Difficulty collaborating with Psychologists

[F0nzie]

Recently I have been facing some challenges in my private practice in collaborating with psychologists. There are 2 psychologists who have referred psychotic patients my way and have subsequently refuted my assessments that they are psychotic and needed antipsychotic medications.

The first patient sent my way was a lady who had some mild cognitive impairment, inattention, poor concentration, thought disorganization and poor working memory. She had a flat affect. MMSE/MOCA was 30/30 neuroimaging was negative. The psychologist felt she had conversion/somatization disorder in which she was feigning her cognitive symptoms. After I assessed her she admitted to hearing party music through her fan, with the belief that Hispanics were having a party outside of her Estate. She stated the party noises would keep her up all night and that she had the desire to "attend the party and have some fun" and "why wasn't I invited?". She also would randomly hear music playing in the house and would have to turn on the radio on to suppress the noise. She also presented with thought blocking in the session and would hear noises outside of my office window. I started on her Abilify because Risperidone was over sedating. The psychosis resolved and her affect significantly improved but she still had mild cognitive issues. Then the psychologist calls me saying he felt she was not psychotic, that she never endorsed psychotic symptoms in the first place, and that she had denial and repression with regards to an affair she had 5 years ago. He subsequently sabotaged the treatment alliance by telling the patient and family that he believes my diagnosis is incorrect and that she just needed an antidepressant with EMDR.

The second patient sent my way was a young male who presented to my office delusional and suicidal and on the verge of requiring inpatient psychiatric hospitalization. He presented with prodromal /1st episode psychosis consistent with Schizophrenia. I started him on Latuda which resulted in dramatic improvement in both positive and negative symptoms and his suicidal thoughts went away. The psychologist then told the patient after he got better "I would bet my entire salary the diagnosis is wrong." The psychologist is convinced this patient just had depression with an episode of
derealization and dissociation". The patient still has mild chronic delusions that are not in the forefront but he is able to work and lead a functional life. This patient also had 7 different trials of antidepressants none of which worked.

I have basically wasted around 10 or more hours of my time coordinating care with these psychologists via phone and email and I am extremely frustrated. I know N=2 but this is really making me wonder if psychologists get any real training in dealing with psychotic patients. Am I just wasting my time trying to provide psychoeducation to professionals who feel they are at the very top of the field when it comes to mental health? I know I am early in practice but this is the first time I have actually considered not accepting referrals from psychologists if there is going to be too much time wasted with disagreement between what the diagnosis is and what medications they need to be on.

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[erg923]

1. You are in CA, no? Psychologist is the PP market in that area are likely to have attended rather subpar professional schools. Psychologist who graduated from rigorous university bsased programs there (Berkley, UCLA, etc) are generally in academia or hold academically affiliated clinical positions rather than PP.

2. Even if thats not the case, its still psychologists who insulated in the private practice world. You are correct. They probably see very few SMI cases.

3. Its no so much the diagreement of the diagnosis, but the unprofessional behavior of slamming a collegue in front of the patient with no actual evidence that anything wrong happened.

4. Some psychologists recieve extensive training in SMI. Some recieve basically zero. Its not the bread and butter that it is in psychiatry.

 

[vistaril]

difficult situation, and I feel for you.....I think part of it is what these psychologists have likely been exposed to over the course of their careers- they've probably seen dozens of their patients overmedicated or given antipsychotics for questionable indications by psychiatrists and psych nps, and so they are coming at it with from that bias.

So I would start with a position that shows them I do understand where they are coming from(if my assumption there is correct). For example, maybe "hey I know you guys have seen a lot of bad polypharmacy and antipsychotics given innapropriately where there was no indication and the patient ended up with diabetes for no benefit, but I really feel this case is different and here is why......." Taking this approach would catch the psychologist off guard and show them that you are different than those other guys....

 

[birchswing]

As a patient, I am impressed that you take calls from psychologists. Theoretically, my psychologist is supposed to be able to talk to my psychiatrist and vice versa, which I think would really be ideal since I see my psychiatrist once every 2-3 months, and I see my psychologist every week. I would like them to talk. However, my psychologist never gets a response. This is not atypical, according to him, among many psychiatrists he tries to contact. It's also not atypical for me. My psychiatrist doesn't do after hours (or business hours) calls.

I was going to an ENT the other week, and I called and asked them if I could fax them a one-sheet with my symptoms for the doctor to look at before he saw me, and she was very honest and said that they would lose it in the piles of paperwork. I had been there before, and the doctor was in and out in about 2 minutes (I wanted him to remove tonsil stones, and he just told me to buy a water pik and left), and I knew there wouldn't be time to go through the list in person (which were more serious: swallowing issues).

There are really good doctors like my primary care doctor, who is amazing, who just never respond to phone calls, e-mails, etc., not out of policy but out of being overwhelmed. And when I see him at his practice at the end of the day after all the office staff have left with stacks of papers, I can see why.

