Do psychiatrists provide psychotherapy?

[deleted343839]

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.

I agree, but high standards for licensed professionals can co-exist with a non-punitive training culture that encourages learning from errors, and I don't think graduate school in psychology is an exemplar of that culture. Undergraduate medical education is way ahead of us on this (as with most things).

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[WisNeuro]

I agree, but high standards for licensed professionals can co-exist with a non-punitive training culture that encourages learning from errors, and I don't think graduate school in psychology is an exemplar of that culture. Undergraduate medical education is way ahead of us on this (as with most things).

Sure, there are honest errors. I'm all about corrective teaching in those instances. But then there are blatant, inexcusable, ****ups. You sleep with a vulnerable patient, I'm fine with you never practicing again.

 

[AbnormalPsych]

misstep is not going to literally kill anyone most of the time but could certainly leave lasting harm of some kind

I think this is also insight into the differences in approach to liability that may exist between medicine and psychology / (good) psychologists.

 

[Grenth]

It's wild that in psychiatry the kind of training discussed above (3 cases, a few classes) makes people feel qualified to do therapy. I mean I've taken three courses in psychopharm I also took the full chem and o chem series in undergrad and I've shadowed psychiatric prescribers and uh please don't let me prescribe.

Also, why of all things are so many psychiatrists here and in my real life trained in psychoanalysis of all possible therapeutic modalities? I had a supervisor who urged me to pursue psychoanalysis training "so I could speak a common language with psychiatrists." I think there was some merit to her saying that although outside of her supervision and some reading I'm not using any more of my time on a modality that is not exactly cutting edge at best.

 

[clausewitz2]

It's wild that in psychiatry the kind of training discussed above (3 cases, a few classes) makes people feel qualified to do therapy. I mean I've taken three courses in psychopharm I also took the full chem and o chem series in undergrad and I've shadowed psychiatric prescribers and uh please don't let me prescribe.

Also, why of all things are so many psychiatrists here and in my real life trained in psychoanalysis of all possible therapeutic modalities? I had a supervisor who urged me to pursue psychoanalysis training "so I could speak a common language with psychiatrists." I think there was some merit to her saying that although outside of her supervision and some reading I'm not using any more of my time on a modality that is not exactly cutting edge at best.

The dominance of psychoanalysis is a very regional thing and much less typical outside of New York and Boston. Historically American analysis was dominated by MDs so that is probably part of it even to this day. These days actually analytical training is relatively unusual for psychiatrists but psychodynamic training remains fairly common. If I had had to hazard guesses as to continued popularity I might start with the privileging of idiosyncratic details of the therapeutic relationship in dynamic theorizing and how that dovetails nicely with the idea of the supremacy of individual clinical judgement, but that is just a sketch of an explanation.

 

[tr]

Whoa you guys. No we do not get as much psychotherapy training as doctoral students in clinical psychology, obviously.
But neither is our therapy training limited to didactics. And no psychiatrist that I know would ever think they could practice a therapeutic modality based on didactic training only.

I attended a residency program which, at the time, was thought weak on psychotherapy. (It's better now.)
We had long-term supervised psychotherapy cases starting in our second year of residency, adding more patients as we went through the program (4 y total).

Most of the available supervision was by psychodynamically oriented MDs, which was a weakness, though I also had individual supervision for CBTi, ERP, and prolonged exposure cases in the regular course of my training. I personally didn't feel the psychodynamic supervision was of much efficacy or utility. I therefore sought out more CBT supervision. I attended an optional/extracurricular group hands-on CBT training (we practiced on each other) one evening per week for most of my residency. I also had individual supervision from the person who ran those groups, who was fantastic, throughout my fourth year. I learned motivational interviewing on an inpatient floor by working with an attending who knew how to do it. The inpatient MI training was incredibly helpful, and MI was also a standard and important part of the type of CBT that I learned to do for outpatients. After my graduation year the program instituted a formal requirement to complete a six-month rotation in CBT, so everyone now has at least that much exposure.

I am a reasonably good psychotherapist. I am sure I am not as good as a really crack clinical psychologist who does nothing but therapy, but I am a heck of a lot better than a lot of these master's level therapists who pretty much just do supportive therapy and hand out bad advice, or the elderly MDs who say almost nothing and call it therapy. (I do not give advice when wearing my therapist hat, though I do when wearing my physician hat obviously - but even then my advice-giving is tempered by an awareness of motivational principles taken from my training in MI.) I know I am a good psychotherapist because all my work is data-informed. I use standard inventories for depression/anxiety as well as a therapist rating form, and if I get a bad eval on the therapist rating form or the PHQ/GAD/whatever scores are not going down, I address the issue directly using the interpersonal and/or motivational techniques I learned in my training. I usually get good evals and good results.

I work in an academic setting where I do a combination of research (as much as I can fund), teaching (as much as they want me to do), and clinical care (all the rest). I always have a few psychotherapy cases because I take insurance and it's really hard to find therapists who take insurance. I therefore will try to find people therapy that they can afford using the various referral channels I know of, and if we can't figure it out then then I'll offer them a time-limited course of CBT myself. So I do enough to keep my therapy skills from getting rusty.

 

[AbnormalPsych]

They think they do.

See.

Whoa you guys. No we do not get as much psychotherapy training as doctoral students in clinical psychology, obviously.
But neither is our therapy training limited to didactics. And no psychiatrist that I know would ever think they could practice a therapeutic modality based on didactic training only.

I attended a residency program which, at the time, was thought weak on psychotherapy. (It's better now.)
We had long-term supervised psychotherapy cases starting in our second year of residency, adding more patients as we went through the program (4 y total).

