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You know, basically the founder of CBT. Not saying he's the rule, just...appreciating?
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Do psychiatrists provide psychotherapy?
Started by Sylvia06
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TBH I can't speak to his medicine skills, only know him as educator/researcher.
Spent the first 3 months watching the Gloria tapes on repeat. Then pretty much just sat around eating cheez-its and asking people about their moms for the next 8 years of training.
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Sanman
O.G.
You mean Aaron Beck, not Tim Beck.
Interestingly, he completed residencies in pathology and neurology with only a single rotation in psychiatry at a VA hospital and then completed a 2 yr fellowship at Austen Riggs focused on psychoanalysis and ego psychology. While he was a psychiatry professor, a bit of a straw man.
He goes by Tim when you meet him in person. Interesting background. Every field needs it's outliers! Thanks for the info.
Psychotherapy is standard and required in psychiatric residency per ACGME rules. More rigorous and standardized than many other degrees
Sanman
O.G.
Great, can you point me to the standards and minimum requirements? That seems to be the crux of the question here. I quickly browsed the AGME requirements for psychiatry residents and it seems to mention psychotherapy exactly once, stating that it is part of an outpatient psychiatry rotation requirement. I didn't see anything about the quality, minimum number of required cases, theoretical orientations represented, etc.
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Sanman
O.G.
You can have quantifiable data that is better and it goes to the heart of proper individual treatment planning. Say you saw a patient with mild depression that is primarily complaining of sleep disturbance. They report disturbance nearly everyday on the PHQ-9 prior to treatment. Following a time limited course of CBT they continue to report disturbance everyday.
Same patient - following PHQ-9 you interview and find out they are getting 2-3 hours of sleep per night. You have them keep a sleep log as part of your time limited treatment. They are getting 4-6 hr sleep every night at the end of treatment despite some ongoing disturbance nightly and report more easily falling back to sleep after a disturbance.
Which is better data? Is the report of being able to fall asleep more easily more informative that a post-treatment phq-9 response that they continue to suffer regular sleep disturbance?
Five to 8 years of coursework, training, practice specifically in psychotherapy by the time of licensure, with research, stats, and assessment as part of courses, but our research generally relates closely to our field as well. Every year we are closely supervised in practicum, sometimes accompanied as a class early on in training to receive more intensive supervision, sometimes just supervised Individually later on. Also trained in supervising others in psychotherapy via coursework and supervising trainees in advanced years and having supervision of supervision to ensure that our supervision was appropriate. Most will be licensed with Anywhere from 3500-5000 hours of practice and practice-related activities, not including research time spent or any of the psychotherapy coursework in the 4-6 years of grad school. Our comprehensive exams were year 4, in which we were given a case vignette on the spot, required to apply Two theories of choice to the case and explain how we would conceptualize and treat the individual via each theory (also included a research study we had to critique on the spot).
Internship (the final year before graduation) is closely monitored and has the highest level of supervision of all years, typically, except for maybe postdoc For some. My internship had 2 individual hours of supervision per week that included playing audio tapes, 2 group hours of supervision Per week, supervision of supervision 2x/month, diversity Group 2x/month (somewhat didactic but we also played our therapy tapes there), supervision with our clinical director 1x/month, etc. It wasn’t uncommon for me to play 2-3 tapes of my sessions per week. This was on top of didactic trainings and psychotherapy I provided every day/week (And other minor activities that were required, including a test battery and two case conceptualization papers and presentations, etc.). That was the most intensive supervision I’ve ever had in my life, but I still had another year of supervised practice (via postdoc) before I was eligible to be licensed.
There is some variability, but it won’t vary greatly given APA’s standards.
