Psychotherapy: Keep or Abolish?

[aspiringdoc09]

I just came across this article that is about a month old, and it poses the question of whether psychotherapy should remain part of psychiatry as advances are being made in the field. Thoughts? If the ACGME/AOA-equivalent governing bodies decide that psychiatry residencies do not need to teach this skill, how will it affect the specialty and patients in the long-term?

Here is the link to the article: http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.2a11

Psychotherapy is one of the reasons why I am interested in psychiatry and without it, psychiatrists will be more like pharmacists.

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[downwithDTB]

I would argue that a lack of psychotherapy/interviewing/motivational training is primarily what's holding back most physicians from providing optimal care... I'd vote to add it to all non-surgical specialties...

 

[Bartelby]

Psychotherapy has to remain a part of any sufficient psychiatry training program in my opinion. When you learn various psychotherapeutic approaches you also learn various models of the mind and mental distress. You learn how to formulate patients, and this can inform your interactions with them both in the therapy hour and in all other contexts (bedside interview on CL, med management visit, etc).

Beyond that our medications and biological interventions are not a cure-all, and sometimes don't help all that much. If we strip ourselves of the skills brought by becoming competent with therapy we remove a huge section of the toolkit that we have to work with patients.

I'm not saying we need to do weekly therapy with each patient, but we should at least thoroughly understand the options as well as when and how to implement them. It will be a sad day if/when we simply write prescriptions based on DSM diagnoses and refer our patients away to the magical black boxes that are the psychologists and social workers.

 

[nexus73]

Give me psychotherapy or give me death

 

[wolfvgang22]

I agree on the importance of therapy for patients, but it is also important to us as the leaders of the mental health treatment team. We can't be ignorant about effective therapies. Also, giving up psychotherapy would be a grave mistake for our profession. It would further open the door for psychiatrists to be replaced by cheaper and less completely qualified social workers, NPs, PAs, psychologists, and others. Lets not make outselves expendable by reducing our skill set.

 

[Ceke2002]

Get rid of psychotherapy? From a patient's point of view, Oh Hell No!

 

[erg923]

I just came across this article that is about a month old, and it poses the question of whether psychotherapy should remain part of psychiatry as advances are being made in the field. Thoughts? If the ACGME/AOA-equivalent governing bodies decide that psychiatry residencies do not need to teach this skill, how will it affect the specialty and patients in the long-term?

Here is the link to the article: http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.2a11

Psychotherapy is one of the reasons why I am interested in psychiatry and without it, psychiatrists will be more like pharmacists.

What advances?

Do we really have more effective clinical interventions for psychiatric illness than 10 years ago, 20 years ago, 30 years ago? Drugs with better tolerated SE profiles, but is there any evidence this actually improves adherence?

 

[romanticscience]

It's also important to consider disorders where the first line treatment IS psychotherapy (eg BPD).

Unless, we just force all phenomenology to fit one of the more conveniently (meds) treated disorders.

Dysthymia = MDD
BPD = Bipolar
Paranoia 2/2 trauma = SZ
Adjustment worry = GAD

If you're not comfortable with therapy as a psychiatrist, that's fine but please let your patients know your limitations and refer properly.


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[Shikima]

No. In fact, we need about 60% more therapists out there doing weekly therapy with the vast majority of the public (world?) which would get rid of a lot poor mannerisms and unhealthy behavioral actions which contribute to the majority of drama. The lions share of psych disorders would also be contained leading to minimal use of psychotropics.

 

[smalltownpsych]

In my experience with psychiatrists, the less they knew about paychotherapy, the more likely they were to argue with patients, misdiagnose, and over-prescribe. Not sure if it matters much to my treatment since my patients get an opportunity to practice their interpersonal skills, but it does make it harder to keep the patient from stopping the medications abruptly as a conversation about the meaning of medication for the patient or the possibility of decreasing or discontinuing is not welcomed by the person writing the script. We would probably be better off having PCPs managing the meds if psychiatrists didn't have the specialized traing in psychotherapy. At least the patients don't expect them to have the same level of understanding of the psychological aspects of mental illness.

 

[aspiringdoc09]

What advances?

Do we really have more effective clinical interventions for psychiatric illness than 10 years ago, 20 years ago, 30 years ago? Drugs with better tolerated SE profiles, but is there any evidence this actually improves adherence?