Most of the available supervision was by psychodynamically oriented MDs, which was a weakness, though I also had individual supervision for CBTi, ERP, and prolonged exposure cases in the regular course of my training. I personally didn't feel the psychodynamic supervision was of much efficacy or utility. I therefore sought out more CBT supervision. I attended an optional/extracurricular group hands-on CBT training (we practiced on each other) one evening per week for most of my residency. I also had individual supervision from the person who ran those groups, who was fantastic, throughout my fourth year. I learned motivational interviewing on an inpatient floor by working with an attending who knew how to do it. The inpatient MI training was incredibly helpful, and MI was also a standard and important part of the type of CBT that I learned to do for outpatients. After my graduation year the program instituted a formal requirement to complete a six-month rotation in CBT, so everyone now has at least that much exposure.

I am a reasonably good psychotherapist. I am sure I am not as good as a really crack clinical psychologist who does nothing but therapy, but I am a heck of a lot better than a lot of these master's level therapists who pretty much just do supportive therapy and hand out bad advice, or the elderly MDs who say almost nothing and call it therapy. (I do not give advice when wearing my therapist hat, though I do when wearing my physician hat obviously - but even then my advice-giving is tempered by an awareness of motivational principles taken from my training in MI.) I know I am a good psychotherapist because all my work is data-informed. I use standard inventories for depression/anxiety as well as a therapist rating form, and if I get a bad eval on the therapist rating form or the PHQ/GAD/whatever scores are not going down, I address the issue directly using the interpersonal and/or motivational techniques I learned in my training. I usually get good evals and good results.

I work in an academic setting where I do a combination of research (as much as I can fund), teaching (as much as they want me to do), and clinical care (all the rest). I always have a few psychotherapy cases because I take insurance and it's really hard to find therapists who take insurance. I therefore will try to find people therapy that they can afford using the various referral channels I know of, and if we can't figure it out then then I'll offer them a time-limited course of CBT myself. So I do enough to keep my therapy skills from getting rusty.

 

[tr]

See.

Numbers don't lie.

 

[AbnormalPsych]

Dunning–Kruger effect - Wikipedia

en.wikipedia.org

 

[forensic13]

Whoa you guys. No we do not get as much psychotherapy training as doctoral students in clinical psychology, obviously.
But neither is our therapy training limited to didactics. And no psychiatrist that I know would ever think they could practice a therapeutic modality based on didactic training only.

I attended a residency program which, at the time, was thought weak on psychotherapy. (It's better now.)
We had long-term supervised psychotherapy cases starting in our second year of residency, adding more patients as we went through the program (4 y total).

Most of the available supervision was by psychodynamically oriented MDs, which was a weakness, though I also had individual supervision for CBTi, ERP, and prolonged exposure cases in the regular course of my training. I personally didn't feel the psychodynamic supervision was of much efficacy or utility. I therefore sought out more CBT supervision. I attended an optional/extracurricular group hands-on CBT training (we practiced on each other) one evening per week for most of my residency. I also had individual supervision from the person who ran those groups, who was fantastic, throughout my fourth year. I learned motivational interviewing on an inpatient floor by working with an attending who knew how to do it. The inpatient MI training was incredibly helpful, and MI was also a standard and important part of the type of CBT that I learned to do for outpatients. After my graduation year the program instituted a formal requirement to complete a six-month rotation in CBT, so everyone now has at least that much exposure.

I am a reasonably good psychotherapist. I am sure I am not as good as a really crack clinical psychologist who does nothing but therapy, but I am a heck of a lot better than a lot of these master's level therapists who pretty much just do supportive therapy and hand out bad advice, or the elderly MDs who say almost nothing and call it therapy. (I do not give advice when wearing my therapist hat, though I do when wearing my physician hat obviously - but even then my advice-giving is tempered by an awareness of motivational principles taken from my training in MI.) I know I am a good psychotherapist because all my work is data-informed. I use standard inventories for depression/anxiety as well as a therapist rating form, and if I get a bad eval on the therapist rating form or the PHQ/GAD/whatever scores are not going down, I address the issue directly using the interpersonal and/or motivational techniques I learned in my training. I usually get good evals and good results.

I work in an academic setting where I do a combination of research (as much as I can fund), teaching (as much as they want me to do), and clinical care (all the rest). I always have a few psychotherapy cases because I take insurance and it's really hard to find therapists who take insurance. I therefore will try to find people therapy that they can afford using the various referral channels I know of, and if we can't figure it out then then I'll offer them a time-limited course of CBT myself. So I do enough to keep my therapy skills from getting rusty.

1. Do your clients explicitly know when you are using your therapist hat and when you are using your physician hat? I would expect when you walk in the room as a psychiatrist, they automatically see you as the "authority" and do not see the difference between the times when you are trying to to be a therapist and when you are giving advice as a physician.

2. I think you majorly underestimate some master's level therapists, many of whom whom have a great deal more training in psychotherapy than you.

 

[tr]

1. Do your clients explicitly know when you are using your therapist hat and when you are using your physician hat? I would expect when you walk in the room as a psychiatrist, they automatically see you as the "authority" and do not see the difference between the times when you are trying to to be a therapist and when you are giving advice as a physician.

Yes there is a very clear delineation. Usually If I have reason to give medical advice in the middle of a therapy session I'll explicitly point out that I'm stepping out of the therapeutic frame. As I said I offer short term targeted CBT and there's a clear trajectory to the work where we spend the early part working on defining goals and clarifying motivation, the middle on applying techniques, and wrap up with relapse prevention. I always give homework and a session eval as a therapist, almost never as a physician. I do use MI, basic behavioral activation, and relaxation breathing in med management sessions without the full therapeutic framework, but I don't give medical advice in a therapy session without explicitly declaring what I'm doing.

2. I think you majorly underestimate some master's level therapists, many of whom whom have a great deal more training in psychotherapy than you.

It's certainly possible for masters level therapists (and MDs) to get more postgraduate training in psychotherapy. For economic reasons, most of them don't. I hear a lot of feedback from my patients about therapists who offer bad advice, judgemental opinions, or just don't provide anything of value other than a listening ear. When I hear this it seems the therapist is more likely to be a master's level than a psychologist. Not always of course. Some master's level clinicians are great. I work closely with a few who are excellent. On the other hand, our EAP is staffed by master's level clinicians and I never hear anything good out of that place.