As for my psychiatrist though, I feel like she could make the time. She says that insurance companies don't allow her to talk about patients on the phone, but I take that to mean she won't get paid for it.

It's just really impressive to me that a psychiatrist would 1) see a patient long enough to notice something a psychologist wouldn't (I once told my psychiatrist I felt she didn't know me well enough, and she said remember what this is: med management, everything else is for your therapist) and 2) pick up a phone.

Good on you!

 

[greenlion]

I know N=2 but this is really making me wonder if psychologists get any real training in dealing with psychotic patients.

They (usually) do not and you need to learn to be more affirmative.

 

[wolfvgang22]

I'd just stop taking referrals from those specific psychologists that don't know how to be professional and collaborate properly. Most psychologists have been very collaborative, professional, and helpful to my patients when I worked in your region, Fonz.

Most psychologists have no more expertise than a well-meaning neighbor when talking about medications, so they shouldn't do it. A good psychologist leaves medication issues to doctors, who have years of training in medicine.
It's great when a psychologist calls me and says they think a patient might be having a side effect or not responding to a medication, and to tell me what they are working on in therapy. I think it's great when they collaborate with me on diagnosis, but not when they feel they have to defend their diagnosis to the death. I wouldn't argue with a gastroenterologist that a patient has a somatization disorder when they tell me the patient has colon cancer, so I don't expect a psychologist to tell me a patient with schizophrenia just has some repressed guilt.

Actually, I always have the biggest problems with social workers trying to do therapy, not actual psychologists, because social workers were mostly not educated well enough to do therapy, much less know much about medication. I have met exceptions to this rule.

 

[erg923]

They (usually) do not and you need to learn to be more affirmative.

I'm not sure what that poster means by that, but I would add that my lab in graduate school was dedicated to research on psychosis ansd thus I saw hundreds of various "spectrum" presentations over the years. Even still, that does not mean that my inter-rater reliability would necessarily improve. Inter-rater for most disorders is terrible. Would we agree on treatment and fundamental elements? Probably. Would we agree on anything else about schizophrenia? Not necessarily. Academia has a way of creating divergent thinking and opinions, so extensive training is not really going to translate to better agreement between various professionals. I happen to be quite partial to Julian Jaynes bicameral mind theory as applied to schizophrenia, but I realize this is likely a minority opinion.

 

[Trismegistus4]

Recently I have been facing some challenges in my private practice in collaborating with psychologists. There are 2 psychologists who have referred psychotic patients my way and have subsequently refuted my assessments

You mean rebutted. To refute means to successfully disprove. If you think they refuted your assessments, you're saying they convinced you and you now think they are right.

 

[nancysinatra]

Just wondering - in the first case, did you rule out Charles Bonnet Syndrome, auditory variant? You didn't mention the patient's age, but Charles Bonnet in general tends to increase with age, so if your patient is old, consider it! Especially consider it if your patient has any underlying hearing problems.

 

[Ceke2002]

Obviously I'm not speaking for all Psychologists out there, but many years ago, way before I started working with my current Psychiatrist, I very quickly learned not to mention or discuss any of my psychotic symptoms with a Psychologist, because invariably I'd either end up being dismissed off hand, labelled 'neurotic', suspected of malingering, and/or have any and all symptoms automatically lumped in with an Axis II based diagnosis. In my case I don't think I really fit all that neatly into a nice little box that says 'Psychosis', my symptoms do tend to be atypical, or statistically lower than what might be expected in a more classic presentation, and added together to some degree they do fit the sort of profile that would be presented by a malingerer. I'm not going to list my symptomology, because obviously that's not what this forum is for, but after the first couple of episodes, and with a few years worth of added continual practice, I've also managed to develop insight so I do recognise that my hallucinations are not real. When I've tried to voice my symptoms, including the fact that I have insight, to a Psychologist, it's like they don't know where to place me so they just stick me into whatever categories they're most familiar with - whether it's the correct category or not. Contrast that with my current Psychiatrist, who is well trained enough to be able to tease out what are 'soft psychosis' pseuodo type hallucinations associated with stress, anxiety and/or emotional disregulation/other residual Axis II traits, and what are true hallucinations associated with an episode of psychosis. I've never worked with a Psychologist who was able to do that, so that would lead me to believe that it is a training/education issue in regards to severe mental illness and the varied presentation of psychosis.

 

[whopper]

I've been in similar situations. One of the private practice (in this case) counselors was referring me patients and she didn't even take notes. She just listened and bobbed her head with her clients. So when I would be in a position where I wanted to know why she wanted me to see them, she really couldn't give me any details.

While I worked with the state, some psychologists were extraordinary, others were terrible. Same goes with psychiatry. Two clinicians could disagree no matter the signs, symptoms and test results.

There is room for respectable disagreement. I've had that several times with good clinicians.