The article mentioned genomics and neuroscience. Since psychiatry seems to be headed down this biological path to join the rest of the "evidence-based" medicine. I think not teaching it would be a huge mistake. Patients come to you guys, not just for drugs, but because they need an unbiased and nonjudgmental person to talk to and listen to their problems.

 

[Mad Jack]

Not everything is genetics and receptors. Conditioning by one's experiences and environment can powerfully affect a person in many ways- to go to a medication only model would completely neglect this well-established fact.

 

[Mad Jack]

The article mentioned genomics and neuroscience. Since psychiatry seems to be headed down this biological path to join the rest of the "evidence-based" medicine. I think not teaching it would be a huge mistake. Patients come to you guys, not just for drugs, but because they need an unbiased and nonjudgmental person to talk to and listen to their problems.

A good psychiatrist isn't just fixing pathology, they're helping a patient grow and improve as a human being. I hate to sound all alternative med about it, but bringing the focus down to merely alleviating symptoms would seriously sell short what psychiatry can offer as a profession.

 

[aspiringdoc09]

A good psychiatrist isn't just fixing pathology, they're helping a patient grow and improve as a human being. I hate to sound all alternative med about it, but bringing the focus down to merely alleviating symptoms would seriously sell short what psychiatry can offer as a profession.

I agree with both your points. I'm all for advances and innovations but that isn't what excites me about psychiatry.

 

[deleted343839]

Let's say you were going hardcore with the goal of only providing treatments that demonstrably affect the underlying neurological substrates of mental disorders. Let's set aside for a moment the fact that this would hobble your clinical practice. Assuming one could actually take this stance in real-world practice, this would require you to (a) include at least certain forms of psychotherapy (there are now enough fMRI studies to demonstrate effects of therapy on brain function), especially those that are first-line treatments for disorders such as PTSD; and (b) throw out some (perhaps many) of the medication options you now use.

 

[Dharma]

This shouldn't even be a question. What is there to gain from throwing away useful tools?

 

[smalltownpsych]

This shouldn't even be a question. What is there to gain from throwing away useful tools?

Because psychotherapy is intangible and difficult to study and especially hard to market. A provider I know is using genetic testing for all of their patients to determine which cocktail of medications and food supplements to prescribe. Not sure how effective this is, but the patients are impressed.

 

[DD214_DOC]

Most patients don't want to invest the time and effort into therapy, and many don't have the luxury of taking off from work/life once a week or once every two weeks. People want the, "quick fix" whether it exists or not, and if you can't offer this to them they will go elsewhere.

 

[erg923]

Most patients don't want to invest the time and effort into therapy, and many don't have the luxury of taking off from work/life once a week or once every two weeks. People want the, "quick fix" whether it exists or not, and if you can't offer this to them they will go elsewhere.

is it a "quick fix?" Or is it simply avoidance, numbness, illusory remission/extinction, etc?

 

[sunlioness]

Because psychotherapy is intangible and difficult to study and especially hard to market. A provider I know is using genetic testing for all of their patients to determine which cocktail of medications and food supplements to prescribe. Not sure how effective this is, but the patients are impressed.

They're really pushing that here because Medicaid covers it. I'm really skeptical.


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[Ceke2002]

Because psychotherapy is intangible and difficult to study and especially hard to market. A provider I know is using genetic testing for all of their patients to determine which cocktail of medications and food supplements to prescribe. Not sure how effective this is, but the patients are impressed.

Most patients don't want to invest the time and effort into therapy, and many don't have the luxury of taking off from work/life once a week or once every two weeks. People want the, "quick fix" whether it exists or not, and if you can't offer this to them they will go elsewhere.

Reading threads like this I sometimes feel like I'm the only person who actually loves therapy. I even love the bad days and the tough days in therapy. I want to anthropomorphise therapy so I can marry it and have adorable little therapy babies. (okay, that last part may be hyperbole )

 

[thoffen]

I don't think it's essential for us to practice psychotherapy, but it is essential for us to be therapeutic in our patient care, and it is something we are grossly underperforming in.

Whittling down the mind to a CBT model and emphasizing manualized treatment technique and structure is not the best way to teach this, although the practice of it and other therapies is great for providing opportunity to learn how to be therapeutic.

Basically, I say it stays forever.