The training group I attended as a resident had a mix of psychologists, LCSW/MSW/MFT, and MDs at all stages of training and career, and I didn't notice any effect of degree there. But all those people were there because they had an explicit interest in becoming better therapists and were spending their time there to do so.

To be clear, I would never say my psychotherapy training approaches that of a clinical psychologist. But there were comments upthread to the effect that MDs are doing psychotherapy based *only* on didactic training. That is grossly divorced from reality.

 

[foreverbull]

It's certainly possible for masters level therapists (and MDs) to get more postgraduate training in psychotherapy.
.....
To be clear, I would never say my psychotherapy training approaches that of a clinical psychologist. But there were comments upthread to the effect that MDs are doing psychotherapy based *only* on didactic training. That is grossly divorced from reality.

Are you saying that only master’s level folks who seek training after licensure as prepared as you are to provide therapy? In the master’s program housed within The same department as my doctoral program, students had a year of part-time practice, then a year of part to full-time practice depending on the internship, and then had to be supervised for at least another year before licensure (3+ supervised years of just psychotherapy practice). Add in specific courses in counseling theory, group therapy, techniques, multicultural Counseling, diagnosis, family therapy, research & stats, and a few other counseling-related elective courses specific to psychotherapy practice. That is the sole focus of the master’s program. Is psychiatry really providing equivalent training and coursework to a master’s program in which therapy is the full focus?

I think the main point of earlier psychiatrists posting here is that the psychotherapy training is highly variable in residency in the way that the psychotherapy-related requirements are met, and that makes sense given that it is not the sole focus of residency, but seems to be peripheral to the main training. Is that not a fair statement?

Certainly there is variability in training in master’s programs, but the coursework alone is fully-focused on training therapists, which is already qualitatively different from a psychiatry residency.

 

[tr]

Are you saying that only master’s level folks who seek training after licensure as prepared as you are to provide therapy? In the master’s program housed within The same department as my doctoral program, students had a year of part-time practice, then a year of part to full-time practice depending on the internship, and then had to be supervised for at least another year before licensure (3+ supervised years of just psychotherapy practice). Add in specific courses in counseling theory, group therapy, techniques, multicultural Counseling, diagnosis, family therapy, research & stats, and a few other counseling-related elective courses specific to psychotherapy practice. That is the sole focus of the master’s program. Is psychiatry really providing equivalent training and coursework to a master’s program in which therapy is the full focus?

I think there's a ton of variability as was stated above.
A master's level clinician is supposed to do 3000 hours total prior to licensure for independent practice.
It's a little difficult to separate out what is specifically 'therapy training' from the residency, but a lighter psychiatry residency is ~3000 hours *each year* in years 1 and 2 and ~2000 hours per year in years 3 and 4.

Regarding the specific things you mentioned,
Groups and family: yes I had both didactic and supervised case experience with group therapy and with family/couples therapy in residency.
Multicultural - covered in didactics, I don't recall doing a supervised case, would be available by request/interest
Diagnosis - covered ad nauseam in the other 7000 hours
Research and stats - pretty much everyone who goes through MD training nowadays gets some training in interpreting the literature as well as some hands-on research experience. How well they learn/apply is a different story for another day. I'm sure this applies to the master's students as well.
Counseling theory - nope, got me there, we sure got a crap ton of psychodynamic/psychoanalytic theory in didactics though

I think the main point of earlier psychiatrists posting here is that the psychotherapy training is highly variable in residency in the way that the psychotherapy-related requirements are met, and that makes sense given that it is not the sole focus of residency, but seems to be peripheral to the main training. Is that not a fair statement?

Of course it is variable, but I would cross out the 'peripheral' statement. I don't think therapy is made peripheral in the curriculum, though some residents can choose to make it so. Conversely, many can choose to make it a specific focus of interest. There are psychotherapy-focused tracks within many psychiatry residencies.
Sometimes the volume/emphasis is fine but the quality is poor (as I mentioned I didn't find the psychodynamically focused training we got to be particularly useful). My point was that our therapy training is not limited to 'didactics and a handful of cases' as was stated upthread.

Certainly there is variability in training in master’s programs, but the coursework alone is fully-focused on training therapists, which is already qualitatively different from a psychiatry residency.

My observations are that the end product is extremely variable. End product of psychology training seems less so. I can't tell what's going on with the MDs because I rarely get patients who say they had psychotherapy with a previous MD. As mentioned above there is financial pressure on MDs to do more med management and less psychotherapy.

 

[foreverbull]

I think there's a ton of variability as was stated above.
A master's level clinician is supposed to do 3000 hours total prior to licensure for independent practice.
It's a little difficult to separate out what is specifically 'therapy training' from the residency, but a lighter psychiatry residency is ~3000 hours *each year* in years 1 and 2 and ~2000 hours per year in years 3 and 4.

Of course it is variable, but I would cross out the 'peripheral' statement. I don't think therapy is made peripheral in the curriculum, though some residents can choose to make it so. Conversely, many can choose to make it a specific focus of interest. There are psychotherapy-focused tracks within many psychiatry residencies.
Sometimes the volume/emphasis is fine but the quality is poor (as I mentioned I didn't find the psychodynamically focused training we got to be particularly useful). My point was that our therapy training is not limited to 'didactics and a handful of cases' as was stated upthread.

I'd be interested to know how common your experience is vs. other psychiatrists in terms of training, because you're the first who said you received more than cursory training in psychotherapy (outside of seeking their own training experiences).

Are those 3000 hours training total each year in psychotherapy specifically? How does this fit with the med management/psychopharmacology side of training? I would like to clarify what is encompassed in that 3000 hours and the balance between psychotherapy vs. med management. In master's programs, the 3000 hours total doesn't include any of the many hours set aside for coursework, which is two years full-time of what would be considered didactic training.

Certainly there is variability in many types of training, I'm just dubious about the notion that psychiatrists are better prepared to provide psychotherapy than master's level clinicians.