IMHO the patient improving with Latuda should be very telling that your hunches were right. Another factor that the psychologist was wrong was their disagreement with your opinion in front of the patient. They should've called you first. In situations where I disagreed with the other doctor, called them up I would have voiced by disagreement, but I'd tell the patient that in the medical field there are grey zones for disagreement.

If I disagreed with the other clinicians to the degree where it was obvious the other doctor was in egregious error, I'd state my own opinions on why I thought I was right without trying to slam the other doctor. I'd tell the patient disagreement will always exist and it's up to the patient to decide who they want to believe.

 

[AcronymAllergy]

Going to agree with the others here--there can be a good be of variability in training for psychologists (unfortunately), meaning that some folks out there are going to do some...odd and potentially unprofessional things, such as undercutting another provider in front of a patient. I'd say just stop taking referrals from those particular psychologists.

As for SMI, again as has been mentioned, it's going to vary. Just about everyone should have some degree of exposure, but it's typically not going to be comparable to your average psychiatrist unless the person undertook dedicated training in the area (which some do).

Oh, and EMDR--bleh.

 

[F0nzie]

Some psychologists recieve extensive training in SMI. Some recieve basically zero. Its not the bread and butter that it is in psychiatry.

Interesting. I have always given a lot of credit to PhD level Psychologists with their extensive years of training and assumed that pretty much all of them would be able to nail psychosis and immediately refer to a Psychiatrist for that very reason. In the same way I would expect an ER doc to rule out an MI if I am having chest pain.

 

[vistaril]

Going to agree with the others here--there can be a good be of variability in training for psychologists (unfortunately), meaning that some folks out there are going to do some...odd and potentially unprofessional things, such as undercutting another provider in front of a patient. I'd say just stop taking referrals from those particular psychologists.

As for SMI, again as has been mentioned, it's going to vary. Just about everyone should have some degree of exposure, but it's typically not going to be comparable to your average psychiatrist unless the person undertook dedicated training in the area (which some do).

Oh, and EMDR--bleh.

seems like all the patients I have who have ever done emdr got a lot better from emdr...I'm a believer.

 

[vistaril]

Interesting. I have always given a lot of credit to PhD level Psychologists with their extensive years of training and assumed that pretty much all of them would be able to nail psychosis and immediately refer to a Psychiatrist for that very reason. In the same way I would expect an ER doc to rule out an MI if I am having chest pain.

well another related question in cases like these is: should someone see a psychiatrist/be on antipsychotics just because they have psychosis?

 

[F0nzie]

Good on you!

Thanks for the praise! Trying my very best to give the best possible care.

 

[F0nzie]

difficult situation, and I feel for you.....I think part of it is what these psychologists have likely been exposed to over the course of their careers- they've probably seen dozens of their patients overmedicated or given antipsychotics for questionable indications by psychiatrists and psych nps, and so they are coming at it with from that bias.

So I would start with a position that shows them I do understand where they are coming from(if my assumption there is correct). For example, maybe "hey I know you guys have seen a lot of bad polypharmacy and antipsychotics given innapropriately where there was no indication and the patient ended up with diabetes for no benefit, but I really feel this case is different and here is why......." Taking this approach would catch the psychologist off guard and show them that you are different than those other guys....

That is an interesting perspective. I have spent a lot of time on the phone with them describing my clinical observations and my rationale for starting medications as well as the risks/benefits. I think in this case there is a disagreement in the diagnosis and understanding of what psychosis is. We are not on the same page and it doesn't seem like we are even speaking the same language.

 

[erg923]

Interesting. I have always given a lot of credit to PhD level Psychologists with their extensive years of training and assumed that pretty much all of them would be able to nail psychosis and immediately refer to a Psychiatrist for that very reason. In the same way I would expect an ER doc to rule out an MI if I am having chest pain.

Nailing psychosis (or underlying psychotic thinking or ilness) when its not frank or florid can be difficult and would indeed take someone trained specifically in assessing SMI. SMI, in the clinical context, has always been the domain of psychiatric profession rather than psychology even though many schizophrenia researchers are acadamic psychologists. So while all psychologists will obvioulsy know about schziophrenia, the criteria, etc....if the sx arent starring them in the face and they haven't had much exposure to SMI, I can see how it slips past them.

 

[vistaril]

While we are on the subject of collaborating with other providers, I remember a funny story from about a year ago. Someone in our class is telling me about how a chiropractor had called them over a patient they shared and was concerned that the medications they were provided weren't working and wondered if the cost/benefit ratio wasn't unfavorable. Imagine that....a freaking chiropractor giving someone a dressing down on evidence based treatment! I think my colleague just mumbled something about it being worth a try and said thanks for calling.

 

[AcronymAllergy]

seems like all the patients I have who have ever done emdr got a lot better from emdr...I'm a believer.