 

[Dharma]

Most patients don't want to invest the time and effort into therapy, and many don't have the luxury of taking off from work/life once a week or once every two weeks. People want the, "quick fix" whether it exists or not, and if you can't offer this to them they will go elsewhere.

Can't one still utilize psychotherapeutic techniques outside of an official therapy visit?

 

[DD214_DOC]

is it a "quick fix?" Or is it simply avoidance, numbness, illusory remission/extinction, etc?

It could be any of these, but it doesn't really matter which it is when all the patient wants is a magical happy pill. Many seem genuinely surprised to learn such a thing doesn't exist.

 

[WisNeuro]

It could be any of these, but it doesn't really matter which it is when all the patient wants is a magical happy pill. Many seem genuinely surprised to learn such a thing doesn't exist.

Of course it does, benzos and painkillers, man. According to many of my patients, their lives would be so much better if they could just get those scripts again after being tapered off.

 

[nitemagi]

Same with therapy. Psychologists can do it just as well, if not better, and cheaper than us. They have more experience with it. And if you're the type to have a full on therapy practice, kudos, but why do you need the MD? We should have a basic therapy knowledge to know who to refer to and to coordinate a treatment team, and calm down an acute issue. But weekly to monthly therapy sessions can be better and more cheaply handled by the full time therapists.

You're presuming that psychiatrists can't be "Experts" in therapy. They can. In fact prior to the 1980s, psychiatrists were the only ones doing therapy. We lose the expertise when we choose not to prioritize it.

 

[erg923]

You're presuming that psychiatrists can't be "Experts" in therapy. They can. In fact prior to the 1980s, psychiatrists were the only ones doing therapy. We lose the expertise when we choose not to prioritize it.

Psychotherapy has been practiced by psychologists since the 50s.

 

[aspiringdoc09]

Abolish.

At one time I too knew the guidelines on how to treat a UTI or manage blood pressure or lipids or any of that other medical stuff. And in the acute setting that knowledge may still have some value.

But it's wasteful for someone so specialized to be managing stuff outside their specialty. Refer out to the expert.

Same with therapy. Psychologists can do it just as well, if not better, and cheaper than us. They have more experience with it. And if you're the type to have a full on therapy practice, kudos, but why do you need the MD? We should have a basic therapy knowledge to know who to refer to and to coordinate a treatment team, and calm down an acute issue. But weekly to monthly therapy sessions can be better and more cheaply handled by the full time therapists.

I'm a medical student too (rising M3) and I haven't rotated in psych, so I may be naïve. You think they should just let the psychologists handle psychotherapy. What is to keep the psychologists from eventually being able to prescribe medications too, which will infringe on what a psychiatrists does? Or is this already happening in some states? I'm not completely up to date on all the news yet, LOL. You have Psych NPs/PAs doing this, so when do psychiatrists rally together and say enough is enough?

 

[erg923]

[QUOTE="aspiringdoc09, post: 17490363, member: 280253] What is to keep the psychologists from eventually being able to prescribe medications too, which will infringe on what a psychiatrists does? [/QUOTE]

Well, actually, too late on that in 3 states. But most don't have an interest in it.

 

[AcronymAllergy]

My take (from a psychologists' point of view): psychiatrists learning something about psychotherapy is just as important as psychologists learning something about the biological bases of behavior. Even if it's not overtly practiced, it's important knowledge. And, as was mentioned above, it's (I would say) crucial in conceptualizing cases and developing general therapeutic techniques/communication.

 

[smalltownpsych]

Can't one still utilize psychotherapeutic techniques outside of an official therapy visit?

Yup, psychotherapy starts the moment they walk in the door. If all a psychiatrist did was write scripts, then a PMHNP could do that.
Of course, they also think they can do psychotherapy because they had one class on it.

 

[deleted343839]

Whittling down the mind to a CBT model and emphasizing manualized treatment technique and structure is not the best way to teach this

Well, that's a bit of a straw-man claim. No reasonable person does this. Treatment manuals are useful mainly for the content (and yes, they do inform structure though more so in controlled trials). You learn technique from supervised experience.