 

[ERK123]

The only thing that I have learned from this thread about the topic "Do psychiatrist provide psychotherapy" is that there are a number of SDN psychologist/psychotherapists who are only interested in the answer being "no". That is the only question that has yet been answered in this thread, and I am doubtful that there will be any further illuminations unless we want to start delving into the various defense mechanisms each side is using to protect the self-image of their professional guild. /s (kinda)

 

[foreverbull]

The only thing that I have learned from this thread about the topic "Do psychiatrist provide psychotherapy" is that there are a number of SDN psychologist/psychotherapists who are only interested in the answer being "no". That is the only question that has yet been answered in this thread, and I am doubtful that there will be any further illuminations unless we want to start delving into the various defense mechanisms each side is using to protect the self-image of their professional guild. /s (kinda)

I don’t see asking for clarification as trying to confirm one side or the other. I asked how common this was, and have learned about psychiatry residency from this thread which has been helpful. It’s a fair question to ask someone who has reportedly had extensive training in psychotherapy how the hours break down in residency.

 

[Fan_of_Meehl]

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.

I'm baffled as to how one would even *conceptualize* an approach to practicing psychiatry or clinical psychology WITHOUT leveraging 'the usefulness of paradigms that integrate biological, psychological, and social influences on behavior' They're not even swatting at a 'straw man' with that statement...they're implying an invisible man (or an empty set).

 

[AbnormalPsych]

Numbers don't lie.

Are you referring to your PHQ-9/GAD scores? The scores of face valid screening measures that do not take into account multicultural contexts and conceptualizations of disorders and are impacted by social desirability bias (probably highly as you "address the issue directly" with scores not going in the direction you want. Not to mention the additional confounds and explanations of the variance. Things like the actual medication management occurring concurrently.

 

[AbnormalPsych]

The only thing that I have learned from this thread about the topic "Do psychiatrist provide psychotherapy" is that there are a number of SDN psychologist/psychotherapists who are only interested in the answer being "no". That is the only question that has yet been answered in this thread, and I am doubtful that there will be any further illuminations unless we want to start delving into the various defense mechanisms each side is using to protect the self-image of their professional guild. /s (kinda)

I think there are different conceptualizations of what psychotherapy is.

Do psychiatrists use psychotherapy techniques. Sure. Do they do it over a course of time. Sure. When put together, might this technically be considered a course of psychotherapy. Sure. Is the depth of their training and quality of the work equal to that of masters or doctoral level providers? Could be. Is this probable? No. Some of us have spent almost a decade learning psychotherapy and still feel some imposter syndrome. Even masters level providers often spend 3 years full time learning this. It does come off a bit in insulting to think someone in another field can just pick it up as a side part of their training and act so hubristic about it.

I have a range of formal coursework and didactic training in psychopharmacology, biology, chemistry, biological bases of behavior, neuroanatomy, and years of experience working with psychiatrists. Does this inform my work? Sure. Do I provide intervention in this area? No. There are others who are licensed in specifically this who know 1000% more than I ever would.

 

[Fan_of_Meehl]

Are you referring to your PHQ-9/GAD scores? The scores of face valid screening measures that do not take into account multicultural contexts and conceptualizations of disorders and are impacted by social desirability bias (probably highly as you "address the issue directly" with scores not going in the direction you want. Not to mention the additional confounds and explanations of the variance. Things like the actual medication management occurring concurrently.

Agree. Definitely possible to lie with symptom self-report...whether numbers are involved or not. One of the most frustrating things to deal with recently is the apparent worship of numbers (to the point of fetish, at times) by the 'measurement-based care' crowd. As if someone who would be prone to symptom overreporting, misattribution or outright malingering and who might provide information of questionable validity in a free response to the verbalized question, "Do you have any disturbing dreams about the (traumatic) incident and, if so, describe a typical dream" but, when filling out a questionnaire and responding to the item, "Repeated, disturbing dreams of the stressful experience?" (0-Not at all, 1-A little bit, 2-Moderately, 3-Quite a bit, and 4-Extremely)--because the are *numbers* involved--all of a sudden we're dealing with data that are somehow 'valid' and meaningfully diagnostic and free of response bias or demand characteristics pertinent to the clinical setting.

 

[Sanman]

Agree. Definitely possible to lie with symptom self-report...whether numbers are involved or not. One of the most frustrating things to deal with recently is the apparent worship of numbers (to the point of fetish, at times) by the 'measurement-based care' crowd. As if someone who would be prone to symptom overreporting, misattribution or outright malingering and who might provide information of questionable validity in a free response to the verbalized question, "Do you have any disturbing dreams about the (traumatic) incident and, if so, describe a typical dream" but, when filling out a questionnaire and responding to the item, "Repeated, disturbing dreams of the stressful experience?" (0-Not at all, 1-A little bit, 2-Moderately, 3-Quite a bit, and 4-Extremely)--because the are *numbers* involved--all of a sudden we're dealing with data that are somehow 'valid' and meaningfully diagnostic and free of response bias or demand characteristics pertinent to the clinical setting.

It's possible to lie or simply not understand the complexity of a question, not take it seriously, etc. Any healthcare worker having been in clinical work for a period of time understands this.

"On a scale of 1-10 what is your pain?"

"12 (the patient says calmly and not screaming in agony), my pain is a 12"

Seems accurate to me, how about you?

At the end of the day, you can rely on simple systems or expertise, simple systems are useful for mass screening, catching unreported symptoms, and places where expertise is unavailable or training everyone is not possible. Let us not mistake it for expertise. We all drive to work, get groceries, and stop at red lights (mostly) and some have been doing this for years. This qualifies none of us to be a race car driver or even makes us a good driver that is prepared for adverse conditions.

 

[tr]

I don’t see asking for clarification as trying to confirm one side or the other. I asked how common this was, and have learned about psychiatry residency from this thread which has been helpful. It’s a fair question to ask someone who has reportedly had extensive training in psychotherapy how the hours break down in residency.

I wouldn't say this was 'extensive' training. I would say it was adequate training to allow me to practice psychotherapy in a way that is more likely to do good than harm. As I mentioned above I have a small number of modalities that I practice and I stick to what I know. I think we all agree that psychotherapy is difficult to do well and takes a lot of time and effort.

