How much talk therapy do psychiatrists do nowadays!?

[Amygdarya]

I'm new to this.... soon to be first year medical student. But currently read books regarding the nature and neuroscience of anxiety and OCD. When you look at it from a neuroscience perspective, it makes me think so much of the behavioral aspects of therapy are flawed because they only focus on cortex-based treatment, when the actual illness could be arising from other areas of the brain!

The picture @MamaPhD posted is on point, and you just keep proving it.

1) We don't really know where in the brain psychiatric disorders arise from; what we can see on imaging of symptomatic patients may be a result of the pathogenic process, not necessarily its cause.
2) There are different kinds but of psychotherapy aside from behavioral therapy (which is very useful for certain conditions) with presumably different mechanisms of action.
3) Even the most superficial Google search will reveal plenty of studies of effects of psychotherapy (most commonly CBT but others as well) on the brain, many of which show that the results are by no means limited to cortex - in fact, limbic system, basal ganglia and other subcortical areas are often affected. There are whole books written about it. Louis Cozolino's "The Neuroscience of Psychotherapy" is a good start.

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[MADD!!!]

The picture @MamaPhD posted is on point, and you just keep proving it.

1) We don't really know where in the brain psychiatric disorders arise from; what we can see on imaging of symptomatic patients may be a result of the pathogenic process, not necessarily its cause.
2) There are different kinds but of psychotherapy aside from behavioral therapy (which is very useful for certain conditions) with presumably different mechanisms of action.
3) Even the most superficial Google search will reveal plenty of studies of effects of psychotherapy (most commonly CBT but others as well) on the brain, many of which show that the results are by no means limited to cortex - in fact, limbic system, basal ganglia and other subcortical areas are often affected. There are whole books written about it. Louis Cozolino's "The Neuroscience of Psychotherapy" is a good start.

1) I never said that psychotherapy only affects the cortex. Rather, I'm saying that psychotherapy isn't always a useful form of treatment because not all mental disease states are related to the cortex.

Ex. There are two types of anxiety: cortex-based or amygdala-based anxiety. An amygdala-based panic attack could be sparked by an association the amygdala has paired a neutral stimulus from to a bad situation.
(Ex. Getting raped and Rolling Stones song playing in background.)

Now said patient may go to therapy and not understand why they experienced this panic attack, and furthermore psychotherapy will not be very effective BECAUSE the amygdala is not logical. But, by understanding how amydala-based anxiety develops, you can detach the neutral stimulus from a bad experience and solve the problem.

2) Psychotherapy, a cognitive-based form of therapy, brings about real change precisely by changing the wiring of the brain. I completely agree with that.

P.s. Can you explain the pic because I don't get it still.

 

[Liquid8]

I don't know that using a more biological lens allows psychiatrists to better treat mental illness or better use medications and ECT.

It’s also about how you apply it to your clinical practice. Generally when I suggest therapy as an adjunct to medication, most patients are ok with this. However, I remember seeing a very anxious but scientifically minded individual who had previously ignored therapy options as he felt it was all a bit of fluff, and was naturally very resistant. However, after talking about the pathophysiology - how hyperventilation and increased respiratory rates can result in a CO2/O2 imbalance and cause panic related symptoms, and explaining how 6 second breathing techniques lowered the resp rate and reverse the process you could tell there was a "light bulb" moment. When I reviewed him a few months down the track, he’d actually done a few sessions of actual CBT with a psychologist with good effect.

I've heard so many therapists doing talk-therapy or "CBT" and it's literally just patients talking about their feelings, crying, and going home and paying for it with very little insight.

None of what you have described above is actually CBT. When a patient states that "CBT" doesn't work, one needs to be skeptical especially in cases where such treatment is clinically indicated. Part of my assessment involves exploring what they actually have done before with therapists - you quickly comes to appreciate that not all psychologists are the same, and it becomes very easy to quickly determine if a patient actually has had appropriate therapy or not.

P.s. Can you explain the pic because I don't get it still.

This graph has more labels

 

[smalltownpsych]

1) I never said that psychotherapy only affects the cortex. Rather, I'm saying that psychotherapy isn't always a useful form of treatment because not all mental disease states are related to the cortex.

Ex. There are two types of anxiety: cortex-based or amygdala-based anxiety. An amygdala-based panic attack could be sparked by an association the amygdala has paired a neutral stimulus from to a bad situation.
(Ex. Getting raped and Rolling Stones song playing in background.)

Now said patient may go to therapy and not understand why they experienced this panic attack, and furthermore psychotherapy will not be very effective BECAUSE the amygdala is not logical. But, by understanding how amydala-based anxiety develops, you can detach the neutral stimulus from a bad experience and solve the problem.

2) Psychotherapy, a cognitive-based form of therapy, brings about real change precisely by changing the wiring of the brain. I completely agree with that.

P.s. Can you explain the pic because I don't get it still.