 

[downwithDTB]

Ultimately, I think this whole thread and specifically the article posted is a HUGE straw-man argument. Insel's original piece was about how psychiatry is attracting more and more scientists. He was speaking largely about a cohort of young MD/PhD grads occupying a large portion of residency slots at top programs and an influx of applications to psych from that cohort specifically, and how they are excited by the potential for improving the physiological understanding of psychiatric illness. Having spoken with many of them, and myself (pending probable match) becoming one of them shortly, my impression is that psychotherapy training is actually a strong draw TO psychiatry specifically FOR MD/PhDs (can't speak for all, but many were excited by the prospect). The view of the brain as a continually plastic organ with multi-functional circuits and immense complexity leads me to conclude that the best treatments for brain illnesses will invariably include a targeting of specific neuron level circuits that can only be accomplished through behavioral level interventions (even if we never know exactly what is changing). Further, the drive to become a physician scientist comes from the idea to improve medicine through education and practice in both science and hands on intervention... what a waste it would be to spend all this time becoming a physician scientist and miss out on training in one of the most important modalities of patient care! Importantly, Insel never mentioned psychotherapy (or the resident's opinions of the topic) in his piece, which cements that the author was attacking none other than the Scarecrow himself.

So, in conclusion: I sincerely doubt that young MD/PhDs at top residency programs would vote to toss or lessen psychotherapy education. I actually spoke with a small handful planning R01 funded careers voluntarily sacrificing protected research time in favor of a bigger therapy load. I think psychotherapy education attracts many MD/PhDs to psych. I doubt that many of them view contemporary psychotherapy as antithetical to contemporary neuroscience. Insel never mentioned axing psychotherapy in the article cited, only an increase in interest in science (which is not in any way inherently antithetical to interest in psychotherapy).

 

[aspiringdoc09]

These are great discussions. Thanks for replying and please keep them coming. Forgive me if anyone felt I was attacking NPs/PAs/Psychologists. That was not my intention at all.

In addition to the posed question: Are there any other signs that indicate that the field may be headed in a direction with less or no psychotherapy? As mentioned by others here, psychologists can provide this service.

 

[smalltownpsych]

We can still be experts at therapy. Just as we can be experts at lipid management or UTI treatment or those other examples above. But there's only 24 hrs in a day and so much to read.

My point is, we cannot be experts at a similar price point. It takes a heckuva lot more train a physician than it does a therapist.

While it could be true that not many psychiatrists are likely to have the expertise in psychotherapy that I would have since it is my primary focus, that does not mean that a psychiatrist cannot make significant sums of money doing just that. I would argue that some of the highest paid psychotherapists are indeed psychiatrists. They have an additional tool at their disposal that I do not and some patients want and will pay for someone who can provide both medications and psychotherapy. The other point is that even if a psychiatrist is not the "best" at providing psychotherapy, I still think they should be better than the average LCPC working at some government agency and from what I have seen that is not a very high bar.

 

[splik]

Psychotherapy is one of the reasons why I am interested in psychiatry and without it, psychiatrists will be more like pharmacists.

I appreciate your enthusiasm for psychotherapy, but you do a great disservice to the field and the overwhelming majority of psychiatrists out there who don't do psychotherapy and I am not sure how not doing psychotherapist makes one a "pharmacist" - that is really derisive to psychiatrists and to pharmacists! Are you saying the almost every salaried psychiatrist is simply a pharmacist? Because, ya know - there are almost no jobs out there for psychiatrists to do psychotherapy.

There are a number of reasons why psychiatrists might not want to do psychotherapy:
1) they want to work with a more acutely unwell, disturbed, or disorganized population
2) they want to be able to help as many patients as possible
3) they can't ethically justify having a psychotherapy-based practice when it means being able to see 8-48 times as few patients
4) they aren't good at it (one can be an excellent psychiatrist in some roles without necessarily being a skilled psychotherapist)
5) they don't find it personally satisfying or rewarding to do psychotherapy
6) they are not working with a patient population who is appropriate for it (i.e. engaged, psychologically minded) - fact is vast swathes of the country do not have patients who are appropriate for psychotherapy, particularly psychoanalytically oriented therapy
7) they find it too emotionally draining and exhausting to provide the kind of intensive holding environment that occurs in the context of psychotherapy

To be honest, I think most psychiatrists are not terribly cut out for it and the majority of training programs are not providing adequate psychotherapy training for psychiatrists to feel comfortable or adept at providing this kind of treatment.