I really am not sure how to break down the hours. The first two years of training include a lot of medicine, neurology, and inpatient psychiatry, so opportunities to practice psychotherapeutic principles are fewer. During those years I did have rotations in, for example, a residential substance use treatment program, where I had training in leading group CBT, and a VA rotation in which I had a supervised PE case. I also learned MI, which was developed for time limited encounters, on the inpatient units. Long term psychotherapy cases start in the second year but usually just one or two cases at the beginning, adding more as you progress through training. Third and fourth years are usually mostly or all outpatient (excluding call). During outpatient rotations there is time dedicated for at least one psychotherapy case. For example I had a six month rotation in OCD in which I carried a couple of ERP cases. People with interest in therapy could choose to use more of their clinic time for psychotherapy cases. The CBT rotation I mentioned was obviously all therapy.

I could guess that maybe 25-35% of the total experience was related to psychotherapy training?

I don't know what is going on in residencies other than the one I trained in and where I stayed on as fellow and then faculty for the following 8 years. That program was considered less psychotherapeutically oriented at the time, nonetheless many residents expressed specific interest in learning to do psychotherapy and integrating it into their practice. I do know that competency in 3 psychotherapeutic modalities (as noted above) is required for graduation from all U.S. psychiatric residencies, and also agree with others above that the means of assessing competency is sufficiently unstandardized that it may not mean much.

The nonstandardization problem, however, is not unique to MDs. I have provided on-paper supervision for clinical hours for PsyD students who were doing SCIDs and other types of work for our research studies. Frankly I never observed one minute of their SCIDs (training was provided directly by postdocs and others associated with the work) but because I was the one with the license I had to fill out the form. I would say that the value of that form as an assessment of the student's clinical skills was approximately zero.

 

[tr]

Are you referring to your PHQ-9/GAD scores? The scores of face valid screening measures that do not take into account multicultural contexts and conceptualizations of disorders and are impacted by social desirability bias (probably highly as you "address the issue directly" with scores not going in the direction you want. Not to mention the additional confounds and explanations of the variance. Things like the actual medication management occurring concurrently.

Are you saying you use no metrics to assess whether you have achieved anything in the course of your work?

Agree. Definitely possible to lie with symptom self-report...whether numbers are involved or not. One of the most frustrating things to deal with recently is the apparent worship of numbers (to the point of fetish, at times) by the 'measurement-based care' crowd. As if someone who would be prone to symptom overreporting, misattribution or outright malingering and who might provide information of questionable validity in a free response to the verbalized question, "Do you have any disturbing dreams about the (traumatic) incident and, if so, describe a typical dream" but, when filling out a questionnaire and responding to the item, "Repeated, disturbing dreams of the stressful experience?" (0-Not at all, 1-A little bit, 2-Moderately, 3-Quite a bit, and 4-Extremely)--because the are *numbers* involved--all of a sudden we're dealing with data that are somehow 'valid' and meaningfully diagnostic and free of response bias or demand characteristics pertinent to the clinical setting.

It's not that the data are error-free or bias-free. It's that they are *better than not having any data at all.*
It shocks me that people will go into all kinds of contortions to argue for the invalidity of validated measures, and then apparently propose that a better alternative is to use, like, "instinct," or "intuition" to assess whether they have made any meaningful impact.

There may be all kinds of problems with a PHQ, but nowhere near as many problems as relying on the *subjective opinion of the treating provider* to assess progress.

 

[Sanman]

Are you saying you use no metrics to assess whether you have achieved anything in the course of your work?



It's not that the data are error-free or bias-free. It's that they are *better than not having any data at all.*
It shocks me that people will go into all kinds of contortions to argue for the invalidity of validated measures, and then apparently propose that a better alternative is to use, like, "instinct," or "intuition" to assess whether they have made any meaningful impact.

There may be all kinds of problems with a PHQ, but nowhere near as many problems as relying on the *subjective opinion of the treating provider* to assess progress.

It doesn't have to be one or the other, there is such a thing as functional improvement. Gee, your PHQ-9 score is the same, but you have not yelled at a person or punched anybody this month (or done so less frequently than in the past).

 

[tr]

It doesn't have to be one or the other, there is such a thing as functional improvement. Gee, your PHQ-9 score is the same, but you have not yelled at a person or punched anybody this month (or done so less frequently than in the past).

That's fine, nothing about using a PHQ precludes you from also asking about whether the patient has punched anyone lately.

 

[AbnormalPsych]

Are you saying you use no metrics to assess whether you have achieved anything in the course of your work?

I did not say that.

 

[AbnormalPsych]

I wouldn't say this was 'extensive' training. I would say it was adequate training to allow me to practice psychotherapy in a way that is more likely to do good than harm. As I mentioned above I have a small number of modalities that I practice and I stick to what I know. I think we all agree that psychotherapy is difficult to do well and takes a lot of time and effort.

I really am not sure how to break down the hours. The first two years of training include a lot of medicine, neurology, and inpatient psychiatry, so opportunities to practice psychotherapeutic principles are fewer. During those years I did have rotations in, for example, a residential substance use treatment program, where I had training in leading group CBT, and a VA rotation in which I had a supervised PE case. I also learned MI, which was developed for time limited encounters, on the inpatient units. Long term psychotherapy cases start in the second year but usually just one or two cases at the beginning, adding more as you progress through training. Third and fourth years are usually mostly or all outpatient (excluding call). During outpatient rotations there is time dedicated for at least one psychotherapy case. For example I had a six month rotation in OCD in which I carried a couple of ERP cases. People with interest in therapy could choose to use more of their clinic time for psychotherapy cases. The CBT rotation I mentioned was obviously all therapy.

I could guess that maybe 25-35% of the total experience was related to psychotherapy training?