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You'll have to ask psychiatry program directors. I don't have access as I'm not in residency anymore
There are many ACGME core competencies in residencies to graduate. Very standardized and rigorous education to become a physician
Psychiatry residency is four years. Rxp is learning psychopharmacology part time over much shorter timespan. We don't spend four years just on meds
The psyds I know especially the ones who graduated from diploma mills, of which there are many, tell me that their undergrad education was more difficult than their psyD education. They were surprised and unhappy about it
There's no diploma mill US physician residency
There is no way to get a sense of quality/depth of training if you remain vague about your activities. I was pretty clear in my post; I would ask the same courtesy of you.
Sanman
O.G.
Well, if there are any lurking on these forums with answers, send them on over.
My residency was a long time ago. I want you to have precise and current information.
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I have no control over other users.
Sanman
O.G.
So does a psychiatric residency require more hours of psychotherapy than an Rxp program requires hours of psychopharmacology training? No one said psychiatrists are not trained in diagnosis, case management, medication management, ECT, etc. The question is specific to psychotherapy training.
Did this thread devolve from a metaphorical "My dad is better than your dad" to a LITERAL ONE?!
Sanman
O.G.
So do we.
Sanman
O.G.
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I don't know the answers to that. You'll have to find someone with more expertise than I have.
Convenient that you make a claim about programs when you haven’t been one in awhile and refuse to provide details. But we should just believe you without info because....?
You'll have to find a better source than me. I just know the acgme has requirements that need to be fulfilled. You can contact them
Sanman
O.G.
I had a physician tell me that psychiatrists are generally bottom of the class grads or hacks from Caribbean med schools who couldn't get into other specialties. Must be true, right?
The bottom person to graduate from med school still has alot more qualifications than most people
And it used to be less competitive, like when I applied.
Sanman
O.G.
So does a bottom of the barrel PsyD compared to the average person, your point?
Sanman
O.G.
And this just got amusing, guess I have a way to kill time for a bit now that my patient cancelled!
So someone comes in, says psychiatrists are trained well in psychotherapy, responds to my in depth description of my PhD training by blasting PsyDs, and can’t provide the same courtesy of providing training details from their program, deflecting and saying to check the standards. Sounds like someone wanting to troll the thread!
To be fair, if I had a chance and the resources I'd probably prefer a psychiatrist who trained at a top program and has a private practice to be my therapist over an MFT or even a PhD/PsyD, especially if the training tends to be more subspecialized (i.e. child, addiction, etc).
That's not to say that the AVERAGE MD is better than the AVERAGE MFT/PsyD in therapy skills. I hope you understand the difference here.
This is also what the market seems to indicate. People ARE willing to pay an MD $500 an hour to do their combined treatment but they are much less willing to do the same for a MFT/PsyD etc. This figure is somewhat a function as well of insurance reimbursement: i.e. an AVERAGE MD *can* get $300+ gross billing from managing medications from insurance alone, and there's an excess of patients who need medication management, so if you want to lure them away from doing therapy privately, you'd have to pay the right price--but if they aren't worth it and alternatives are available, why would you? The fact that people are willing to pay, and that this dynamic seems to persist despite the fact that other prescribers/therapists have grown quite a bit since the 90s, suggests that there's not really an alternative. The kind of service a high-end MD provides in private practice is very unique. It's not easily replaceable by an NP/RxP+MFT.
There are a lot of MFTs that are not getting paid very well. But high-end MD therapists, if anything, are paid even better now than before, when MDs did more therapy. This is similar to the dynamic that while a bag at Walmart is getting cheaper and cheaper, this seems to not affect the price of a Gucci bag much...
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Sanman
O.G.
1. You are entitled to you personal preferences as a patient.
2. We are discussing averages here and the right to practice independently, this is not which INDIVIDUAL might be the most qualified in what area based on this blah, blah training. My point simply was that psychiatry (the profession) has argued for a gold standard in one area of practice (medication management) while giving its members the ability to practice in another area (psychotherapy) where they might not be the gold standard.
3. $500/hr private pay is more about individual markets and a lack of available prescribers vs psychotherapists than it is who is "better". Said another way, they are willing to pay a lot more for meds than psychotherapy. Part of that is also better historical marketing on the part of the AMA, pharma companies, etc.