Personally, I find the evaluation part of psychiatry the most interesting which I why have chosen the subspecialties that I have. Also I know many psychiatrists (including myself) who find it satisfying to provide consultation or treatment for complex psychopharm cases including providing case consultation over the telephone. Much of psychiatry does not really require one to use your skills and knowledge and this kind of work (such as you might do in collaborative care) actually puts ones hard-earned psychiatric knowledge and skill to good use.

Now I am one of the least biomedically oriented psychiatrists out there - I don't really believe in psychiatric diagnoses, don't believe mental illnesses are brain disorders or that we really have to think anything about the brain during our day to day work, don't believe most people need long-term treatment with drugs, think that drugs are vastly overprescribed (too many drugs, at too high doses, too early, too, for too long) but the fact is psychotherapy isn't some panacea that everyone can benefit from. The reality is that many psychiatric patients are recalcitrant to both pharmacological and psychotherapeutic treatments. It is a shame that patients do not have access to skilled psychotherapists as readily as they do expensive and often highly toxic drugs - but there is no reason why one has to have an MD to provide psychotherapy (in fact an MD is the worst possibly training I can think of), or why psychiatrists should be all providing psychotherapy. The elephant in the room is that like surgery, outcomes in psychotherapy is highly dependent on the sensitivity and skill of the therapist (and alot of this cannot be taught), and the reality is that few people can work effectively and intensively with seriously disturbed individuals (this is true whether one is an MD, PhD, PsyD, LCSW, MFT, LMHC or whatever).

Even in clinical trials 1/3 of patients drop out of psychotherapy (particularly the CBT oriented ones) before even starting! In real life the figure is even greater! Psychotherapy has actually made somewhat of a renaissance in psychiatric training over the past 15 years

 

[splik]

the other thing i call bs on is this recent trend the claim that psychiatrists are doing psychotherapy in the course of their typical visits. sorry but talking to your patient is not psychotherapy. There is no such a thing of "doing a bit of CBT" or "doing a bit of supportive therapy". Being empathetic to your patient is called being human and doing your f***king job, it's not psychotherapy even though our CPT codes allow us to bill it as such. We've actually cheapened and diluted what it means to be psychotherapeutic by claiming this. Also one can be a highly skilled interviewer without being a psychotherapist or psychotherapy oriented. It all smacks of desperation and expediency, and was quite the opposite of what was claimed 40 years ago.

 

[WisNeuro]

the other thing i call bs on is this recent trend the claim that psychiatrists are doing psychotherapy in the course of their typical visits. sorry but talking to your patient is not psychotherapy. There is no such a thing of "doing a bit of CBT" or "doing a bit of supportive therapy". Being empathetic to your patient is called being human and doing your f***king job, it's not psychotherapy even though our CPT codes allow us to bill it as such. We've actually cheapened and diluted what it means to be psychotherapeutic by claiming this. Also one can be a highly skilled interviewer without being a psychotherapist or psychotherapy oriented. It all smacks of desperation and expediency, and was quite the opposite of what was claimed 40 years ago.

Ah the "provided 15-20" mins of supportive therapy addition to a note. "15-20 mins of supportive therapy" is like the HJ of the mental health world. It's better than nothing, but doesn't do a whole lo to satisfy the person receiving it.

 

[aspiringdoc09]

I appreciate your enthusiasm for psychotherapy, but you do a great disservice to the field and the overwhelming majority of psychiatrists out there who don't do psychotherapy and I am not sure how not doing psychotherapist makes one a "pharmacist" - that is really derisive to psychiatrists and to pharmacists! Are you saying the almost every salaried psychiatrist is simply a pharmacist? Because, ya know - there are almost no jobs out there for psychiatrists to do psychotherapy.

There are a number of reasons why psychiatrists might not want to do psychotherapy:
1) they want to work with a more acutely unwell, disturbed, or disorganized population
2) they want to be able to help as many patients as possible
3) they can't ethically justify having a psychotherapy-based practice when it means being able to see 8-48 times as few patients
4) they aren't good at it (one can be an excellent psychiatrist in some roles without necessarily being a skilled psychotherapist)
5) they don't find it personally satisfying or rewarding to do psychotherapy
6) they are not working with a patient population who is appropriate for it (i.e. engaged, psychologically minded) - fact is vast swathes of the country do not have patients who are appropriate for psychotherapy, particularly psychoanalytically oriented therapy
7) they find it too emotionally draining and exhausting to provide the kind of intensive holding environment that occurs in the context of psychotherapy

To be honest, I think most psychiatrists are not terribly cut out for it and the majority of training programs are not providing adequate psychotherapy training for psychiatrists to feel comfortable or adept at providing this kind of treatment.