I don't know what is going on in residencies other than the one I trained in and where I stayed on as fellow and then faculty for the following 8 years. That program was considered less psychotherapeutically oriented at the time, nonetheless many residents expressed specific interest in learning to do psychotherapy and integrating it into their practice. I do know that competency in 3 psychotherapeutic modalities (as noted above) is required for graduation from all U.S. psychiatric residencies, and also agree with others above that the means of assessing competency is sufficiently unstandardized that it may not mean much.

This is really nice to see. Thanks for sharing your experiences.

 

[Sanman]

That's fine, nothing about using a PHQ precludes you from also asking about whether the patient has punched anyone lately.

No one said that it did or that the PHQ does not have its place. However, symptom inventories often give you a good look at the weather right now. Functional improvement is often more like the climate. A sunny day in June does not mean you improved the climate. Likewise, a rainy day in April does not mean that the climate is getting worse. Simply having clients show improvement on a PCL/PHQ is not necessarily correlated to therapeutic success, it might just be June.

 

[Therapist4Chnge]

To put this in a different perspective, if you swapped out therapy cases for medication management cases and training experiences from psychotherapy to prescribing, would your perspective change?

You wrote that you had "...adequate training to allow [you] to practice [skill]....in a way that is more likely to do good than harm." Now consider how that feels, the number of cases, training, and comparing experiences....does anything change?

I just wanted to give you a perspective of how I hear what you are saying.

I wouldn't say this was 'extensive' training. I would say it was adequate training to allow me to practice psychotherapy in a way that is more likely to do good than harm. As I mentioned above I have a small number of modalities that I practice and I stick to what I know. I think we all agree that psychotherapy is difficult to do well and takes a lot of time and effort.

I really am not sure how to break down the hours. The first two years of training include a lot of medicine, neurology, and inpatient psychiatry, so opportunities to practice psychotherapeutic principles are fewer. During those years I did have rotations in, for example, a residential substance use treatment program, where I had training in leading group CBT, and a VA rotation in which I had a supervised PE case. I also learned MI, which was developed for time limited encounters, on the inpatient units. Long term psychotherapy cases start in the second year but usually just one or two cases at the beginning, adding more as you progress through training. Third and fourth years are usually mostly or all outpatient (excluding call). During outpatient rotations there is time dedicated for at least one psychotherapy case. For example I had a six month rotation in OCD in which I carried a couple of ERP cases. People with interest in therapy could choose to use more of their clinic time for psychotherapy cases. The CBT rotation I mentioned was obviously all therapy.

I could guess that maybe 25-35% of the total experience was related to psychotherapy training?

I don't know what is going on in residencies other than the one I trained in and where I stayed on as fellow and then faculty for the following 8 years. That program was considered less psychotherapeutically oriented at the time, nonetheless many residents expressed specific interest in learning to do psychotherapy and integrating it into their practice. I do know that competency in 3 psychotherapeutic modalities (as noted above) is required for graduation from all U.S. psychiatric residencies, and also agree with others above that the means of assessing competency is sufficiently unstandardized that it may not mean much.

The nonstandardization problem, however, is not unique to MDs. I have provided on-paper supervision for clinical hours for PsyD students who were doing SCIDs and other types of work for our research studies. Frankly I never observed one minute of their SCIDs (training was provided directly by postdocs and others associated with the work) but because I was the one with the license I had to fill out the form. I would say that the value of that form as an assessment of the student's clinical skills was approximately zero.

 

[tr]

To put this in a different perspective, if you swapped out therapy cases for medication management cases and training experiences from psychotherapy to prescribing, would your perspective change?

You wrote that you had "...adequate training to allow [you] to practice [skill]....in a way that is more likely to do good than harm." Now consider how that feels, the number of cases, training, and comparing experiences....does anything change?

I just wanted to give you a perspective of how I hear what you are saying.

Uh, not really? I'm not sure what you are trying to get at.

Are you assuming that I have the same sort of turf-protecting territorial fixation I've seen displayed by some posters on this thread and elsewhere on this board? I, uh, don't have that.

Or are you making an unstated comparison to the movement for limited Rx by psychologists, while assuming, without asking, that I would be opposed to that type of treatment approach?

Or are you asking how I would feel if I had relatively more training in psychotherapy and less in psychopharmacology? That would be fine, psychopharmacology is pretty straightforward, definitely more so than psychotherapy.

Otherwise I have no idea what you're talking about. Please clarify.

 

[tr]

No one said that it did or that the PHQ does not have its place. However, symptom inventories often give you a good look at the weather right now. Functional improvement is often more like the climate. A sunny day in June does not mean you improved the climate. Likewise, a rainy day in April does not mean that the climate is getting worse. Simply having clients show improvement on a PCL/PHQ is not necessarily correlated to therapeutic success, it might just be June.

So because we have seasons, we shouldn't also use thermometers?

 

[Sanman]

So because we have seasons, we shouldn't also use thermometers?

A thermometer is a tool. How you use that tool determines if it has utility. Would you use a single temp reading to forecast climate change for the next decade? How about the temp everyday from January to June? Temp is rising, so climate change right?

 

[AbnormalPsych]

Uh, not really? I'm not sure what you are trying to get at.

Are you assuming that I have the same sort of turf-protecting territorial fixation I've seen displayed by some posters on this thread and elsewhere on this board? I, uh, don't have that.

Or are you making an unstated comparison to the movement for limited Rx by psychologists, while assuming, without asking, that I would be opposed to that type of treatment approach?

Or are you asking how I would feel if I had relatively more training in psychotherapy and less in psychopharmacology? That would be fine, psychopharmacology is pretty straightforward, definitely more so than psychotherapy.

Otherwise I have no idea what you're talking about. Please clarify.

I don't think there were assumptions made. Just questions and a thought exercise posed. To help share their perspective.

May I try and reframe from what I read:

What would your thoughts be if overnight you awoke to a world where psychologists substituted some of our therapy, assessment, and research training to get trained in psychiatric prescribing and we all now have the perceived competence and confidence to do this, do so with only some of the time consulting the medical colleagues with more training in this area (screw their tx plans and interventions - I do what I want), the blessings from our health care systems to do so, and bill for it?