Definitely, there are components of EMDR that work great. I basically just haven't seen any compelling evidence to convince me that it's anything more than exposure (e.g., PE) + the therapeutic equivalent of fairy dust. But hey, I could be end up being wrong if the literature eventually supports additive effects related to the eye movement component.

But let me not hijack the thread.

Getting to what erg said re: psychosis, I agree. If it's prodromal, for example, it can sometimes be tough to pin it down definitively, particularly if you haven't seen thousands of cases of prodromal schizophrenia and if you're also thinking there might be various other possible competing explanations (e.g., visual illusions induced by hypervigilance rather than full-blown hallucinations, culturally-related experiences such as seeing/speaking to deceased relatives, etc.). Although unless it's the psychologist's area of expertise, many (as you've mentioned) would probably refer out at that point for further evaluation.

 

[F0nzie]

well another related question in cases like these is: should someone see a psychiatrist/be on antipsychotics just because they have psychosis?

It's ultimately up to the patient to receive antipsychotics for psychosis unless they are on a court order. But as physicians we have a duty to protect our patients from harm if psychosis is resulting in severe impairment, suicidality or homicidality. Also anticipating further deterioration with worsening psychosis is an important risk/benefits discussion. I do have stable patients with chronic psychosis that are able to cope with the symptoms and choose not to be antipsychotics. There are probably a lot more people out there that are semi-stable with chronic untreated psychosis.

 

[erg923]

EMDR offends my sense of scientific parsimony.

 

[F0nzie]

I did not learn about EMDR in residency (or maybe I did and was not paying attention) so this is new territory for me. I did recently refer a patient to a psychologist for CBT and the patient ended up receiving EMDR instead. Anxiety is improved and we have been tapering his meds. Seems like many therapists in PP in my area are offering EMDR. I have been having difficulty collaborating with a psychologist that focuses on CBT.

 

[erg923]

EMDR is CBT with extra neurobabble. Neurobabble sells. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778755/

 

[whopper]

Interesting. I have always given a lot of credit to PhD level Psychologists with their extensive years of training and assumed that pretty much all of them would be able to nail psychosis and immediately refer to a Psychiatrist for that very reason.

As a demographic whole, I've found psychologists to better document their findings, use more objective signs, and have a better grasp of psychometric testing. I speculate this is based on the training. Psychologists get more training in things such as psychometric testing, validity and reliability, and being able to say with a straight face that they are a science, then get tested on it. To become a doctor in their field, they have to do something new and scholarly on their dissertation.

As a comparison, we psychiatrists, once in residency, are in a medical culture where our lectures are not tested, our attendings would rather us be on the floor working to relieve them instead of making a test for us and have us study for it further taking time away from grunt-work, and the less time we spend on a patient, so long as there are patients to see, the more money we or the institution makes. The only time we really get tested is on the USMLE and board exams, and based on the medical academic culture, we get the idea they're really about just obstacles to pass instead of trying to learn the importance of such things as validity and reliability as important ends themselves. (Of course, we're better when it comes to the medical stuff!)

Don't let that blind you to the fact that anyone in any field could be bad. Just as some people think that medical doctors, priests, police officers, etc are more ethical because of the importance of virtue in our fields, no, I think we're all smart enough to know there's bad people everywhere.

 

[smalltownpsych]

I am appalled at your experience with these two psychologists. Even when I disagree with the diagnosis of another practitioner, what would be the point of disputing that with the patient? There is no clinical rationale for that. I wonder what the rationale for the referral was if they weren't going to accept your findings. I second what other posters said above that unfortunately there are probably many psychologists who have limited to no experience with psychosis. I specifically sought out inpatient treatment settings because I saw early on the benefits of being exposed to severe forms of mental illness. I remember hearing other students in the doctoral program talk about how severe the depression was for one of their clients at the outpatient college clinic and I would think, "that's nothing compared to what i am seeing." I really believe there is no substitute for good inpatient psychiatric experience where you get exposure to patients who are floridly psychotic, bleeding, and desperately trying to kill themselves with anything they can get there hands on. I always said I would hate for my first experience with x,y, or z to be in my outpatient therapy office.

 

[whopper]

More often than not, if I don't know why the practitioner did something that appeared odd, I simply called them up and it turned out the reasoning was solid. The problem was I was in a situation where I wasn't provided their documentation. E.g. I was an inpatient doctor and when the patient came into the PES, they didn't have their outpatient records on them.

The only times I've outright said I thought a doctor was terrible, I usually only did so among colleagues where we all had solid evidence to back it up. E.g. a doctor in my area puts everyone on a benzo, sleep med, antipsychotic, antidepressant, and mood stabilizer no matter what they have. I wish I was joking. Most of the doctors I work with know this guy and have dozens of patients that have said things to the effect that they've lost a year of their life when he was their doctor--not being able to remember much, be able to stay awake, etc. That same guy is known for giving any attractive female patient a breast exam. Again, I wish I was joking. The state has already taken action against him and his partner lost his license for similar practice, but this guy has managed to maintain it.