Personally, I find the evaluation part of psychiatry the most interesting which I why have chosen the subspecialties that I have. Also I know many psychiatrists (including myself) who find it satisfying to provide consultation or treatment for complex psychopharm cases including providing case consultation over the telephone. Much of psychiatry does not really require one to use your skills and knowledge and this kind of work (such as you might do in collaborative care) actually puts ones hard-earned psychiatric knowledge and skill to good use.

Now I am one of the least biomedically oriented psychiatrists out there - I don't really believe in psychiatric diagnoses, don't believe most people need long-term treatment with drugs, think that drugs are vastly overprescribed (too many drugs, at too high doses, too early, too, for too long) but the fact is psychotherapy isn't some panacea that everyone can benefit from. The reality is that many psychiatric patients are recalcitrant to both pharmacological and psychotherapeutic treatments. It is a shame that patients do not have access to skilled psychotherapists as readily as they do expensive and often highly toxic drugs - but there is no reason why one has to have an MD to provide psychotherapy (in fact an MD is the worst possibly training I can think of), or why psychiatrists should be all providing psychotherapy. The elephant in the room is that like surgery, outcomes in psychotherapy is highly dependent on the sensitivity and skill of the therapist (and alot of this cannot be taught), and the reality is that few people can work effectively and intensively with seriously disturbed individuals (this is true whether one is an MD, PhD, PsyD, LCSW, MFT, LMHC or whatever).

Even in clinical trials 1/3 of patients drop out of psychotherapy (particularly the CBT oriented ones) before even starting! In real life the figure is even greater! Psychotherapy has actually made somewhat of a renaissance in psychiatric training over the past 15 years

I can admit, maybe I should not have made such a generalization equating the two. Your argument has definitely enlightened me because I assumed that all psychiatrists used psychotherapy. I thought that was the main skill they utilized. I didn't realize they had the option to forgo it.

 

[smalltownpsych]

the other thing i call bs on is this recent trend the claim that psychiatrists are doing psychotherapy in the course of their typical visits. sorry but talking to your patient is not psychotherapy. There is no such a thing of "doing a bit of CBT" or "doing a bit of supportive therapy". Being empathetic to your patient is called being human and doing your f***king job, it's not psychotherapy even though our CPT codes allow us to bill it as such. We've actually cheapened and diluted what it means to be psychotherapeutic by claiming this. Also one can be a highly skilled interviewer without being a psychotherapist or psychotherapy oriented. It all smacks of desperation and expediency, and was quite the opposite of what was claimed 40 years ago.

I agree with most of this, but I would say that I think that being trained in psychotherapy is important to prevent the "doing a bit of CBT" "a little supportive therapy" type of thinking. When you know what it really is, then you are less likely to confuse giving some advice as psychotherapy. I also think that conceptualizing what is going on in the patient's interpersonal and intrapersonal world and how that relates to their diagnosis or symptoms is a skill that is usually best developed and practiced through supervised clinical experience of psychotherapy.

 

[notdeadyet]

Are you saying the almost every salaried psychiatrist is simply a pharmacist? Because, ya know - there are almost no jobs out there for psychiatrists to do psychotherapy.

Not true. About half of my graduating residency class that didn't go the academic route ended up in practices in which psychotherapy was a bulk of their job (>50%). The other half ended up in fellowship or acute care/public psych. I don't know anyone who wanted psychotherapy work that wasn't able to find it.

Selection bias is at play in these things. If your view is that there is almost no psychotherapy being done by psychiatrists, you are less likely to see all the psychotherapy that IS being done.

If folks are interested in being psychiatrists that will make psychotherapy s big part of their lives, I'd recommend going to residencies that prioritize psychotherapy. You'll be fine. No one will hold a gun to your head and force you to go to work at Kaiser.

And in case folks haven't read the article the OP linked to, it was about the APA president talking about the IMPORTANCE of psychotherapy, not that it was going away. It's worth noting that the lions share of the great residencies have strong psychotherapy training.

