Do psychiatrists provide psychotherapy?

[Sylvia06]

Hello,

What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

---

Members don't see this ad.

 

[psych.meout]

Hello,

What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

Most psychiatrists are "clinically-focused," they just mostly provide medication management, because it's far more lucrative than therapy, which can be done by master's-level providers.

 

[deleted343839]

Some do, some don't. Where I live, a very typical patient encounter includes medication management plus brief (15-20 min) therapy. However, some psychiatrists in my area charge upwards of $300/hour cash for therapy with or without med management. Many patients like the option of a "full service" clinician who can use both medicine and therapy. You can have this kind of model in private practice, but it's not feasible in a hospital or health system-based practice, so if you are interested in working with, say, medical inpatients or the underserved, you might have to rethink what profession would best suit your career goals.

You might visit the Psychiatry board for a more nuanced answer.

 

[AbnormalPsych]

They think they do.

 

[clausewitz2]

They think they do.

Hey! I resemble that remark!

In practice I am relatively competent in working in an ACT framework, which is convenient because it can more usefully be adapted to briefer encounters than the traditional therapy hour. I probably have enough DBT training to call myself DBT-informed with a straight face and have some MBT training but not enough to ever advertise it in a professional context. I had to seek out the appropriate training and supervision to get there and it was not really a part of my training program. In some places psychiatrists graduate having had a grand total of three therapy cases over the course of their training. I hope and pray those folks understand they are not therapists.

In terms of business models depending on the market and the payors for us doing two evaluation and management appointments per hours with add-on psychotherapy codes is pretty much equivalent to cramming in three med-only clients and is 1/3rd less paperwork and agita. Hence the popularity in said markets.

Agree that this will not be happening inpatient or in big systems. I know a couple of academic attendings who spend a lot of time doing therapy but they a) have research grants to do so or b) eat it as part of their protected time

 

[AbnormalPsych]

I had to seek out the appropriate training and supervision to get there and it was not really a part of my training program.

That's awesome, kuddos to you. I wish more would do this. It would be such a nice compliment to medication management services in some ways.

Psychotherapy is just one of those things that takes so many years of work and clinically takes up so much face to face time that it wouldn't be feasaible, or wise financially, for psychiatry programs/departments to integrate (well). I see a lot of psychiatrists talking AT people and engaging in advice giving. Some have gotten punched for this. Some intervene in ways that contradict my treatment plan/interventions because they don't know any better. To be fair some do some pretty decent solution focused work, motivational interviewing, and basic cognitive/behavioral stuff well.

 

[AcronymAllergy]

Hello,

What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

Short answer: yes. If it's something you're interested in, you could make efforts to select a residency that places an emphasis on therapy and/or obtain additional post-graduate training in it.

Psychiatrists are sometimes pressured (and some surely prefer) to provide shorter appointments and to focus primarily on medication management. This improves "access" for the patients and makes more money for the hospital/clinic/etc. But there's a nationwide shortage of psychiatrists, which provides some negotiating power.

 

[romanticscience]

Psychotherapy is just one of those things that takes so many years of work and clinically takes up so much face to face time that it wouldn't be feasaible, or wise financially, for psychiatry programs/departments to integrate (well).

I'm a psychodynamic psychiatrist who mostly provides therapy. This observation is spot-on. It's very expensive in regards to time and money to train a resident in psychotherapy. You're likely more valuable from a billing standpoint working in other places. Also, the one-on-one supervision and the continuous nature of cases makes it difficult to force into a "psychotherapy rotation," which would fit nicely with the other aspects of post-graduate medical training.

If you're interested in my path: As a medical student, I completed an elective at Austen Riggs in psychodynamic psychiatry. As a second-year resident, I reached out to a psychoanalyst in the community who agreed to supervise 2 cases of mine every week. Concurrently, I completed psychodynamic psychotherapy didactics at the local institute. I had to make arrangements with other rotation supervisors, which sometimes caused conflict, to be free to drive across town to meet with my supervisor. I'm very grateful for my supervisor, who essentially gave me 1-hour (~$200) every week because he was in private practice. In my last year and into my first year in private practice, I transitioned to training in transference-focused psychotherapy through Columbia's online program. TFP is a modified form of psychodynamic psychotherapy geared toward more difficult to work with personalities (ie, BPD).

 

[beginner2011]

I'm a psychodynamic psychiatrist who mostly provides therapy.

From the description you linked:

"Neither organized psychiatry nor organized psychology presently advocates for the usefulness of paradigms that integrate biological psychological and social influences on behavior."