With patients or anyone else that was a health professional, I would just try to gently suggest they see another doctor.

 

[smalltownpsych]

More often than not, if I don't know why the practitioner did something that appeared odd, I simply called them up and it turned out the reasoning was solid. The problem was I was in a situation where I wasn't provided their documentation. E.g. I was an inpatient doctor and when the patient came into the PES, they didn't have their outpatient records on them.

The only times I've outright said I thought a doctor was terrible, I usually only did so among colleagues where we all had solid evidence to back it up. E.g. a doctor in my area puts everyone on a benzo, sleep med, antipsychotic, antidepressant, and mood stabilizer no matter what they have. I wish I was joking. Most of the doctors I work with know this guy and have dozens of patients that have said things to the effect that they've lost a year of their life when he was their doctor--not being able to remember much, be able to stay awake, etc. That same guy is known for giving any attractive female patient a breast exam. Again, I wish I was joking. The state has already taken action against him and his partner lost his license for similar practice, but this guy has managed to maintain it.

With patients or anyone else that was a health professional, I would just try to gently suggest they see another doctor.

On the old ER show they referred to that practice as a TUBE, totally unnecessary breast exam. It cost Dr. Pratt (great role by Mehki Phifer) a promotion or residency or something like that.

 

[hamstergang]

seems like all the patients I have who have ever done emdr got a lot better from emdr...I'm a believer.

I had you pegged as an evidence-based guy. As others have alluded to, do you know something that we don't about the EM part of EMDR?

 

[vistaril]

I had you pegged as an evidence-based guy. As others have alluded to, do you know something that we don't about the EM part of EMDR?

gosh no....but me not knowing a mechanism for why it works hardly constitutes evidence it doesn't work.

I think a lot of the anti-emdr(all the magic sprinkles/fairy dust/whatever) comments from psychiatrists on emdr relate to jealousy.....here is something that has really caught on with many patients(who have often had a rough go of it in terms of mental health treatment) and it's something that in 19/20 cases is not being run by a psychiatrist but another mh provider. So it's only natural that many psychiatrists are going to want to minimize this treatment as not being novel(or at least what makes it effective not being novel).....

 

[smalltownpsych]

gosh no....but me not knowing a mechanism for why it works hardly constitutes evidence it doesn't work.

I think a lot of the anti-emdr(all the magic sprinkles/fairy dust/whatever) comments from psychiatrists on emdr relate to jealousy.....here is something that has really caught on with many patients(who have often had a rough go of it in terms of mental health treatment) and it's something that in 19/20 cases is not being run by a psychiatrist but another mh provider. So it's only natural that many psychiatrists are going to want to minimize this treatment as not being novel(or at least what makes it effective not being novel).....

As a psychologist, my criticism of EMDR is that much of the research that I have reviewed shows that the effects are attributed to the exposure and not the blinking lights. Trauma-focused CBT works and we don't need no stinkin blinkin lights!

 

[hamstergang]

gosh no....but me not knowing a mechanism for why it works hardly constitutes evidence it doesn't work.

Yeah, I'm not asking for a mechanism, simply evidence that the eye movement part contributes anything to its success.

I mean, Haldol works on psychosis. Having the patient take the pills alternating between using their left and right hands will work just as well, but I'm not going to market my Alternating Hand Haldol as a treatment option.

 

[vistaril]

Yeah, I'm not asking for a mechanism, simply evidence that the eye movement part contributes anything to its success.

I mean, Haldol works on psychosis. Having the patient take the pills alternating between using their left and right hands will work just as well, but I'm not going to market my Alternating Hand Haldol as a treatment option.

I'm not familiar with the research on emdr vs cbt for trauma patients, so I can't comment to your first point.....what I am familiar with is snarky comments from psychiatrists who don't do emdr(or really any novel treatments that don't involve throwing meds at pts and referring them to therapy) when they hear of a therapeutic success from emdr

 

[nitemagi]

Pretending that someone with schizophrenia doesn't have a developmental history and relationships is shortsighted and reflective of many. Psychodynamics can affect the presentation of many symptoms, including psychotic ones. That doesn't mean it isn't a legitimate psychosis. Many psychologists I have found are exclusively trained in psychodynamic therapy (yes, even today), and so see everything through that lens.

ALL that being said, psychosis doesn't equal schizophrenia, and I've seen far too many psychiatrists slap a SZP label on anyone who complains of "voices" without doing a good history, even digging around in the phenomenology of the sx's let alone looking for mimics like dissociative disorders. How many borderlines have you see get dx'd with SZP because they complain of "voices." /Soapbox off.