 

[aspiringdoc09]

No, most psychiatrists do not do psychotherapy. They may claim to, but most are not.

See: http://archpsyc.jamanetwork.com/article.aspx?articleid=210114 and this for office-based practice - psychiatrists work in a number of other settings too (psychiatric hospitals, VAs, state hospitals, psych inpatient units, general hospitals, prisons, jails, community mental health centers, primary care/FQHCs etc, nursing homes, colleges/universities)

are you really a med student? the situation is so dire many people don't even realize psychiatrists do provide psychotherapy! Recently one of my patients apologized for unloading on me saying "I'm sorry for telling you about my problems". I said "if you can't tell your psychiatrist, then who can you?" and he replied "Don't psychiatrists just write prescriptions? When I was at Kaiser, I didn't even see a psychiatrist, they would just give me prescriptions." (facepalm).

Yes, a rising M3. My limited exposure (i.e. shadowing) in outpatient and inpatient, I assumed was some form of psychotherapy. Not so much on the inpatient wards but more in the outpatient clinics when they did med management. I am wrong to make these assumptions? I DO understand they work in various settings, but I assumed they used psychotherapy for treatment. I'm learning, so thanks for pointing that out. Like they say, when you assume you make an a** out of yourself, LOL! There is a lot I don't know, but I will read up some more. Thanks.

 

[splik]

Yes, a rising M3. My limited exposure (i.e. shadowing) in outpatient and inpatient, I assumed was some form of psychotherapy. Not so much on the inpatient wards but more in the outpatient clinics when they did med management. I am wrong to make these assumptions? I DO understand they work in various settings, but I assumed they used psychotherapy for treatment. I'm learning, so thanks for pointing that out. Like they say, when you assume you make an a** out of yourself, LOL! There is a lot I don't know, but I will read up some more. Thanks.

I think you are probably wrong in your assumptions. At least it depends on how far we stretch the definition of psychotherapy. I mean I can bill (and frequently do) a 90833 for providing 16+ minutes of psychotherapy. But I think most people would agree that spending 16 minutes talking with a patient isn't really psychotherapy, nor is 30 minutes really. However psychiatrists have now become so used to telling themselves they are "doing psychotherapy" in these encounters that it is quite possible that this was communicated to you.

It is actually most likely you haven't had the chance to see any psychotherapy as a medical student because having another person in the room changes the dynamic. Sometimes students get to observe through a 1-way mirror, or watch videos, and sometimes you may be permitted to sit in a group psychotherapy, but otherwise its very hard to get exposure to this. I actually let medical students observe sessions of hypnotherapy (but that is because the patient has their eyes closed for the most part and its fine) - otherwise they can only watch through the 1-way mirror.

I believe Austen Riggs has a medical student elective in psychodynamic psychotherapy if you want get some hands on experience and training. Also at the Menninger clinic you may be able to do a rotation and get some experience providing psychotherapy under supervision as a medical student.

 

[F0nzie]

I carry 3-5 therapy patients at any given time to keep my psychodynamic and CBT skills sharp. I do this because I know that every interaction I have with a patient is an opportunity for me to help them get better.

People do not like being told what to do. As physicians how often do we make recommendations to improve our patients lives and they actually follow through with it? People need to come to these conclusions on their own. Without therapy skills to understand your patient's desires or know how to spark their motivation for change you may as well throw your psych meds at a wall.

In many settings you can be the worst psychiatrist and still get paid the same as the best psychiatrist. If the patient is dissatisfied, too bad for them. There are 100 other people waiting in line for an appointment.


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[notdeadyet]

I should have clarified I am talking about salaried positions. There is nothing stopping one going into private practice (group or solo) and that is what you would have to do if you want to focus on psychotherapy.

Some of those private practice gigs they are taking are in fact salaried. I also know CDCR docs doing a fair bit of therapy as well, also salaried.

I get what you mean. And you are right that many salaried gigs (HMOs, County gigs, inpatient units, etc) will not have much psychotherapy time.

I just have to call out when things are generalized beyond what's true for effect. I don't know if it's the elections but for some reason I've been noticing it more on SDN and in the real world.

 

[notdeadyet]

You haven't really discounted anything I've said.

No, I agree with a lot of your reasoning for why folks don't do more psychotherapy. It's just the claim that there are "almost no jobs" in which psychiatrists can do psychotherapy that is untrue.