That...is a bold claim.

 

[WisNeuro]

From the description you linked:

"Neither organized psychiatry nor organized psychology presently advocates for the usefulness of paradigms that integrate biological psychological and social influences on behavior."

That...is a bold claim.

A lot of the niche orgs like to put out misleading or flat out false information to make themselves look better for recruitment and such. This is simply one of them. Unfortunately, for people who actually know how things work, it just makes them look bad. I'm sure they'll be advocating for qEEG and DTI for every patient soon enough.

 

[beginner2011]

A lot of the niche orgs like to put out misleading or flat out false information to make themselves look better for recruitment and such. This is simply one of them. Unfortunately, for people who actually know how things work, it just makes them look bad. I'm sure they'll be advocating for qEEG and DTI for every patient soon enough.

The biopsychosocial model is the bedrock of the whole field of behavioral medicine, which dates back to at least the 1970s. And that's just one very obvious example of efforts in both disciplines to integrate the domains. What a bizarrely misinformed claim to make.

 

[WisNeuro]

The biopsychosocial model is the bedrock of the whole field of behavioral medicine, which dates back to at least the 1970s. And that's just one very obvious example of efforts in both disciplines to integrate the domains. What a bizarrely misinformed claim to make.

Agreed, most, if not all, of the more well-established EBT's incorporate all of this. Heck, in proper PE treatment you hit all of those in the first 1-2 sessions.

 

[foreverbull]

Hello,

What is the main role of psychiatrists? Are any mainly clinical focused? Interested in medicine but want to provide more therapy over anything.

From what I’ve seen, prescribing medications is the main role of most (diagnostic assessment as part of that, as well). As some psychiatrists in here have pointed out, psychotherapy training is not standard (unless you seek it out yourself, as these folks have done). I would add that there is no coursework for theory/practice/psychotherapy ethics, per my understanding, so from an ethical standpoint, it isn’t really appropriate for most psychiatrists to practice psychotherapy because they lack the competence to do so. Others have mentioned that psychotherapy training takes years—even at the master’s level you’re looking at 3-4 years of supervised practice before you can be fully licensed and independent, and doctoral level is about 6-8 years before licensure. And both of these include relevant coursework as a foundation.

Psychiatry has a completely different focus with standard medical school training plus the additional rotations/residency to specialize, etc. I’ve heard multiple psychiatrists say that they had very little to no psychotherapy training en route to the M.D. So it’s possible, but not ethical without seeking out appropriate training.

 

[romanticscience]

From the description you linked:

"Neither organized psychiatry nor organized psychology presently advocates for the usefulness of paradigms that integrate biological psychological and social influences on behavior."

That...is a bold claim.

My understanding of this claim is that "organized" refers to the formal academic interest groups within the fields (e.g, APA). For instance, I don't really feel at home within the American Psychoanalytic Association/Institutes (too Freud) nor the American Psychiatric Association/DSM (too Brain). It wasn't until recently that there was a subdivision of the APA for psychotherapists.

 

[WisNeuro]

My understanding of this claim is that "organized" refers to the formal academic interest groups within the fields (e.g, APA). For instance, I don't really feel at home within the American Psychoanalytic Association/Institutes (too Freud) nor the American Psychiatric Association/DSM (too Brain). It wasn't until recently that there was a subdivision of the APA for psychotherapists.

But the claim is still wrong in that interest groups within the APA (psychology) do strongly advocate for paradigms and treatments that include all of these areas. It's either a claim made of ignorance or willful deceit. Really not a great look.

 

[BuckeyeLove]

this one got weird real fast

 

[ERK123]

From what I’ve seen, prescribing medications is the main role of most (diagnostic assessment as part of that, as well). As some psychiatrists in here have pointed out, psychotherapy training is not standard (unless you seek it out yourself, as these folks have done). I would add that there is no coursework for theory/practice/psychotherapy ethics, per my understanding, so from an ethical standpoint, it isn’t really appropriate for most psychiatrists to practice psychotherapy because they lack the competence to do so. Others have mentioned that psychotherapy training takes years—even at the master’s level you’re looking at 3-4 years of supervised practice before you can be fully licensed and independent, and doctoral level is about 6-8 years before licensure. And both of these include relevant coursework as a foundation.

Psychiatry has a completely different focus with standard medical school training plus the additional rotations/residency to specialize, etc. I’ve heard multiple psychiatrists say that they had very little to no psychotherapy training en route to the M.D. So it’s possible, but not ethical without seeking out appropriate training.

