Do Psychiatrists Still Learn How to Do Psychotherapy?

[PsychevalIII]

Do Psychiatrists Still Learn How to Do Psychotherapy?


In fact, psychiatrists may have better training than other mental health professionals.

Some may be concerned that the psychosocial component of psychiatric treatment is taking a back seat to pharmacotherapy. To examine the extent of training in psychotherapy in U.S. postgraduate mental health education, researchers surveyed training directors from 300 representative accredited psychiatry residency, PhD psychology, PsyD psychology, or social work (MSW) programs. Response rates were 70% to 77% - sufficient for analysis.

The investigators asked about seven evidence-based therapies (EBTs; i.e., manual-based therapies supported by at least two randomized controlled
trials): behavior therapy, cognitive-behavioral therapy, dialectical behavior therapy, family therapy, interpersonal therapy (IPT), multisystemic therapy, and parent training. The survey also covered 16 non-EBTs. The "gold standard" of training was didactic coursework plus clinical supervision.

Overall, the gold standard was met for an average of 18% of EBTs and 23% of non-EBTs. Psychiatry programs met the gold standard for significantly more therapies (mean, 2 EBTs [28%]; 7 non-EBTs [46%]). Ninety-nine percent of psychiatry programs required didactic coursework in CBT, 60% in IPT, 99% in psychodynamic psychotherapy, and 90% in group therapy. Similarly, 93% required clinical supervision in CBT, 29% in IPT, 96% in psychodynamic psychotherapy, and 81% in group therapy. The two disciplines with the largest number of students and greatest focus on psychotherapy practice (PsyD and MSW) had a far greater proportion of programs with no EBT training (67% and 62%, respectively) than did psychiatry (4%).

Comment: The high rate of gold-standard training for CBT in psychiatry programs reflects its recent addition to accreditation standards. Similar gold-standard training in psychodynamic psychotherapy might reflect stronger standards and, perhaps, evidence supporting this method. Accreditation standards for graduate psychology programs permit them to ignore EBTs that are inconsistent with their "philosophy of training," and specific curricula for psychotherapy or even counseling are not required of social work programs. Despite economic pressures to focus clinical practice on pharmacotherapy, psychiatrists still are more likely than other mental health professionals to receive gold-standard education in both EBT and non-EBT psychotherapies.

- Steven Dubovsky, MD

Published in Journal Watch Psychiatry October 2, 2006

Citation(s):

Weissman MM et al. National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry 2006 Aug; 63:925-34.

---

Members don't see this ad.

 

[Logic Prevails]

Psychiatry programs met the gold standard for significantly more therapies (mean, 2 EBTs [28%]; 7 non-EBTs [46%]). The two disciplines with the largest number of students and greatest focus on psychotherapy practice (PsyD and MSW) had a far greater proportion of programs with no EBT training (67% and 62%, respectively) than did psychiatry (4%).

Comment: Despite economic pressures to focus clinical practice on pharmacotherapy, psychiatrists still are more likely than other mental health professionals to receive gold-standard education in both EBT and non-EBT psychotherapies.

So what am I getting? - a 'brown' standard education in non EBT psychotherapies?

Something here doesn't add up, but I don't have the time right now to figure it out (maybe it's because a psychiatrist did the statistical analyses for the study - JK)

P.S. I find it really hard to believe that 99% of these psychiatry programs require coursework in psychodynamic psychotherapy.

 

[PsyDGrrrl]

Sure, they might neglect psychodynamic theory on a practical level (though likely not a historical one), but it isn't empirically supported and why bother?

For one, that's not true, and for two, what do you mean "why bother"?

 

[PsyDGrrrl]

What's not true?

By, why bother, I query the point of learning to practically implement traditional psychodynamic theory given the general lack of empirical support, nearly metaphysical constructs (no place in science), and length of time it supposedly requires to be effective.

It's not true that psychodynamic therapy is not empirically supported. Ever hear of TLDP (Time Limited Dynamic Psychotherapy)?

And do explain how "nearly metaphysical contructs," which somehow means "no place in science" to you, invalidates a treatment that has worked for a good 100 years?

