we need to be careful not to over value or under value the role of meds and therapy. Accept their limitations and constantly reevaluate the treatment plan and minimize risk to the pt.

 

[smalltownpsych]

Reminds me of a patient of mine who had a manic episode 8 years ago, was hospitalized and stabilized on medications. After discharge, he did not take any medications or treatment and was functioning well for those 8 years. Life stressors (possibly) began to trigger a recurrence of symptoms, GP prescribed an SSRI because patient was reporting anxiety, it was actually mild paranoia fueled by the mania. He eventually became acutely manic and severely paranoid at which point he was hospitalized and re-stabilized. He saw me for a few follow-ups and then resumed work with my stamp of approval that he was stable. Not sure if he is still taking medications or not. To me this points out a flaw in how we often manage severe mental illness in an all or none way. The APA had an article awhile back about having mental health be a bit more like dentistry where you get regular checkups and only an intervention if something is going on.

 

[SmallBird]

Incidentally, this is why I tell residency applicants to look for programs that offer a wide variety of environments/clinical exposure (private practice, county, VA, community health, acute inpatient) and teaching/practice in a wide variety of modalities. Residents are MILES better off training at programs that are strong in many modalities than in the Best Cognitive Behavioral program that emphasizes this at the detriment of others.

You don't know what you don't know. If you don't get good exposure to high acuity, you will never have a good sense of when to admit your private practice outpatients. If you don't get good exposure to the use of different medications for different conditions in different settings, you will be a psychiatrist that develops "favorites" and the expense of potentially more helpful solutions. If you don't get good exposure to a broad variety of psychotherapy, you will never know when someone is a good candidate for one that you don't regularly practice yourself. If I never used an MRI, I'm sure I'd be quite happy CTing everything, but it would come at a cost to my patients.

Great post - working at the VA early in my training led to exposure to many patients on SSRIs that still had such chaotic lives it was hard to imagine the medication was doing anything. And then this year, working with high functioning college students, it's been astounding to see how well people can respond to SSRIs for anxiety and mood disorders. Of course none of these experiences change the clinical trial data that one is aware of at the outset, but actually seeing patients both improve and clearly not improve is important to instilling a balanced sense of the role of medication (or any other intervention).

 

[Ceke2002]

My favorite type of psychotherapy patient to work with are the ones who want to improve their interpersonal functioning and try out new ways of relating to others based on our work and then come back saying things like, "I really thought a lot about how I always say yes to people regardless of how I really feel so I did something different and this is what happened". That's when some real change can happen!

Ha! This is totally how I am in therapy..."You know I was thinking a bit more about what we discussed a few sessions back, when we were talking about issue X, and I've realised now that *insert long winded explanation of realisation that has occurred*, and I've decided to make a list of emotionally healthier responses to X issue that I can use instead of falling back into negative coping mechanism, please allow me to now give you an example of how I've actually implemented one of those healthier responses in the last couple of weeks...btw where's my cookie and a gold star"

 

[Ceke2002]

Incidentally, this is why I tell residency applicants to look for programs that offer a wide variety of environments/clinical exposure (private practice, county, VA, community health, acute inpatient) and teaching/practice in a wide variety of modalities. Residents are MILES better off training at programs that are strong in many modalities than in the Best Cognitive Behavioral program that emphasizes this at the detriment of others.

Wait, you mean not all programs in the US provide this sort of wide experience in a variety of mental health settings? I don't have the entire 5 year course specifications for fellowship into RANZCP (Royal Australian New Zealand College of Psychiatrists), but it requires rotations in community Psych, acute inpatient settings, consultation-liaison, child psychiatry, electives in things like old age or forensic Psychiatry, and so on. I thought it would have been a given that programs in the US would have offered the same sort of experiences across a broad range of Psychiatric settings on top of teaching therapeutic modalities.

 

[Armadillos]

Wait, you mean not all programs in the US provide this sort of wide experience in a variety of mental health settings? I don't have the entire 5 year course specifications for fellowship into RANZCP (Royal Australian New Zealand College of Psychiatrists), but it requires rotations in community Psych, acute inpatient settings, consultation-liaison, child psychiatry, electives in things like old age or forensic Psychiatry, and so on. I thought it would have been a given that programs in the US would have offered the same sort of experiences across a broad range of Psychiatric settings on top of teaching therapeutic modalities.

It's required for all US programs to have those rotations, but the experiences can be extremely different depending on where you do the rotation. The differences in experience during outpatient rotations being the most striking. From what I've seen basically all reputable residency programs will give a fair amount of experience working with the uninsured and chronically mentally ill. The tough patients to get experience with as a resident are the very high functioning, professional types because they are more likely to be paying cash to a private psychiatrist. (Unlike vistaril I don't know everything about all programs, so my impressions may not be completely accurate)

 

[Shikima]

Experiences are vastly different between programs. I wish they were all standardized but impossible due to employment factors.