This part is not really true (though it may have been true during certain eras of psychiatry residency training). I think every psychiatry residency program today has formal coursework in theory/practice/psychotherapy ethics for at least psychodynamic and cognitive and behavioral therapy principles. From my understanding these courses are required for the residency to be accredited. The coursework generally begins in the second year of residency with psychotherapy patient's beginning in the 3rd year and continuing into the 4th year of residency. Now, the amount of focus on this aspect of training varies from program to program, and I do not really know the extent of this variation. Also, there are psychiatry residency programs that allow for additional training and supervision through local psychoanalytic centers.

I also did a psychodynamic rotation at Austen Riggs in medical school, and chose a residency program with a heavy emphasis on psychodynamic psychotherapy with a good relationship with the local psychoanalytic center. I get the impression that these types of programs are fairly prevalent (though not ubiquitous) in large cities across the U.S. I think any psychiatrist who wants to significantly utilize psychotherapy in their practice will need to seek out additional supervision after completing residency, but there is the potential to obtain a significant foundation for those who want it. Additionally, even for those psychiatrists who see themselves as mostly psychopharmacologists there is tremendous opportunity to utilize the principles taught in psychotherapy to enhance the therapeutic relationship in this setting. I think some foundation in psychotherapy principles is necessary to be a good psychiatrist.

 

[beginner2011]

My understanding of this claim is that "organized" refers to the formal academic interest groups within the fields (e.g, APA). For instance, I don't really feel at home within the American Psychoanalytic Association/Institutes (too Freud) nor the American Psychiatric Association/DSM (too Brain). It wasn't until recently that there was a subdivision of the APA for psychotherapists.

I know very little about the APA (psychiatry), but Division 38 of the APA (psychology) was founded in 1978 and is specifically devoted to the application of the biopsychosocial model to clinical care. A description from a quick google:

"The importance of health psychology as a discipline is best illustrated by the fact that behavioral factors predispose, precipitate, and perpetuate many of the leading causes of illness and death in the USA and around the world. And, perhaps more importantly, behavioral and psychological interventions have been shown to encourage disease prevention, enhance coping with acute and chronic illness, and improve health outcomes when delivered in isolation and in conjunction with existing medical procedures. To promote further progress in each of these areas, APA Division 38 supports the educational, scientific, and professional efforts within psychology to understand the etiology, promotion, and maintenance of health in the prevention, diagnosis, treatment, and rehabilitation of physical illness; conduct research related to the psychological, social, emotional, and behavioral factors that contribute to physical illness; make active contributions to improving the health care system; and assist in the formulation of health policy."

American Psychological Association Division 38 (Health Psychology)

'American Psychological Association Division 38 (Health Psychology)' published in 'Encyclopedia of Behavioral Medicine'

link.springer.com

From the looks of it, that description you linked was published in a peer-reviewed journal (Psychodynamic Psychiatry), and it made an obviously inaccurate statement. Purely from a professional ethics standpoint that's really disappointing, and hopefully not a reflection of the quality of the science that gets published.

It's really striking to see how much ignorance there is among psychiatrists about what psychology is up to, and vice-versa.

 

[romanticscience]

It's really striking to see how much ignorance there is among psychiatrists about what psychology is up to, and vice-versa.

Agreed. Thanks for the perspective. It does seem the description is misapplied to the field psychology.

 

[ERK123]

It's really striking to see how much ignorance there is among psychiatrists about what psychology is up to, and vice-versa.

I think there is a lot of ignorance in psychiatry about what psychiatry is up to. It is a confusing field with a ton of different focuses and cliques. I haven’t really had the chance to delve into the current state of psychology much. I imagine that it is a field with many different focuses as well.

 

[foreverbull]

This part is not really true (though it may have been true during certain eras of psychiatry residency training). I think every psychiatry residency program today has formal coursework in theory/practice/psychotherapy ethics for at least psychodynamic and cognitive and behavioral therapy principles. From my understanding these courses are required for the residency to be accredited. The coursework generally begins in the second year of residency with psychotherapy patient's beginning in the 3rd year and continuing into the 4th year of residency. Now, the amount of focus on this aspect of training varies from program to program, and I do not really know the extent of this variation. Also, there are psychiatry residency programs that allow for additional training and supervision through local psychoanalytic centers.