 

[PsyDGrrrl]

And might I add, something else that has been empirically supported is that the orientation of the therapist and model of treatement (i.e. CBT vs. dynamic) actually isn't the important variable. The relationship between the therapist and client has been shown to be the most effective at helping the client, regardless of the type of therapy.

 

[JatPenn]

It's not true that psychodynamic therapy is not empirically supported. Ever hear of TLDP (Time Limited Dynamic Psychotherapy)?

And do explain how "nearly metaphysical contructs," which somehow means "no place in science" to you, invalidates a treatment that has worked for a good 100 years?

PsyDGrrrl - can you offer a paper that shows us that psychodynamic treatment has "worked" for 100 years?

 

[Logic Prevails]

. . . and I might add, the constructs underlying psychodynamic therapy are generally not empiricially supported.

The reason for psychodynamic therapy not being "empirically supported" is most likely due to it being extremely difficult to manualize. New short term approaches (TLDP & STPP) are changing this and showing psychodynamic approaches to be quite effective.

I want to know what you mean by 'constructs underlying' psychodynamic therapy, because as far as I am concerned, newer psychodynamic approaches (no we are not talking about freud and his psychosexual stages) overlap quite well with attachment theory and theories relating to neurobiological mechanisms (i.e. the defense mechanism of 'intellectuaization' is thought to represent a lack of neural integration between prefrontal and limbic systems).

Jon, it seems to me that you are thinking of traditional long term psychodynamic/psychoanalytic approaches (which did have some pretty wacky metaphysical concepts) which, for the most part (and thankfully so), are not being utilized as much by therapists.

 

[Logic Prevails]

PsyDGrrrl - can you offer a paper that shows us that psychodynamic treatment has "worked" for 100 years?

Just because CBT has been proven effective for certain types of patients, doesn't mean that you can use it in all situations. It certainly does not mean that we have to discredit other theories or approaches, we just need to compare them to CBT (which by the way is much easier to study because it is a manualized approach).

 

[PsyDGrrrl]

Right, which is why I argued in earlier threads that psychotherapy is not a doctoral level skill.

. . . and I might add, the constructs underlying psychodynamic therapy are generally not empiricially supported.

There is voluminous data supporting the constructs underlying CBT.

And so because psychotherapy is not a "doctoral level skill" it's not worthy of doing? And somehow "empirically supported treatments" are only worthy of doctoral level work, and only employable by doctoral level practitioners?

Furthermore, as Logic Prevails pointed out, there is voluminous data supporting the constructs underlying psychodynamic therapy. The difference is, the theory was developed before we had the data to support it. In this technological age, we can now use brain scans to support attachment theory and other previously "metaphysical" constructs of defense mechanisms.

 

[PsyDGrrrl]

I don't have one, single paper that demonstrates this, but the past 50 years of, say the Journal of Psychoanalytic Psychotherapy, Psychoanalytic Quarterly, or Psychoanalytic Psychology, might be a good place for you to start.

 

[ElektraComplex]

You guys seem to be arguing about two different things. One of Jon's original points (and he's right) is that there is no empirical support for Freudian Psychodynamic theory. It doesn't matter how long some therapists have been using it and how much success they've supposedly had. This doesn't translate into empirical evidence. In fact, you can't find support for Freud's grand theories because it is fundamentally impossible to prove or disprove something that is not falsifiable. Freud's theories, if molded the appropriate way, can account for any therapeutic outcome that may happen. So how is one supposed to test said theories?

More modern psychodynamic offshoots are working towards incorporating empricicism. Some support has been found for the success rates of these, and that's a good thing for aspiring practitioners/researchers, though I would say that the case is still far from being closed. As has been pointed out, the type of therapy seems to matter far less than the therapist/client relationship.

Anyway, maybe we now can get back to talking about the original point of the thread regarding the ways in which psychiatric and psychological training differ.

 

[doctorpsych]

so getting back to the point... from my experience and speaking a number of psychiatrists, and many times, informally, their psychological treatment training is mainly adhoc... in fact, one informed me that the psychiatric residencies do "advertise" that they train their md's to do therapy but their training is very minimal, by means of gues speakers, no actual structured learning. The programs are required to advertise that they provide such training but in reality often times they are dismissive of them...I suspect because of economic reasons. I know for a fact that in one program which was supposed to provide CBT training, their class consisted of a psychologist "correcting" the resident's CBT conceptualization of a pt... and that was it... however, there are some very knowledgable psychiatrist, which they tend to be more traditional and older in age who are classically trained in psychoanalysis. But these guys are only among the few. Comments from any psychiatrists out there?