 

[tr]

I don't think there were assumptions made. Just questions and a thought exercise posed. To help share their perspective.

May I try and reframe from what I read:

What would your thoughts be if overnight you awoke to a world where psychologists substituted some of our therapy, assessment, and research training to get trained in psychiatric prescribing and we all now have the perceived competence and confidence to do this, do so with only some of the time consulting the medical colleagues with more training in this area (screw their tx plans and interventions - I do what I want), the blessings from our health care systems to do so, and bill for it?

I think that would depend on what the exact prescribing rights and training were. It's incredibly difficult to kill someone with an SSRI and I don't think there needs to be a very high bar for prescribing rights for those. It's pretty easy to kill someone with lithium and I think there should be a lot of training required to prescribe it.

Along the same lines, I have enough training to provide basic CBT for depression and anxiety competently and effectively. I don't try to provide DBT because that's a complex therapy for high-risk patients that I have not been adequately trained to provide.

In general I do not feel the need to engage in professional turf wars. I think they are silly.

 

[AbnormalPsych]

I think that would depend on what the exact prescribing rights and training were.

I don't try to provide DBT because that's a complex therapy for high-risk patients that I have not been adequately trained to provide.

Agreed. As you mentioned, goes both ways.

Back to the OP, this is the crux of the matter.

 

[Sanman]

I think that would depend on what the exact prescribing rights and training were. It's incredibly difficult to kill someone with an SSRI and I don't think there needs to be a very high bar for prescribing rights for those. It's pretty easy to kill someone with lithium and I think there should be a lot of training required to prescribe it.

Along the same lines, I have enough training to provide basic CBT for depression and anxiety competently and effectively. I don't try to provide DBT because that's a complex therapy for high-risk patients that I have not been adequately trained to provide.

In general I do not feel the need to engage in professional turf wars. I think they are silly.

Fully independent prescribing rights, possibly at higher pay than a psychiatrist.

Training? 1-1.5 yrs of training. I Mean NPs are prescribing with 2 years, so close enough right?

 

[tr]

Fully independent prescribing rights, possibly at higher pay than a psychiatrist.

The pay thing is completely irrelevant and again just suggests your real complaint is a turf war. But you're talking to someone with 14 years of post college education (MD+PhD+residency+fellowship) who makes a salary in the bottom 5% of all psychiatrists, by choice. What do I care what anybody else makes? I'm happy with my life. There's no way an NP could do my job. But also, no NP would want my salary.

The independence thing is also totally irrelevant. I don't want to have to supervise some other professional. I have enough BS on my plate.

My only concern, again, would be safety issues. The most commonly used psych meds are relatively benign, with little in the way of serious side effects or drug interactions. It's fine with me if psychologists want to prescribe SSRIs. It's better care to see one mental health provider than two.

Lithium? Clozapine? Anyone stupid enough to want to prescribe those without going through med school and psych residency should not be treating patients in any capacity. Other MDs won't even prescribe them, just like I wouldn't prescribe digoxin or methotrexate.

Training? 1-1.5 yrs of training. I Mean NPs are prescribing with 2 years, so close enough right?

NP is a whole nother issue and again, the concern is safety. You can actually find old posts of mine on this site where I argue that NPs fill a need given the shortage of psychiatrists. I don't think I understood at that time how thin their training really is. I've seen some very concerning medical decisions since then that make me extremely wary of the whole NP thing.

Psychologists prescribing SSRIs would actually be safer than NP, because about the worst thing you can do with an SSRI is give it to someone with undiagnosed bipolar disorder, and a psychologist would be way better at figuring that out than an NP.

 

[Sanman]

The pay thing is completely irrelevant and again just suggests your real complaint is a turf war. But you're talking to someone with 14 years of post college education (MD+PhD+residency+fellowship) who makes a salary in the bottom 5% of all psychiatrists, by choice. What do I care what anybody else makes? I'm happy with my life. There's no way an NP could do my job. But also, no NP would want my salary.

The independence thing is also totally irrelevant. I don't want to have to supervise some other professional. I have enough BS on my plate.

My only concern, again, would be safety issues. The most commonly used psych meds are relatively benign, with little in the way of serious side effects or drug interactions. It's fine with me if psychologists want to prescribe SSRIs. It's better care to see one mental health provider than two.

Lithium? Clozapine? Anyone stupid enough to want to prescribe those without going through med school and psych residency should not be treating patients in any capacity. Other MDs won't even prescribe them, just like I wouldn't prescribe digoxin or methotrexate.



NP is a whole nother issue and again, the concern is safety. You can actually find old posts of mine on this site where I argue that NPs fill a need given the shortage of psychiatrists. I don't think I understood at that time how thin their training really is. I've seen some very concerning medical decisions since then that make me extremely wary of the whole NP thing.

Psychologists prescribing SSRIs would actually be safer than NP, because about the worst thing you can do with an SSRI is give it to someone with undiagnosed bipolar disorder, and a psychologist would be way better at figuring that out than an NP.

No turf war, just completing your thought exercise.

Psychiatrists often charge more for therapy sessions than psychologists despite less training. That is simply better marketing. They also have complete independence to practice psychotherapy without consultation despite the most lax standards of training in psychotherapy. The defense of this is that prescribing routine anti-psychotics is more dangerous than providing psychotherapy improperly. Some of us hope for higher standards in prescribing and psychotherapy.

 

[tr]

A thermometer is a tool. How you use that tool determines if it has utility. Would you use a single temp reading to forecast climate change for the next decade? How about the temp everyday from January to June? Temp is rising, so climate change right?

No, and I wouldn't use a single PHQ to project the trajectory of a mood disorder over the next ten years either. But as repeated measures, they're quite helpful for trying to figure out whether you're going in the right direction during a targeted course of therapy. What's your point again?

 

[PsychPhDone]

Hey @tr in spite of your avatar, I appreciate your participation in this thread.