 

[hamstergang]

I'm not familiar with the research on emdr vs cbt for trauma patients

Well then take this thread as education that current literature suggests that the eye movements don't to add anything to the exposure therapy. That is, as far as we can tell right now, EMDR is exposure therapy (which works) plus nonsense (which doesn't help or hurt but also isn't baser in evidence).

 

[erg923]

Shapiros marketing and subsequent cult-like following does not help matters of science but sure does lure in scientifically ignorant practitioners. I still have a hard time with highly educated practitioners buying the idea that eye moments "reprogram hemispheres" or whatever. I mean. Paaaaa.....lease!!

 

[vistaril]

Well then take this thread as education that current literature suggests that the eye movements don't to add anything to the exposure therapy. That is, as far as we can tell right now, EMDR is exposure therapy (which works) plus nonsense (which doesn't help or hurt but also isn't baser in evidence).

well I'd actually be willing to take it as education if you would...you know....actually post the current literature that describes what you are talking about and that way I could read it and decide for myself based on what the studies show.

My guess is your knowledge of the 'current literature' on this matter is hearing a few psychiatrists ramble on about what the 'current literature' said, which they probably didn't personally read(at least not more than an abstract of that) either....

 

[hamstergang]

well I'd actually be willing to take it as education if you would...you know....actually post the current literature that describes what you are talking about and that way I could read it and decide for myself based on what the studies show.

My guess is your knowledge of the 'current literature' on this matter is hearing a few psychiatrists ramble on about what the 'current literature' said, which they probably didn't personally read(at least not more than an abstract of that) either....

No, my knowledge comes from me researching this myself when I first heard of EMDR 2 years ago, and from what my psychologist supervisor told me this year.

If you were actually interested in the evidence, you would have looked for it by now as we've been discussing it in this thread for a while. You do know how to find such evidence, right? Do you really need me to do the work for you, because that doesn't sound like a good set up for you to practice EBM? My guess is that you just want to argue.

 

[PikminOC]

Vistaril, please educate us on EMDR. Show us the literature instead of assuming what other psychiatrists are thinking.

"My guess is that you just want to argue."

 

[Ceke2002]

While we are on the subject of collaborating with other providers, I remember a funny story from about a year ago. Someone in our class is telling me about how a chiropractor had called them over a patient they shared and was concerned that the medications they were provided weren't working and wondered if the cost/benefit ratio wasn't unfavorable. Imagine that....a freaking chiropractor giving someone a dressing down on evidence based treatment! I think my colleague just mumbled something about it being worth a try and said thanks for calling.

I think I've mentioned this on here before, but I actually had a GP I was seeing at one time phone me to ask my advice on what Psychiatric medication he should prescribe a particular patient. Naturally I declined to comment, apart from saying something along the lines of 'dude, WTF?', but I would have loved to have been a fly on the wall if he was doing a follow up consult with a Psychiatrist - "Well I wasn't sure which direction to go in terms of medication, so I rang one of my patients to get their advice"...."Say what?!"

 

[Ceke2002]

It's ultimately up to the patient to receive antipsychotics for psychosis unless they are on a court order. But as physicians we have a duty to protect our patients from harm if psychosis is resulting in severe impairment, suicidality or homicidality. Also anticipating further deterioration with worsening psychosis is an important risk/benefits discussion. I do have stable patients with chronic psychosis that are able to cope with the symptoms and choose not to be antipsychotics. There are probably a lot more people out there that are semi-stable with chronic untreated psychosis.

For around 10 years or so after I had my first episode I coped by taking illicit substances - a LOT of illicit substances. Me, experience hallucinations due to a possible severe mental illness? Ha, never! It's just the speed/acid/ecstasy/insert whatever other drug I've taken. Once I got clean then it became a case of 'Okay, maybe it's actually time to try and get some help with this', which lead to the scenario(s) I mentioned with psychologists and other counsellors in my previous post. I kind of just muddled along by myself for a few more years after that. Obviously having insight helped, but when my symptoms were particularly bad it was pretty difficult at times - when you're having to expend a lot of your mental energy on just dealing with various hallucinations/other symptoms it often doesn't leave a lot of space to be able to properly manage basic day to day living. These days my Psychiatrist does leave it up to me whether I take medication or not, although he does monitor my symptoms fairly closely, and if he feels I'm reaching a point where things are becoming too difficult then he'll gently suggest that perhaps it's time to allow the meds to give me a bit of a break for a while. My own personal litmus test for when I choose to go on an antipsychotic is if my symptoms have gotten to the point that I'm not really functioning that well on a daily basis, and/or if my symptoms decide to throw a party and invite Mr and Mrs Word Salad-Aphasia along with them (or whatever the correct term is for when you lose the ability to express language properly). Other than that, if my symptoms are just mild-moderate, and I'm able to deal with them adequately enough with distraction techniques, reality checking, and so on, then I choose to remain off meds. That's just me though.