I don't disagree. OTOH, I don't know what's the gold standard for psychotherapy. There's a downward spiral where it used to be that doctoral-level training is required (implicitly by the culture of the mental health industry) before you can practice psychotherapy. It now appears that many people can do it and there's little regulation. The cat is out of the bag. Where I work highly qualified PhDs are competing with LCPCs and MFTs and the system is absolutely not willing to pay more for their services. This facet has little to do with what MDs and AMA have done. MDs are more materially competing with NPs, tho.
Everyone wants to protect its turf. MDs tried very hard to protect its turf in the 70s and 80s on the therapy side (esp. the psychoanalysis oriented therapies) and that battle is thought to be lost. The most lucrative things in mental health aren't therapy at this point so MDs are not focused on advocating on this aspect anyway. A more fundamental problem facing therapy providers, IMO, is that there's little in terms of innovation on the therapy side and little in terms of quality control. There are a handful of new meds coming out every year, and somatic treatments are getting more prevalent. While effectiveness is obviously debatable, this lends credence to the people who matter (i.e. payors and patients) that MDs will be needed to manage an increasingly complex body of medications. PhDs of course rightfully argue that many meds don't work well without [quality] therapy, but this gets drowned out when their clinical practices are being overwhelmed from competition for their respective cheaper replacements.
PhDs and PsyDs also specialize in areas, so I think it’s unfortunate to prefer a psychiatrist for psychotherapy over a psychologist, but certainly that is your right to hold a differing opinion.
That said, I think the point made early in this thread by a few psychiatrists was similar to yours about how there are some programs out there with more extensive training, but that isn’t the average experience, but more atypical of psychiatry residencies overall. This does not seem to be an extreme opinion, although a couple of psychiatrist folks in this thread have argued vehemently that this is not the case—that the standards ensure quality training. Yet there is still very wide variability somehow and not much info about how those standards are applied in the typical program or what it actually looks like in the average residency.
And as for the point about financial feasibility, yes it makes sense that given the cost of psychiatry services, the emphasis has shifted in psychiatry over the past several decades. Back in the day, psychiatry was heavily involved with psychotherapy—it just doesn’t seem to be the case as much today.
D
deleted343839
I agree with this. In general, consumers hold the MD degree in higher regard, and they like the option of medication.
That said, most people paying upwards of $500/hr aren't going to their psychiatrist more than once a month, and often they're going less frequently than that. I mean, we've all heard stories of physician psychoanalysts in high-income areas who are making bank, but this is atypical. At least in the short term, the bottom line works out not all that differently than for those paying $125/hr for weekly psychotherapy. I don't know how many sessions the typical patient attends in $500/hr psychiatric treatment versus $125/hr therapy from a non-physician. I'd be interested to know.
Interesting. I've yet to meet a graduate of a marginal PsyD program who was willing to admit that they were anything but well trained, so kudos to your PsyD colleagues who are willing to acknowledge the deficits in their training.
And yes, you're right. I was having drinks with an APA staffer who openly rolled their eyes at me when I expressed concern about inconsistent training standards in our field. That said... a lot.
Not sure I agree with this. Telehealth and mHealth are booming and there is a lot of innovation in that sector. There is also research on various sorts of time-compressed therapies, therapies delivered in atypical settings, etc., though these are obviously slower to translate into real-world practice.
I'm not holding a differing opinion. It's not *just* my opinion. It's a prevalent opinion and market reality. In most markets, MDs who do both meds and therapy can typically charge more on a per session basis than someone who does only meds. OTOH, the system may end up saving money because the total outlay of cost may be actually lower than when you have MD managing meds and a PhD managing therapy. Secondarily, patients may prefer the former over the latter due to convenience, etc.