You will also have to concede the bay area is one of those areas where it is very common for psychiatrists to have psychotherapy-based practices and there is market for it, but this does not represent vast swathes of the country.

The country doesn't represent the country. All markets are local. I know psychiatrists doing psychotherapy in rural areas as well as urban ones. I know places where mental health care is scarce that has psychiatrists practicing psychotherapy and I can say the same for areas with saturation of psychiatrists.

What kind of psychiatry you want to practice largely becomes an element of how you prioritize. If psychotherapy is a priority, there are ways to get the skills (outside of the top programs) and get the jobs (outside of the major cities). It may not be for the pay you want and it may not be in the exact place, but such is compromise. Getting what we want, when we want it, where we want it, and for the pay we want isn't a realistic expectation.

Folks saying they can't do psychotherapy is a cop out. It's like folks who end up at high paying gigs who can't work with the underserved. It's a matter of prioritizing what's important to you. It ain't the easy way, but it's do-able if you want it bad enough.

 

[smalltownpsych]

I carry 3-5 therapy patients at any given time to keep my psychodynamic and CBT skills sharp. I do this because I know that every interaction I have with a patient is an opportunity for me to help them get better.

People do not like being told what to do. As physicians how often do we make recommendations to improve our patients lives and they actually follow through with it? People need to come to these conclusions on their own. Without therapy skills to understand your patient's desires or know how to spark their motivation for change you may as well throw your psych meds at a wall.

In many settings you can be the worst psychiatrist and still get paid the same as the best psychiatrist. If the patient is dissatisfied, too bad for them. There are 100 other people waiting in line for an appointment.


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Exactly. Even if you are not the one providing the paychotherapy, the skills are being utilized and in my opinion may be benefitting the patient. Maybe we should conduct a study with psychiatrists trained in therapy vs those who aren't and have them see patients for 15 minute med checks and see which patients do better.

 

[splik]

Folks saying they can't do psychotherapy is a cop out. It's like folks who end up at high paying gigs who can't work with the underserved. It's a matter of prioritizing what's important to you. It ain't the easy way, but it's do-able if you want it bad enough.

I agree with this and to clarify didnt say that people can't do psychotherapy (unless by virtue of incompetence which is not what you're getting at).

 

[thoffen]

I do not feel that the opportunity for psychiatrists to practice psychotherapy is as narrow as being described here. Certainly there are bigger limitations in a salary system, but the opportunity exists in any metro area for private practice psycotherapy with or without meds, and in many places much more easily on a cash only basis. One advantage for psychiatrists is that they can offer med services in a psychotherapy frame, and they can charge more for their services.

There is a separate point, though. It is not necessary to practice psychotherapy as a psychiatrist, and I would agree that most do not even if they are billing with add-on codes. What I do believe, though, is that the most important piece of our work is our ability to be therapeutic in our interactions with patients. It is pointless to know that medication X is 10% better or more tolerated than medication Y if you don't have sufficient alliance with the patient for them to fill the script, take the medicine, come back to you, report honestly their experience, and navigate successfully the moments where you and your patient disagree.

 

[aspiringdoc09]

I think you are probably wrong in your assumptions. At least it depends on how far we stretch the definition of psychotherapy. I mean I can bill (and frequently do) a 90833 for providing 16+ minutes of psychotherapy. But I think most people would agree that spending 16 minutes talking with a patient isn't really psychotherapy, nor is 30 minutes really. However psychiatrists have now become so used to telling themselves they are "doing psychotherapy" in these encounters that it is quite possible that this was communicated to you.

It is actually most likely you haven't had the chance to see any psychotherapy as a medical student because having another person in the room changes the dynamic. Sometimes students get to observe through a 1-way mirror, or watch videos, and sometimes you may be permitted to sit in a group psychotherapy, but otherwise its very hard to get exposure to this. I actually let medical students observe sessions of hypnotherapy (but that is because the patient has their eyes closed for the most part and its fine) - otherwise they can only watch through the 1-way mirror.

I believe Austen Riggs has a medical student elective in psychodynamic psychotherapy if you want get some hands on experience and training. Also at the Menninger clinic you may be able to do a rotation and get some experience providing psychotherapy under supervision as a medical student.

I suppose I have not seen real psychotherapy. Thanks for the references.