 

[Ceke2002]

As a psychologist, my criticism of EMDR is that much of the research that I have reviewed shows that the effects are attributed to the exposure and not the blinking lights. Trauma-focused CBT works and we don't need no stinkin blinkin lights!

I'm planning on asking my Psychiatrist about the efficacy of EMDR, purely out of academic interest, but personally I can't see how it differs that much from just working through trauma in a safe and supportive environment with a caring, empathic therapist, only minus the finger waggling flashy lights stuff.

 

[billypilgrim37]

I know psychiatrists who do EMDR and who make the exact same comments about it. I tend to say "magic sprinkles" instead of fairy dust or whatever. It's a product. The training is trademarked. It's a lot of marketing making the originators a lot of money. THAT'S the reason people resent it. I don't care if people put their thumbs in their ears and fart while they do their exposure therapy if it helps them.

I do find that many of the non-psychiatrists I meet who are "in" to EMDR are generally full of **** about most other topics as well. If only *****s like something, it doesn't make you think much of that thing.

 

[PikminOC]

I'm sure it works on both fronts but I had a psyd send me a suicidal patient. When I contacted her several times over the next week she didn't answer. I ended up meeting with her several weeks later. She said she was too busy to talk to me before. I don't want or take referrals from people like that.

 

[Ceke2002]

I know psychiatrists who do EMDR and who make the exact same comments about it. I tend to say "magic sprinkles" instead of fairy dust or whatever. It's a product. The training is trademarked. It's a lot of marketing making the originators a lot of money. THAT'S the reason people resent it. I don't care if people put their thumbs in their ears and fart while they do their exposure therapy if it helps them.

I do find that many of the non-psychiatrists I meet who are "in" to EMDR are generally full of **** about most other topics as well. If only *****s like something, it doesn't make you think much of that thing.

That is one thing I've noticed with a lot of the advertising that's done for EMDR therapy, it appears to be couched in a lot of insta!enlightment, new agey type BS hype - and I'm saying that as someone who would probably be considered fairly 'new age' myself. The trouble with the modern new age movement is that a vast majority of it is just prepackaged, mass marketed nonsense designed to take money from those who want to instigate change in their lives without having to do any actual work...'Yes, you too can unlock the awesome hidden god power of the Cthulu brain by jumping up and down on one foot and slapping yourself in the face with a wet fish for just five easy payments of $49.95'. Wicca is a perfect example of this. 25 years ago when I first got into practicing Wicca there were very few published books available on the subject, and to access them you often had to travel out of your way to find the one Occult bookshop that even stocked them. On top of that you were pretty much expected to find a mentor and under go a minimum of a year and a day of fairly vigorous, disciplined training, that included learning stuff like critical thinking. These days you can practically walk into any book shop and pick some book off the shelf, complete with 'starter kit' - forget the training, forget the dedication and discipline required, just fork over the cash and away you go. I can see a lot of similarities with the practice of EMDR vs more traditional therapeutic approaches. You tell someone who's expectations have been molded into 'but I want it now!!!' by a bunch of marketing buzzwords that they can either undergo long term evidence based talk therapy to deal with their issues, or they can just sit in a chair and have a light flashed in their eyes whilst someone waves their finger at them and their response is more likely going to be 'to hell with the long term evidence based option, I'm gonna go with the cool sounding quick fix option'.

 

[AcronymAllergy]

The main problem I've run into with EMDR are the subsequent quasi-scientific attempts to try and explain the mechanism of the EM component and why/how it works (e.g., something about stimulating both cerebral hemispheres and then maybe adding in something about the RAS and how this allows for more thorough re-encoding and re-processing of the trauma memory, and other such stuff).

I'm all for attempting to develop novel therapeutic techniques, and hey, I'm also as much about leveraging placebo whenever possible as the next guy/gal (which is my current take on what the EM component represents once you remove the exposure). But when the practitioners uncritically accept that the EM is special, and the developers, rather than say, "hey, the eye movements may or may not actually do anything and we don't know how they work" try and throw in some (as erg called it) neurobabble to add an air of authority, that's when I as a scientist start to balk.

My take is that, as has been said, EMDR is very marketable because of the uniqueness and engaging nature of the paradigm. Additionally, pretty much anytime the practitioner truly believes and is passionately pushing the idea that the therapy will work, it's going to be more efficacious than if they're lackluster/dry/etc. in their delivery. Also, for many folks with PTSD, the idea of PE/CPT and exposure is scary as hell; we acknowledge that prior to beginning the therapy, but EMDR might mask some of that and make it seem less frightening because of the reduced focus on the exposure component.

To look at another example: like EMDR, ACT could potentially be said to have/be developing a "cult-like" following. Difference is, ACT has a fairly significant amount of research backing it when compared with medication, CBT, and/or generic "supportive therapy," and it was developed out of underlying theoretical models that are based in said research. It also has a snazzy and uniquely-appropriate acronym, which never hurts.