 

[Logic Prevails]

One of Jon's original points (and he's right) is that there is no empirical support for Freudian Psychodynamic theory. It doesn't matter how long some therapists have been using it and how much success they've supposedly had.

You must be an undergrad student - so I'll forgive your ignorance.

Psychodynamic theories have come a long way since freud and have little to do with some of his theories. Jon's comments were pretaining to psychodynamic therapy NOT Freudian psychoanalysis (unless he got the two confused), so please don't go twisting what was said so you can get your haughty 2 cents in to make yourself feel good.

P.S. I didn't mean to hijack the thread, I just wanted to get a few things straightened out.

 

[PsiKo]

You must be an undergrad student - so I'll forgive your ignorance.

Thankfully someone around here knows how to model empathy, you know, for those know-nothing undergrads. Good going!

Not!

 

[Logic Prevails]

Thankfully someone around here knows how to model empathy, you know, for those know-nothing undergrads. Good going!

Haha... I didn't mean to generalize - I just meant that if this person were a grad student, they should have the coursework to know the difference between freudian psychoanalysis and current psychodynamic theories.

I didn't mean to sound harsh, it just gets in my grill when ignorance is paired with arrogance (i.e. this persons comments had a condescending tone)

 

[ElektraComplex]

I am NOT an undergrad and I never once said psychodynamic theory hasn't come a long way since Freud. I believe I merely mentioned the differences between Freudian theory and modern theory when it comes to empricism, which, the way I was reading the discussion, needed some clearing up.

Also, if you refrain from resorting to cheap shots it tends to strengthen your argument.

 

[Logic Prevails]

Firstly, I appologize for the 'cheap shot.' That said, I feel your comments were condescending and irrelevant to the discussion.

One of Jon's original points (and he's right) is that there is no empirical support for Freudian Psychodynamic theory.

If you re-read the thread, you will notice that Jon was not talking about a lack of empirical support for "Freudian Psychodynamic theory" - he was referring to psychodynamic theory. Before you went on your rant about Freud, I was trying to feel him out to see what he meant by his comments. If you wanted to clarify to others reading this post, you might have done so in a less dismissive way.

 

[ElektraComplex]

Fine. If the point I made was not what Jon was trying to get at then I apologize. I wasn't trying to hijack the thread either, and was only trying to clarify what seemed like people arguing about a misunderstanding.

 

[Logic Prevails]

The programs are required to advertise that they provide such training but in reality often times they are dismissive of them...I suspect because of economic reasons. I know for a fact that in one program which was supposed to provide CBT training, their class consisted of a psychologist "correcting" the resident's CBT conceptualization of a pt... and that was it... however, there are some very knowledgable psychiatrist, which they tend to be more traditional and older in age who are classically trained in psychoanalysis. But these guys are only among the few. Comments from any psychiatrists out there?

I guess the above study flies in the face of our common perceptions. Personally, I find it hard to believe that psychiatric training has more EBT training than taught in clinical psychology programs. Then again, maybe this is all butter and no bread. Psychology programs are also notorious for advertizing one thing and only providing minimal depth. I don't think this kind of study tells us much, however I think it is worth considering that pscyhiatrists likely get paid more for prescribing versus doing therapy (they can see more clients in an hour and therefore bill more), so I would venture a guess that this would favor thier views of treatment (conciously or not) towards prescribing drugs.

 

[zenman]

The relationship between the therapist and client has been shown to be the most effective at helping the client, regardless of the type of therapy.

...and the shaman rules

 

[Pterion]

I think it is worth considering that pscyhiatrists likely get paid more for prescribing versus doing therapy (they can see more clients in an hour and therefore bill more), so I would venture a guess that this would favor thier views of treatment (conciously or not) towards prescribing drugs.