I also did a psychodynamic rotation at Austen Riggs in medical school, and chose a residency program with a heavy emphasis on psychodynamic psychotherapy with a good relationship with the local psychoanalytic center. I get the impression that these types of programs are fairly prevalent (though not ubiquitous) in large cities across the U.S. I think any psychiatrist who wants to significantly utilize psychotherapy in their practice will need to seek out additional supervision after completing residency, but there is the potential to obtain a significant foundation for those who want it. Additionally, even for those psychiatrists who see themselves as mostly psychopharmacologists there is tremendous opportunity to utilize the principles taught in psychotherapy to enhance the therapeutic relationship in this setting. I think some foundation in psychotherapy principles is necessary to be a good psychiatrist.

I’ve had discussions with psychiatrists and med students and this is the first I’ve heard of psychotherapy coursework being required. Has this been a recent change? Is this true of all residencies for psychiatry?

 

[ERK123]

I’ve had discussions with psychiatrists and med students and this is the first I’ve heard of psychotherapy coursework being required. Has this been a recent change? Is this true of all residencies for psychiatry?

This is required of all psychiatry residency programs. It is an accreditation requirement. I do not believe requiring some form of formal psychotherapy training is a recent change, but I do not know the full history. I would not be surprised if there was a period during the 90's early 2000's when psychotherapy was particularly deemphasized, but I am not sure if it was removed as an accreditation requirement.

Here is a 2015 statement from the APA that mentions continued support for psychotherapy as an accreditation requirement.

"Position Statement The APA advocates for psychotherapy to remain a central treatment option for all patients and for psychotherapy (alone or as part of combined treatment) by psychiatrists to be reimbursed by payers in a manner that integrates care and does not provide financial incentives for isolating biological treatments from psychosocial interventions, e.g., isolated use of medication management without consideration of psychosocial issues requiring essential psychotherapy. The APA supports the Accreditation Council for Graduate Medical Education (ACGME)/ Residency Review Committee (RRC) in their continued accreditation requirement that psychiatry resident training programs provide comprehensive training in evidence-based psychotherapies, as well as in collaborative treatment models. It collaborates with AADPRT and AACDP to address the increasing difficulty programs face in supporting the time and money required for teaching and supervising psychotherapy."

file:///Users/Gordon/Desktop/Position-Psychotherapy-as-an-Essential-Skill-of-Psychiatrists.pdf

I will say that medical students are very unlikely to encounter anything related to psychotherapy when they are on their psychiatry clerkship as most of these exclusively occur in some combination of in-patient units/Emergency psych/Consult psych where there is unlikely any exposure to psychotherapy or psychiatrists who practice psychotherapy.

 

[clausewitz2]

I’ve had discussions with psychiatrists and med students and this is the first I’ve heard of psychotherapy coursework being required. Has this been a recent change? Is this true of all residencies for psychiatry?

As stated above ABPN does require training in psychotherapy as part of residency accreditation. Specifically, residents must receive training in three different therapy modalities. So it is required.

What ABPN does not specify is almost any details of what this training should consist of. Thus, there is very wide latitude in how to interpret this, and a very minimal interpretation (the three clients total across 4 years) is not super rare. This a damn sight different from some fourth year residents I know who are carrying 15 long term psychodynamic clients in addition to other clinical duties. Much like mid-level therapists, this means there is going to be wild variation in the quality and experience of psychiatrists when it comes to psychotherapy.


I would push back against the idea of being aware of psychotherapeutic principles being the same as doing therapy. @WisNeuro is familiar with side effects of a couple of broad classes of medications and how they impact cognition, for example, but this does not mean they are practicing medicine.

 

[Fan_of_Meehl]

That's awesome, kuddos to you. I wish more would do this. It would be such a nice compliment to medication management services in some ways.

Psychotherapy is just one of those things that takes so many years of work and clinically takes up so much face to face time that it wouldn't be feasaible, or wise financially, for psychiatry programs/departments to integrate (well). I see a lot of psychiatrists talking AT people and engaging in advice giving. Some have gotten punched for this. Some intervene in ways that contradict my treatment plan/interventions because they don't know any better. To be fair some do some pretty decent solution focused work, motivational interviewing, and basic cognitive/behavioral stuff well.

Psychiatrists who value psychotherapy are a dying breed. There are a few, but they're rare as hen's teeth and likely to be near retirement. It just doesn't pay nearly as well as medication management. I'm of the opinion that it's really as simple as that.

 

[WisNeuro]

Psychiatrists who value psychotherapy are a dying breed. There are a few, but they're rare as hen's teeth and likely to be near retirement. It just doesn't pay nearly as well as medication management. I'm of the opinion that it's really as simple as that.