 

[vistaril]

No, my knowledge comes from me researching this myself when I first heard of EMDR 2 years ago, and from what my psychologist supervisor told me this year.

If you were actually interested in the evidence, you would have looked for it by now as we've been discussing it in this thread for a while. You do know how to find such evidence, right? Do you really need me to do the work for you, because that doesn't sound like a good set up for you to practice EBM? My guess is that you just want to argue.

No, nobody has actually discussed it......what people have done is make the same snarky comments on it they have made for the last few years. Nobody bothered to post a link to the relevant studies....which in this case I guess would be efficacy of emdr vs cbt in trauma patients in a head to head. I have little interest in it and will admit I haven't those either.........but for a few years now I've been hearing psychiatrists(from premeds to med students to interns to 20 year vets) rambling on about literature and fairy dust and it would be nice if just once they had read the supposed primary literature themselves. A few months ago I had this same discussion with someone and he admitted what he meant by literature was a few paragraphs in a journal by an esteemed neuroscientist who wasn't aware of any mechanism by which the em in emdr would work.......which means something different. Hell try explaining the mechanism of how Lithium works to a non-neuroscientist and see how convincing you can be.....and Lithium does actually sorta work.

Heck maybe this massive bounty of literature does exist. I'm not all that concernd because it's not something I will do anyways. But it's just hilarious to hear everyone in psychiatry at every different level step all over themselves to slam this in a snarky manner.

 

[AcronymAllergy]

Here are a few links/studies:

http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/11393607

http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/10225502

http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/?term=A controlled comparison of eye movements and finger tapping in the treatment of test anxiety

http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/?term=Eye movement desensitization of public speaking anxiety: A partial dismantling

Now of course some of those were attempting to treat things other than PTSD, so perhaps the eye movements are uniquely beneficial in trauma, but the meta didn't seem to support that idea. Although to be fair, some of the research attempting to support the benefits of eye movements have also looked at general memory recall rather than recall of trauma memories specifically.

If nothing else, though, as I mentioned above, having a practitioner who truly buys into the treatment and delivers it in an engaging and passionate way is likely going to increase its efficacy regardless of what they're doing. And especially so when you're working with something as intimidating as recalling trauma memories. EMDR certainly works to treat trauma. And it represents another tool in the toolbag. But in keeping with the concept of parsimony, if the eye movements can be withheld without affecting outcomes, then perhaps they should be.

 

[smalltownpsych]

To get back to the original topic as this has digressed a bit. I am wondering why the OP would be surprised to find inept practitioners. I have worked with quite a few psychiatrists where I question their competency. My biased perspective has always been that they are not as competent as the average physician. Participating in this board has changed my perspective on that, my fear is that you guys are the exception. Of course, one of my supervisors pointed out that I didn't trust my colleagues in psychology very much and she was right because I hear too many stories of incompetence. I could give example after example from both professions. Psychologist who told my sister-in-law that she was likely a victim of satanic ritual abuse because she had difficulty remembering childhood, psychiatrist who prescribes stimulants to kid with anxiety due to sexual abuse and testifying against the perp, psychologists and psychiatrists who work with kids but have no ability to develop rapport and just have painful awkward sessions (this happens all the time, especially with adolescents), psychiatrists who prescribe benzos to substance abusers, team of psychiatrists who agreed ECT was best treatment for Borderline. Psychologists and psychiatrists who take sides with their patients and begin doling out advice about how to deal with people they have never met. I would think disagreement over diagnosis ranks pretty low down the list.

 

[Indodo]

1. You are in CA, no? Psychologist is the PP market in that area are likely to have attended rather subpar professional schools. Psychologist who graduated from rigorous university bsased programs there (Berkley, UCLA, etc) are generally in academia or hold academically affiliated clinical positions rather than PP.

2. Even if thats not the case, its still psychologists who insulated in the private practice world. You are correct. They probably see very few SMI cases.

3. Its no so much the diagreement of the diagnosis, but the unprofessional behavior of slamming a collegue in front of the patient with no actual evidence that anything wrong happened.

4. Some psychologists recieve extensive training in SMI. Some recieve basically zero. Its not the bread and butter that it is in psychiatry.

This, to me, is really interesting. Partially because its new information but also because you imply that its a standard. I'm in california and I work in an a sort of community/UC academic environment and private practice. The private practice psychologists are terrible although I should generally say therapists because the majority aren't psychologists. I had assumed they were being lazy or dumping. Some of the psychologists got their training in prisons and they are proud of it. I am sure they have seen SMI, but the quality of work is subpar.

The psychologists I work with at the govt job are top notch, which I had always attributed to having a working relationship. The difference is remarkable when I think about it. I get annoying calls from the PP psychologists telling me I need to increase meds on a borderline patient while we regularly discuss how not to enable a similar borderline and give more structure/boundaries in the pseudo-academic setting.