 

[Ceke2002]

It's required for all US programs to have those rotations, but the experiences can be extremely different depending on where you do the rotation. The differences in experience during outpatient rotations being the most striking. From what I've seen basically all reputable residency programs will give a fair amount of experience working with the uninsured and chronically mentally ill. The tough patients to get experience with as a resident are the very high functioning, professional types because they are more likely to be paying cash to a private psychiatrist. (Unlike vistaril I don't know everything about all programs, so my impressions may not be completely accurate)

Thanks, interesting to know more about the similarities and differences between countries when it comes to Psych training. Obviously not knowing what each individual training facility/placement for Psychiatry is like in Australia I can see how it might be more similar to situations in the US where rotations are a requirement, same as here, but depending on where you're doing he location you could end up with vastly different experiences and/or exposure to the mental health system and its consumers. I know from what I've read about RANZCP though they do seem to try and ensure that trainees are exposed to as many different scenarios within the mental health system + patient population as is possible.

 

[splik]

Thanks, interesting to know more about the similarities and differences between countries when it comes to Psych training. Obviously not knowing what each individual training facility/placement for Psychiatry is like in Australia I can see how it might be more similar to situations in the US where rotations are a requirement, same as here, but depending on where you're doing he location you could end up with vastly different experiences and/or exposure to the mental health system and its consumers. I know from what I've read about RANZCP though they do seem to try and ensure that trainees are exposed to as many different scenarios within the mental health system + patient population as is possible.

The kinds of rotations are much more standardized in the US then in Oz or anywhere else. There is more of a service provision role for registrars than there are for US psychiatry residents. In Oz addictions, geriatrics, emergency psychiatry are not mandatory parts of the training. And the psychotherapy requirements are fairly weak across the board unless in Australia one chooses to get further training there. I also hear that registrars are having a hard time seeing more minor problems for psychotherapy or a more private practice experience. the US is unusual in only requiring 2 months of child and adolescent psychiatry, whereas Canada, UK, Oz, and NZ all require 6 months of C&A for general psychiatrists.

 

[Ceke2002]

The kinds of rotations are much more standardized in the US then in Oz or anywhere else. There is more of a service provision role for registrars than there are for US psychiatry residents. In Oz addictions, geriatrics, emergency psychiatry are not mandatory parts of the training. And the psychotherapy requirements are fairly weak across the board unless in Australia one chooses to get further training there. I also hear that registrars are having a hard time seeing more minor problems for psychotherapy or a more private practice experience. the US is unusual in only requiring 2 months of child and adolescent psychiatry, whereas Canada, UK, Oz, and NZ all require 6 months of C&A for general psychiatrists.

Yes, I actually went and took a closer look at the training requirements here and was more than a little surprised at what they constituted as an 'elective' in terms of study - not to mention it does seem that Psychotherapy training is more geared towards those who wish to be listed as being in 'Advanced' or 'Specialist' practice. Just going by what I'd remembered looking at previously I thought the Psych training program in Oz was a little more comprehensive across the board than that.

Edited to add: And that'll teach me to double check information I last read about at least 2 years ago, before bringing it up for discussion.

 

[Ceke2002]

From a patient currently in long term Psychotherapy's point of view, in terms of the effectiveness of Psychotherapy being tied to the Therapeutic Bond I'd have to agree with that, but you also still better know what you're doing in terms of providing therapy. Admittedly my current Psychiatrist is the first Therapist I've ever actually formed an actual therapeutic bond with, but I've worked with other Therapists in the past who I got along really well with (almost instant personality connection, lots in common, enjoyed their company, etc etc) and I'm sure given time I would have developed a therapeutic bond with them as well, except for the fact that they just weren't very good at the therapy side of things. So yes absolutely I do think the therapeutic bond does play a big role in the effectiveness of Psychotherapy (I know the effectiveness of Psychotherapy for me feels like it's increased a lot since a bond was established, like I'm making a lot more progress than I was earlier on), but if you don't also have good therapy skills to back it all up then it sort of becomes a moot point.

As for the use of medication in a Psychotherapeutic setting, I know I've said before that I have somewhat of an issue with simple life stressors being pathologised as mental illnesses, but at the same time if those life stressors have gotten someone so beat down that they're unable to benefit from therapy, then yes I think at that point medication is called for in order for the person to at least start to receive some benefit from the therapeutic process.