At least in my work in a large healthcare system, I'd say that there is also large institutional pressure as well. None of our psychiatrists do therapy, and the hospital system does not want them to. Most therapy is done by midlevels, and they want psychiatry to be pumping out medchecks as fast as they can.

 

[Fan_of_Meehl]

At least in my work in a large healthcare system, I'd say that there is also large institutional pressure as well. None of our psychiatrists do therapy, and the hospital system does not want them to. Most therapy is done by midlevels, and they want psychiatry to be pumping out medchecks as fast as they can.

I'd say that corporatism and an uncritical acceptance of the medical model/metaphor have had a deleterious impact on the scientifically-informed practice of clinical psychology in many large systems such as the VA. I'm currently cosigning notes for a colleague and I don't know whether to laugh or vomit at the title of the note of MENTAL HEALTH DIAGNOSTIC STUDY NOTE that the system mandates for a damn administration of a face-valid self-report checklist of symptoms that any veteran knows will have relevance to the size of their monthly disability income. 'DIAGNOSTIC STUDY' my anus...it's a PCL-5.

 

[Sanman]

I'd say that corporatism and an uncritical acceptance of the medical model/metaphor have had a deleterious impact on the scientifically-informed practice of clinical psychology in many large systems such as the VA.

Might also lead to an opioid epidemic, but what do we know.

 

[Fan_of_Meehl]

Might also lead to an opiod epidemic, but what do we know.

It's the 'fifth vital sign' and no patient under any condition for any length of time should report pain without immediate pharmacological intervention / escalation of dose, dontcha know?

3:16 Bible of Joint Commission, Book of Pain: The Fifth Vital Sign

 

[str63]

I know very little about the APA (psychiatry), but Division 38 of the APA (psychology) was founded in 1978 and is specifically devoted to the application of the biopsychosocial model to clinical care. A description from a quick google:

"The importance of health psychology as a discipline is best illustrated by the fact that behavioral factors predispose, precipitate, and perpetuate many of the leading causes of illness and death in the USA and around the world. And, perhaps more importantly, behavioral and psychological interventions have been shown to encourage disease prevention, enhance coping with acute and chronic illness, and improve health outcomes when delivered in isolation and in conjunction with existing medical procedures. To promote further progress in each of these areas, APA Division 38 supports the educational, scientific, and professional efforts within psychology to understand the etiology, promotion, and maintenance of health in the prevention, diagnosis, treatment, and rehabilitation of physical illness; conduct research related to the psychological, social, emotional, and behavioral factors that contribute to physical illness; make active contributions to improving the health care system; and assist in the formulation of health policy."

American Psychological Association Division 38 (Health Psychology)

'American Psychological Association Division 38 (Health Psychology)' published in 'Encyclopedia of Behavioral Medicine'

link.springer.com

From the looks of it, that description you linked was published in a peer-reviewed journal (Psychodynamic Psychiatry), and it made an obviously inaccurate statement. Purely from a professional ethics standpoint that's really disappointing, and hopefully not a reflection of the quality of the science that gets published.

It's really striking to see how much ignorance there is among psychiatrists about what psychology is up to, and vice-versa.

Just to add to this, you can also get Board Certification in Clinical Health Psychology, which also formally addresses these domains. Clinical Health

I also want to add that I do some teaching in a residency program that is known to have more exposure to learning therapy than other programs. Although rare, some of the residents do therapy after leaving the program and I still feel that they are grossly underprepared. I agree that the "coursework" in the programs vary widely - I believe they can essentially check a box if they had a 1 hour didactic on CBT and that counts toward that requirement. I think what worries me the most is that many of the residents don't even recognize that they are underprepared and feel that they've had adequate training in delivering therapy. In my opinion, in order to have appropriate training, this needs to be done outside the residency program.

 

[ERK123]

Psychiatrists who value psychotherapy are a dying breed. There are a few, but they're rare as hen's teeth and likely to be near retirement. It just doesn't pay nearly as well as medication management. I'm of the opinion that it's really as simple as that.

Just a small nugget of optimism. The American Psychiatric Association started a psychotherapy caucus in 2014. They have grown from 14 to over 700 members in that time. Does this mean anything? No idea. I am starting my residency in about a month and certainly am plan to have to attain a solid foundation in psychotherapy (especially psychodynamic) during the course of my career, but I am so early on that I have little insight into the prevalence of psychotherapy in psychiatry even though I have been exploring this issue somewhat diligently for the past 1.5 years. I know that it exists, but do not know the extent.