That said, the competing reality is that MDs typically get paid more by only doing med management. This then implies that on an individual basis, there's a push-pull between MDs who might want to do therapy to take a cut to do some therapy, and competing forces of PhDs who also want to do therapy. This leads to some MDs having larger therapy practices than others (presumably because they are better at it), and those who do are often getting paid even more for the therapy.
Sanman
O.G.
There is a downward spiral for both prescribing and psychotherapy which has to do with the ongoing battle of healthcare/provider costs vs quality. Rxp psychologists, NPs, PAs all prescribe. Physicians have done a much better job of protecting their turf than psychology. I would argue that a solid scientist-practitioner program (PhD or PsyD) is probably the gold standard base for psychotherapy training today. Now we have done a terrible job of marketing this as a field. Following WWII where psychologists started to use psychotherapy and the explosion of psychopharmacology in the 1950s and 1960s, psychiatry began a slow march away from psychotherapy and psychology picked up the ball (and then poorly defended it).
Lack of innovation in psychotherapy is not as large of a problem as whackadoodle stuff has been, Supportive hand-holding is compensated the same a evidence-based psychotherapy by an expert. A consumer has a hard time knowing what therapy is good and effective, but everyone knows what Paxil is.
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Your first point is neither here nor there. Plenty of people pay $500 a session weekly therapy, but portion of their cost is defrayed by out of network reimbursement, especially as there is a max out of pocket. This is less common obviously in most markets, but I think you aren't fully clear on the economics of this. Secondly, many MDs need to see patients more frequently than once a month at least for a time, but not for "therapy" in the usual sense. The therapy addons are usually needed to do case management. For example, severe depression, bipolar, suicide, psychosis, severe substance relapse, etc. PhDs frankly don't deal with these things well (if at all), and are not exposed to them in training. PhDs are also not qualified and generally do not make recommendations about ER or inpatient placements. Most state laws require physician signatures for involuntary civil commitment. So any outpatient services that might touch on the more severe spectrum of things can easily spill over. I am also not seeing NPs/RxPs fighting over managing the sickest patients, and systems generally do not retain NPs/RxPs to manage those, even in outpatient settings, IMO with sound logic--though this is changing so I would allow that many things in this facet can change.
The second point I'm fully aware, but on the economics side these innovations are actually WORSE for your practicing PhDs. The value of your service on the low end will diminish even more once things are either automated or outsourced.
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Right. Agree 100%.
However, you recognized the problem without having any way to solve it. For trainees, this is a facet of reality that one needs to deal with. For clinicians on an individual basis, it's very obvious that the problem is much more proximal on the marketing side than the advocacy side.
Sanman
O.G.
Yes and no, I have dealt with a lot of the highlighted in my career and managed many serious conditions as a geriatric psychologists in LTC, SNF, ALF. There are a segment of psychologists who work in SUDs, inpatient, etc and have great training. The training in many cases is ahead of the legislation to allow us to do certain jobs (again MDs protect turf better) outside some areas like VA hospitals. I have been trained in non-medication behavioral management of dementia and BPSDs and can do this better than average psych prescriber. I lack access to the E/M code to bill for appropriate management, thus making it a poorly compensated part of my practice.
@sluox
I think it’s telling that you acknowledge that there are wide variations in psychotherapy training in psychiatry but still prefer psychiatrists for psychotherapy knowing that psychology training standards are more clear cut and training across the board very extensive in an average PhD program.
To suggest that psychologists aren’t as proficient in working with suicidality and severe depression, etc. is a very bold claim. Can you point me to a study that supports this?
I think it’s telling that you acknowledge that there are wide variations in psychotherapy training in psychiatry but still prefer psychiatrists for psychotherapy knowing that psychology training standards are more clear cut and training across the board very extensive in an average PhD program.
To suggest that psychologists aren’t as proficient in working with suicidality and severe depression, etc. is a very bold claim. Can you point me to a study that supports this?
No: re-read what I wrote: I prefer a psychiatrist who trained at a top program and who has a private practice with experience in therapy over an average PhD for therapy, especially if it's a specialized setting.