Personally, I enjoy working with my psychiatry colleagues. Do some get on my nerves when they call doing nothing particularly skillful "psychotherapy" in their notes? Yeah. But I work with a bunch who have adequate training in some types of therapy, and more importantly, know when to refer for something more involved.

 

[tr]

No turf war, just completing your thought exercise.

Psychiatrists often charge more for therapy sessions than psychologists despite less training. That is simply better marketing. They also have complete independence to practice psychotherapy without consultation despite the most lax standards of training in psychotherapy. The defense of this is that prescribing routine anti-psychotics is more dangerous than providing psychotherapy improperly. Some of us hope for higher standards in prescribing and psychotherapy.

Well I have zero interest in payments. Here are the insurances we take; if you have an issue, please, talk to the billing department.

Really, why do you care if I offer psychotherapy? I'm trained to do it, I like to do it, I take insurance, and all my therapy patients are people who couldn't afford to see someone for cash, so it's not like I'm eating your lunch. What's your issue? You want me to 'consult' with you before I start a course of CBT? What would be the point of that? Haven't we both got enough to do?

 

[PsychPhDone]

Also, Tim Beck, you guys.

 

[Sanman]

Also, Tim Beck, you guys.

?

 

[Sanman]

Well I have zero interest in payments. Here are the insurances we take; if you have an issue, please, talk to the billing department.

Really, why do you care if I offer psychotherapy? I'm trained to do it, I like to do it, I take insurance, and all my therapy patients are people who couldn't afford to see someone for cash, so it's not like I'm eating your lunch. What's your issue? You want me to 'consult' with you before I start a course of CBT? What would be the point of that? Haven't we both got enough to do?

1. If you have zero interest in payments, why charge at all? Just provide full-time pro bono services.

2. Do you think that all psychologists don't accept insurance for psychotherapy?

3. You are a member of a profession that zealously attempts to guard their trade by claiming anyone with less training than them that attempts to do their job is creating public harm. However, give themselves the legal right to practice something they often have minimal training in and wonder why others are concerned about public harm?

You may be adequately trained in psychotherapy or not, I don't know. However, many on your profession are not, but all have the legal right to do it. You can't be so naive as to think that might not ruffle some feathers.

 

[Sanman]

No, and I wouldn't use a single PHQ to project the trajectory of a mood disorder over the next ten years either. But as repeated measures, they're quite helpful for trying to figure out whether you're going in the right direction during a targeted course of therapy. What's your point again?

That the PHQ doesn't necessarily provide accurate information as to treatment gains and that there are better ways to measure progress.

 

[tr]

1. If you have zero interest in payments, why charge at all? Just provide full-time pro bono services.

Like I said I'm on salary. The institution charges. I just show up to work.

2. Do you think that all psychologists don't accept insurance for psychotherapy?

I've never seen it outside academia, and even internally our attending level psychologists are always full. I always have to send insurance patients to the trainee clinic. Problem is Medicare won't pay for trainees, so that's usually where I end up just doing the therapy myself.

3. You are a member of a profession that zealously attempts to guard their trade by claiming anyone with less training than them that attempts to do their job is creating public harm. However, give themselves the legal right to practice something they often have minimal training in and wonder why others are concerned about public harm?

I don't speak for the AMA or the APA (and actually they support NP practice, which I am worried about). The OP asked if psychiatrists ever do therapy. We do. Then there was some speculation that we do this based only on didactic education. We don't.

You may be adequately trained in psychotherapy or not, I don't know. However, many on your profession are not, but all have the legal right to do it. You can't be so naive as to think that might not ruffle some feathers.

Feel free to be ruffled, then. Enjoy. If you ever decide you want to free your mind from this interesting mix of anxiety, insecurity, and righteous indignation, I would be happy to offer you a time-limited course of very basic and no-frills psychotherapy.

 

[tr]

That the PHQ doesn't necessarily provide accurate information as to treatment gains and that there are better ways to measure progress.

Sure. What's your preferred metric? I'm not wedded to the PHQ (it's actually not my most commonly used metric), but I am wedded to the necessity of having quantifiable data to guide practice.

 

[Sanman]

Like I said I'm on salary. The institution charges. I just show up to work.



I've never seen it outside academia, and even internally our attending level psychologists are always full. I always have to send insurance patients to the trainee clinic. Problem is Medicare won't pay for trainees, so that's usually where I end up just doing the therapy myself.



I don't speak for the AMA or the APA (and actually they support NP practice, which I am worried about). The OP asked if psychiatrists ever do therapy. We do. Then there was some speculation that we do this based only on didactic education. We don't.



Feel free to be ruffled, then. Enjoy. If you ever decide you want to free your mind from this interesting mix of anxiety, insecurity, and righteous indignation, I would be happy to offer you a time-limited course of very basic and no-frills psychotherapy.

Who is insecure or anxious? I just think you are a bunch of hypocrites.

Your responses wreak of naivete of business and a lack of insight into the fact that the AMA and ApA have insulated you from having to be informed and assured you comfortable existence. You need to step out of academia into the real world.

 

[ERK123]

Also, Tim Beck, you guys.

AKA An unqualified psychiatrist?

Also, how much training to psychologist Phd programs have in psychotherapy? My father got his PhD in psychology several decades ago, and his psychotherapy training was quite minimal until he pursued further training after finishing.

 

[foreverbull]

3. You are a member of a profession that zealously attempts to guard their trade by claiming anyone with less training than them that attempts to do their job is creating public harm. However, give themselves the legal right to practice something they often have minimal training in and wonder why others are concerned about public harm?

You may be adequately trained in psychotherapy or not, I don't know. However, many on your profession are not, but all have the legal right to do it.

I think this is where I’m confused about psychiatry. Who oversees practice and malpractice of psychotherapy by psychiatrists in a field in which the majority do not provide psychotherapy at all?

As I’d asked before, I’d also like to know what proportion of training in therapy-heavyresidencies (As @tr mentioned theirs was) is psychotherapy training and practice vs. med management and unrelated training.

...And how common this is. How many residencies provide the bare minimum vs. thorough training? This might be a question for the psychiatry forum.