I believe this to be the case in most markets. The psychiatrists who make their living doing primarily psychotherapy in this area tend to do fee-for-service, as they can command a better return than third-party reimbursement for that service. Some providers - and again this may vary somewhat in different areas of the country - are reimbursed the same dollar amount for a "med check" of 15 minutes that they are for an hour of psychotherapy. Prescribing psychologists will face these same market forces.
There are some psychiatry programs that have very good training in psychotherapy. In fact, I have visited a [psychiatry program who's psychotherapy curriculum was more in-depth than the PhD program attached to the same university. (Do NOT twist that last statement as a slam on PhD programs. It's a report of a single situation).
As psychotherapy becomes more cookbook, and psychologists continue to find ways to publish research that shows results can be had with less and less formal training you can look for Medicare and private payors to begin progressively decreasing their reimbursement for this service. Oh - wait, that's already happening. Nevermind.

 

[doctorpsych]

LP,
I couldn't agree with you more... prescription is much more economically advantagious and sure, money talks...and like psychiatry, some of the rxp psychologist will surely abandon their psychological roots as also dictated by the market but also like psychiatry, the ones who are more 'traditional' will attempt to hold onto their fundamental training... but I have to disagree that psychology programs are notorious for 'false advertizing', at least presently...I know there are some programs out there that do indeed mislead applicants, again because students are their source of income, but as a whole, psychology programs do provide much more in-depth training in psychotherapy than most other mental health programs... I'm sure that there are psychiatric residencies that provide very thorough training (maybe you can let me know which) but in general, from my understanding as a clinical psychologist, and perhaps the majority of psychologist that I have been in contact with, agree that most psychiatric residences do not provide adequate training in psychotherapy, as being mislead by that article. That was the whole point of the article, it is misleading to the public and other scientific communities who are not familiar with our field.

I guess the above study flies in the face of our common perceptions. Personally, I find it hard to believe that psychiatric training has more EBT training than taught in clinical psychology programs. Then again, maybe this is all butter and no bread. Psychology programs are also notorious for advertizing one thing and only providing minimal depth. I don't think this kind of study tells us much, however I think it is worth considering that pscyhiatrists likely get paid more for prescribing versus doing therapy (they can see more clients in an hour and therefore bill more), so I would venture a guess that this would favor thier views of treatment (conciously or not) towards prescribing drugs.

 

[phd2006]

Something here doesn't add up, but I don't have the time right now to figure it out

I agree. And, I don't know if there is where you were going with this LP, but to me this is a good example of: I can make the numbers mean what I want them to mean.

First off, they give us a variable response rate (70 to 77%) -- would be more informative to give the actual number of each psychiatry residency, phd, psyd and msw programs that responded so we have an accurate idea of program representation. Additionally, no indication of the theoretical orientations of any of the schools -- which of course, is going to skew the results.

Two of the points I found funniest in this article:

"Psychiatry programs met the gold standard for significantly more therapies (mean, 2 EBT [28%]; 7 non-EBTs [46%])." So, Psychiatry had a mean of 2/7 for EBT -- which the author claims is significantly higher than the other programs, which means the other programs had a mean of 0 or 1/7 (rounded for ease of calculation) -- I'd hardly call that significant. A good example just because something is statistically significant does not mean it is practically or meaningfully significant. Psychiatry had a mean of 7/16 for non-EBT, which again the author claims is significantly greater than the other programs -- without giving us the mean of the other programs, this is a meaningless piece of information.

"The two disciplines with the largest number of students and greatest focus on psychotherapy practice (PsyD and MSW) had a far greater proportion of programs with no EBT training (67% and 62% respectively) than did all psychiatry (4%)." "Specific curricula for psychotherapy or even counseling are not required for social work programs." This contradiction just makes me laugh -- the author admits to including in the analyses MSW programs that are not concerned with psychotherapy!

 

[docjohng]

Results of a study like this are interesting to spur discussion (as it's doing here), but honestly, what does this mean?

More than 90% of the psychiatry training programs were complying with the new cognitive behavior therapy requirement.

What "new cognitive behavior therapy requirement?" And if it's a "requirement" for psychiatry programs, isn't it a given that you'd expect to find such a large percentage complying with it?

John

 

[50960]

Yes... and most of how to do therapy is learned well after anyone has graduated from school, as I have said 1 million times. This argument is like trying to guage how good parents are by how much they learned from their OB doc about parenting.