 

[foreverbull]

What ABPN does not specify is almost any details of what this training should consist of. Thus, there is very wide latitude in how to interpret this, and a very minimal interpretation (the three clients total across 4 years) is not super rare. This a damn sight different from some fourth year residents I know who are carrying 15 long term psychodynamic clients in addition to other clinical duties. Much like mid-level therapists, this means there is going to be wild variation in the quality and experience of psychiatrists when it comes to psychotherapy.

I also want to add that I do some teaching in a residency program that is known to have more exposure to learning therapy than other programs. Although rare, some of the residents do therapy after leaving the program and I still feel that they are grossly underprepared. I agree that the "coursework" in the programs vary widely - I believe they can essentially check a box if they had a 1 hour didactic on CBT and that counts toward that requirement. I think what worries me the most is that many of the residents don't even recognize that they are underprepared and feel that they've had adequate training in delivering therapy. In my opinion, in order to have appropriate training, this needs to be done outside the residency program.

I think this is why I thought that psychiatry residents didn't receive any coursework/extensive training as standard, because the psychiatrists I've talked to said psychotherapy was not the focus of their residency at all.

I had a semester-long, 2 hours/month didactic seminar on DBT for BPD on internship, but I definitely don't feel like that was adequate preparation/training for treating BPD. I'm wondering if experiences like these more generally are comparable to the frequency/depth of psychotherapy training that psychiatrists might receive? Do trainees have supervision of their psychotherapy skills? And coursework that requires assignments/attendance, or is this just passive didactic trainings here and there?

 

[WisNeuro]

I would imagine that we view the average psychiatrists training in therapy akin to how they view our RxP providers.

 

[deleted343839]

I think what worries me the most is that many of the residents don't even recognize that they are underprepared and feel that they've had adequate training in delivering therapy.

I find this disturbingly common among psychiatry residents at my institution, and we have a decent reputation for psychotherapy training. But the junior faculty who collaborate well and ask questions give me hope.

 

[clausewitz2]

I think this is why I thought that psychiatry residents didn't receive any coursework/extensive training as standard, because the psychiatrists I've talked to said psychotherapy was not the focus of their residency at all.

I had a semester-long, 2 hours/month didactic seminar on DBT for BPD on internship, but I definitely don't feel like that was adequate preparation/training for treating BPD. I'm wondering if experiences like these more generally are comparable to the frequency/depth of psychotherapy training that psychiatrists might receive? Do trainees have supervision of their psychotherapy skills? And coursework that requires assignments/attendance, or is this just passive didactic trainings here and there?

I can only speak for my program but it might be illuminating nonetheless. Our didactics certainly did require attendance, as ACGME requires residents attend at least 60% of all offered didactics (while not specifying how much programs have to offer, don't think about it too hard). My program tried to make sure we never had anyone not graduate because of this rile by requiring 70% attendance averaged over the year.

We had some psychodynamic didactics split up into two courses that probably added up to about 20 hours. We also had to have at least one long term psychodynamic case for at least 18 months, though this wasn't really enforced. For that case we were assigned a supervisor of variable quality, I pulled an ancient child psychiatrist who was a very pure Kleinian but at least one of my co-residents got a freshly licensed LCSW. We would meet with this supervisor for one hour for every two hours of client contact. We were allowed to take on more dynamic cases but not required, so again, wildly variable.

For IPT, we had another 15 hours of scheduled didactic time, but a lot of that was taken up with group supervision for like five residents at a time (three supervisors splitting 14 residents between them). We each got assigned one case that we had to see for at least 16 sessions. Similar set up for CBT, although 20 sessions were required and we were encouraged to see people twice weekly.

While on our consult service we got I think two hours of didactics on brief supportive psychotherapy in a medical setting and then were required to do one session with someone from our follow-up list with an attending observing. We got feedback afterwards. Niggling, persnickety feedback. Academic consult-liaison psychiatrists are a special, pedantic breed.

Our program also made a big deal out of an experience all of our interns got on our dial diagnosis inpatient floor. Every morning we would do 15-20 minutes of MI with patients assigned to us, generally 3-4 at any given time, while the rest of the team sat in the same room and watched. The attending, who had written a book on MI and was an enthusiast, was...very French and made many interns cry. He did a very bad job concealing impatience (I knew it was time to wrap up when he started playing with his wristwatch or tapping his pen) and one of my patients referred to him when I worked with him later on the unit as "that guy with the accent, that German assh*le". His feedback was... impassioned? Overwhelmingly and consistently negative. First time in front of him always drew a response along the lines of "well, zis was a f*cking disaster...." I twigged to this fact early on and realized I could elicit more positive commentary by rubbishing whatever I had done. Then he would tell about "why zee f*ck do you zink zere was anyzing wrong wiz zat?"