On the second point: I don't need a study to show that psychiatrists can't practice surgery--this is a regulatory question, not a scientific one. PhDs have never been and will never be the physician of record for severe patients. Many NPs and PAs do practice medicine but they'll never be physicians. If you want to say that PhDs are competent THERAPISTs for severe patients, that point I agree with, as many NP/PAs can become competent practicing [some aspect of] medicine. But because of the critical nature of these cases, there'll be the invariable final person, and in our society that final person in a physician. People just can't be discharged from the psych ER or inpatient psych unit without seeing a physician. That's just the bottom line. It doesn't matter how well trained an average psychologist is. There's also virtually no overlap in the training between being a psychiatrist in the ER and that of a psychologist--and the regulatory pathway reflects this: in a pinch, ER docs (not a psychologist) can discharge an acute psych patient.
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Just curious what kind of setting you work in because our side/mdd/psychosis groups here are multidisciplinary and include phds who generally focused on their respective areas in grad school. I know this might not be the case everywhere.
MDs almost never staff groups--but PhDs never make final decisions regarding hospitalization or discharge--they are legally (constitutionally, in fact) prohibited from doing so. Civil commitment is a narrow privilege that's specifically bestowed upon physicians in our society. Associated with that in a set of training and knowledge that's only allocated to physicians--even in case of NPs staffing inpatient units, as of current, the final discharge orders would be counter-signed by an MD licensed in a particular state.
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PhDs can also receive specialized training experiences as well. Are you saying you’d prefer a specialized-training psychiatrist from a “top” program over a specialist-training psychologist from a “top” program? Choosing a specialist over a generalist is a bit of an apples to oranges comparison here.
As to the second part, this is a different point than what you initially suggested, which was that PhDs don’t receive training and/or don’t work “well (if at all)” with severe mental illnesses/symptoms. Dealing with psychosis in particular may be less likely for PhD trainees to work extensively with unless they have an inpatient practicum—that said, I have colleagues who work in skilled care facilities and encounter clients with delusions and hallucinations on a daily basis, so it is not the average experience of a trainee, but also not extremely rare to work with folks with these concerns and do so skillfully. Severe depression, bipolar disorder, and suicidality are par for the course for the majority by licensure.
If you’re saying that hospitals require an MD to sign off on paperwork and/or see a patient even if a psychologist is working with the patient, that’s quite a different point that speaks more to the bureaucracy & biases of the medical system. And since psychologists don’t prescribe meds, it makes sense that a doctor would be involved to manage that aspect. That is very different than arguing that PhDs aren’t good at working with all high acuity cases.
This was the point of my thought experiment posted above.
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Only if you want to pay $64 for the book. 152 pages
APA - Core Competencies for Psychiatric Education
Sanman
O.G.
Only if you want to pay $64 for the book. 152 pages
APA - Core Competencies for Psychiatric Education
www.appi.org
Do I get a discount if I only want chapter 6?
What is the goal of the treatment in this exercise? Are you doing CBT for insomnia (in which case ISI would be a good choice) or CBT for depression (in which case PHQ9 is a useful metric)? The metric should be tailored to the goal of the therapy.
I don't disagree with most of the things you are saying. However, the point remains: when there's no clear scope of practice, patients pick and choose based on credentialism.
OTOH, decisions re: hospitalization and more severe cases, is not just bureaucratic--it's primarily clinical--a decision that PhDs lack the training and scope of practice to make, as you well admitted--these decisions typically involve calculations that require medication involvement. The therapy bills from gathering the info necessary to make these decisions are therefore of a different nature. That was my original point. It has little to do with whether PhDs would be good at doing CBT with a psychotic patient.
Sanman
O.G.
This was the point being made. There is not always a standardized metric for every goal and just throwing a standardized measure at a patient is not enough without appropriately tailoring the goal. When, based on goals, a PHQ-9 might be an appropriate metric use it. If it is not, don't. Sometimes you need to create your own metrics.
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