In retrospect I guess I was unwittingly applying MI principles after a fashion.

As I said, I sought out a lot more than this, but if I had wanted to do even less, well...monitoring of the other cases was minimal and I know people who took advantage of that fact.

 

[clausewitz2]

I find this disturbingly common among psychiatry residents at my institution, and we have a decent reputation for psychotherapy training. But the junior faculty who collaborate well and ask questions give me hope.

I share your concern but to contextualize they are coming from the see one, do one, teach one ethos of medical education. "This is your second surgical case, med student? Step on up, you're closing the incisions today."

Optional addition: "I'm going next door to assist on the ex lap, page me if you need something"

 

[str63]

I share your concern but to contextualize they are coming from the see one, do one, teach one ethos of medical education. "This is your second surgical case, med student? Step on up, you're closing the incisions today."

Optional addition: "I'm going next door to assist on the ex lap, page me if you need something"

I understand the context because I work at an AMC. However, would a med student be capable of doing surgery after having a few 1-hour didactics on the topic? I know that this isn't the best comparison, but it seems like our psychiatrists and residents think they're capable of using CBT/DBT/MI/psychodynamic/etc. after having a few hours of didactics. You also need appropriate practice and supervision to be competent delivering these. I supervise residents for some of their therapy cases and I can't count the number of times they say they're doing CBT when they're really just doing supportive therapy. Supportive therapy definitely has a place, but it's concerning that these residents don't know the difference. I'm glad to hear you've taken it upon yourself to extend your education - kudos to you!

 

[clausewitz2]

I understand the context because I work at an AMC. However, would a med student be capable of doing surgery after having a few 1-hour didactics on the topic? I know that this isn't the best comparison, but it seems like our psychiatrists and residents think they're capable of using CBT/DBT/MI/psychodynamic/etc. after having a few hours of didactics. You also need appropriate practice and supervision to be competent delivering these. I supervise residents for some of their therapy cases and I can't count the number of times they say they're doing CBT when they're really just doing supportive therapy. Supportive therapy definitely has a place, but it's concerning that these residents don't know the difference. I'm glad to hear you've taken it upon yourself to extend your education - kudos to you!

They might be expected to do more minor things, like biopsying a skin lesion or intubating someone under supervision. They totally also would be asked to drive the camera for a laparoscopic surgery. Those are not perfect but I think a bit closer to the stakes of any given psychotherapy session (i.e. a moment's misstep is not going to literally kill anyone most of the time but could certainly leave lasting harm of some kind). I don't disagree with you at all about needing supervision and how residents have a tendency to assume they are more competent than they are. I'm just trying to lay out why they have been trained to do this and not had expressions of uncertainty about their capabilities reinforced. "Sometimes wrong, never in doubt" is definitely part of the ethos.

 

[deleted343839]

I'm just trying to lay out why they have been trained to do this and not had expressions of uncertainty about their capabilities reinforced

Thank you for pointing this out. This is such a critical distinction between graduate school and medical school. My sense is that graduate training tends to emphasize the other end of the continuum. On a related note, we also tend to crucify those who step out of line from our norms and our science, whereas medicine tends to circle the wagons and protect their own (I realize I'm speaking in broad strokes here but these are my general observations). This might help explain the wishy-washy stereotype of our profession.

 

[Fan_of_Meehl]

Thank you for pointing this out. This is such a critical distinction between graduate school and medical school. My sense is that graduate training tends to emphasize the other end of the continuum. On a related note, we also tend to crucify those who step out of line from our norms and our science, whereas medicine tends to circle the wagons and protect their own (I realize I'm speaking in broad strokes here but these are my general observations). This might help explain the wishy-washy stereotype of our profession.

This is so true. In many ways we are ridiculously hard on our own.

 

[Fan_of_Meehl]

Thank you for pointing this out. This is such a critical distinction between graduate school and medical school. My sense is that graduate training tends to emphasize the other end of the continuum. On a related note, we also tend to crucify those who step out of line from our norms and our science, whereas medicine tends to circle the wagons and protect their own (I realize I'm speaking in broad strokes here but these are my general observations). This might help explain the wishy-washy stereotype of our profession.

It's also a pet peeve of mine when I see the word 'science' or the phrase 'evidence-based' uttered as some sort of magical incantation to shut down critical examination of a particular position or practice handed down by some authority. Science is not a static body of knowledge or commands from authority. Just look at what passed for received truth or scientific consensus 10, 20, or 50 years ago. As we all know, science is a process that encourages critique, critical thinking, arguments over what the relevant 'evidence' is and how it should be interpreted and real scientists are notably skeptical of arguments from authority.

 

[mypointlesspov]

We had psychiatry residents at our two day TF-CBT training at the beginning of internship, but I doubt that they're actually engaging in any type of therapeutic intervention.

 

[Sanman]

It's also a pet peeve of mine when I see the word 'science' or the phrase 'evidence-based' uttered as some sort of magical incantation to shut down critical examination of a particular position or practice handed down by some authority. Science is not a static body of knowledge or commands from authority. Just look at what passed for received truth or scientific consensus 10, 20, or 50 years ago. As we all know, science is a process that encourages critique, critical thinking, arguments over what the relevant 'evidence' is and how it should be interpreted and real scientists are notably skeptical of arguments from authority.

Absolutely. but that background is also what does make psychology wishy-washy is the eyes of healthcare practitioners. Four psychologists could spend hours arguing about the best way to attack treatment for a depressed patient while the psychiatrist has already given him a pill, a supportive talk, and sent him on his way...best practice or not. This is the difference between a background as a scientist vs a guild that trains you for a trade.

 

[Fan_of_Meehl]

Absolutely. but that background is also what does make psychology wishy-washy is the eyes of healthcare practitioners. Four psychologists could spend hours arguing about the best way to attack of treatment for a depressed patient while the psychiatrist has already given him a pill, a supportive talk, and sent him onhis way...best practice or not. This is the difference between a background as a scientist vs a guild that trains you for a trade.

Good points.

 

[WisNeuro]

This is so true. In many ways we are ridiculously hard on our own.

I dunno, at least in my area of neuro and trauma, we're not hard enough with the pseudoscience people. Looking at you EMDR people, and you too, people who feed into somatic symptoms with very mild TBI.

 

[Fan_of_Meehl]

No arguments here...on either of those.

 

[WisNeuro]

Plus, I am all for calling people out who do ****ty things. I don't want to be like police officers, or other professions who will protect the ****bags within their ranks no matter what they do. If you royally f up, your colleagues should call you out on it. If it's bad enough, and you hurt someone through gross negligence, you never practice again. Fine by me.

 

[Therapist4Chnge]

I would imagine that we view the average psychiatrists training in therapy akin to how they view our RxP providers.

Yeah, though they were hating on 2 years of additional training, while we have questioned seeing a handful of patients and having 1-2hr of didactics on it. I know some programs offer more, but they are very few and far between. This doesn't include going to an institute (like the Beck Institute) or a psychodynamic-based institute for additional training after residency.

 

[Sanman]

Yeah, though they were hating on 2 years of additional training, while we have questioned seeing a handful of patients and having 1-2hr of didactics on it. I know some programs offer more, but they are very few and far between. This doesn't include going to an institute (like the Beck Institute) or a psychodynamic-based institute for additional training after residency.

I feel as though many of the institutes filled this gap for psychiatrists in the past. However, with student loans as they are now people just want to work to get life started rather than worrying about doing more. Our grad school class got exposed to some psychoanalytic stuff and even the interested ones gagged at the idea of 5 more years of training.

 

[Therapist4Chnge]

I dunno, at least in my area of neuro and trauma, we're not hard enough with the pseudoscience people. Looking at you EMDR people, and you too, people who feed into somatic symptoms with very mild TBI.

I see their pseudoscience every week. The last 3 TBI-related IMEs I've done all involved some sort of EMDR, Brainspotting, and/or some kind of energy-transfer something or other....I wish I were kidding. Those hacks are all over the place.

 

[Therapist4Chnge]

I feel as though many of the institutes filled this gap for psychiatrists in the past. However, with student loans as they are now people just want to work to get life started rather than worrying about doing more. Our grad school class got exposed to some psychoanalytic stuff and even the interested ones gagged at the idea of 5 more years of training.

Yup. I'm not a huge fan of psychodynamic training in general, though I think there is some value with knowing about it....but your point is what I've also seen. It's not that I expect every psychiatrist to get training in therapy, though it's the "don't know what you don't know" part of it that rubs me the wrong way. The irony being this is the RxP argument in reverse....and the longer I'm in practice, the more I realize that most ppl need more training in everything.