Effective forms of treatment for anxiety disorders involve exposure in order to directly counter the classical conditioning response. It's called extinction and it is more difficult when fear is involved as opposed to salivating when a bell is rung. The only reason I engage the cortex is so that the patient will understand why they need to be exposed to the fear provoking stimulus and be willing to participate in it. Effedtive psychotherapy uses both behavior and cognition to effect change in the limbic system which is where the problem lies. Also, humans directly interact wi each other's limbic system so how I regulate, amplify, and express emotions affects the patients ability to experience and express emotions. This is just a quick glimpse of some of what I do, I could go on for days about the complexity of effective psychotherapy and how it is very much directed at the function of the CNS. Lou Cozolino (cite above) was one of my psychotherapy instructors so I very much think neurologically when I am in the room with a patient. Another related concept is the self-regulating other.

 

[PistolPete]

Effective forms of treatment for anxiety disorders involve exposure in order to directly counter the classical conditioning response. It's called extinction and it is more difficult when fear is involved as opposed to salivating when a bell is rung. The only reason I engage the cortex is so that the patient will understand why they need to be exposed to the fear provoking stimulus and be willing to participate in it. Effedtive psychotherapy uses both behavior and cognition to effect change in the limbic system which is where the problem lies. Also, humans directly interact wi each other's limbic system so how I regulate, amplify, and express emotions affects the patients ability to experience and express emotions. This is just a quick glimpse of some of what I do, I could go on for days about the complexity of effective psychotherapy and how it is very much directed at the function of the CNS. Lou Cozolino (cite above) was one of my psychotherapy instructors so I very much think neurologically when I am in the room with a patient. Another related concept is the self-regulating other.

Can you expand on self-regulating other?

 

[Ceke2002]

1) I never said that psychotherapy only affects the cortex. Rather, I'm saying that psychotherapy isn't always a useful form of treatment because not all mental disease states are related to the cortex.

Ex. There are two types of anxiety: cortex-based or amygdala-based anxiety. An amygdala-based panic attack could be sparked by an association the amygdala has paired a neutral stimulus from to a bad situation.
(Ex. Getting raped and Rolling Stones song playing in background.)

Now said patient may go to therapy and not understand why they experienced this panic attack, and furthermore psychotherapy will not be very effective BECAUSE the amygdala is not logical. But, by understanding how amydala-based anxiety develops, you can detach the neutral stimulus from a bad experience and solve the problem.

2) Psychotherapy, a cognitive-based form of therapy, brings about real change precisely by changing the wiring of the brain. I completely agree with that.

You might like to take a look at this slideshow on the neurobiology of shame (as it relates to childhood attachment difficulties) and how an interpersonal neurobiological inspired therapist might actually be working to activate a lot more areas of the brain than just the amgydala and cortex. There's usually more going on in a therapy session than just a patient talking and the therapist dutifully listening.



edited to add: Also this is good as well, explains concepts of dynamic supportive psychotherapy. Hope these provide a bit more understanding that therapy, when done properly, is a lot more effective than just the equivalent of unloading to a friend.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330607/

 

[smalltownpsych]

Can you expand on self-regulating other?

I get that term that from Daniel Stern, MD who wrote a book called the Interpersonal World of the Infant. Basic underlying theory is that there is an optimal level of CNS arousal for neurodevelopment. I use tone, proximity, choice of material to discuss, activation of higher level defenses to try to help the patient stay within that optimal zone. When you have an understimulated, depressed, shame-filled, or dissociated patient it can be hard to get them up from that and the converse is true with the over-emotional, reactive types. Also, attunement is key, that is meet them where they are at and mirror the same tone and rhythm of speech and affect, then begin shifting into the healthier direction. Typical staff misattunements often lead to us being called in to talk to the patient and then half hour later the patient who was withdrawn and uncommunicative is now engaged in conversation and the patient who was threatening to beat the crap out of everyone is now calmly talking. We all do this and people with good social skills do it unconsciously.

 

[PistolPete]

I get that term that from Daniel Stern, MD who wrote a book called the Interpersonal World of the Infant. Basic underlying theory is that there is an optimal level of CNS arousal for neurodevelopment. I use tone, proximity, choice of material to discuss, activation of higher level defenses to try to help the patient stay within that optimal zone. When you have an understimulated, depressed, shame-filled, or dissociated patient it can be hard to get them up from that and the converse is true with the over-emotional, reactive types. Also, attunement is key, that is meet them where they are at and mirror the same tone and rhythm of speech and affect, then begin shifting into the healthier direction. Typical staff misattunements often lead to us being called in to talk to the patient and then half hour later the patient who was withdrawn and uncommunicative is now engaged in conversation and the patient who was threatening to beat the crap out of everyone is now calmly talking. We all do this and people with good social skills do it unconsciously.

Very interesting. Sounds like you have some very nicely developed mirror neurons.

 

[Ceke2002]

I get that term that from Daniel Stern, MD who wrote a book called the Interpersonal World of the Infant. Basic underlying theory is that there is an optimal level of CNS arousal for neurodevelopment. I use tone, proximity, choice of material to discuss, activation of higher level defenses to try to help the patient stay within that optimal zone. When you have an understimulated, depressed, shame-filled, or dissociated patient it can be hard to get them up from that and the converse is true with the over-emotional, reactive types. Also, attunement is key, that is meet them where they are at and mirror the same tone and rhythm of speech and affect, then begin shifting into the healthier direction. Typical staff misattunements often lead to us being called in to talk to the patient and then half hour later the patient who was withdrawn and uncommunicative is now engaged in conversation and the patient who was threatening to beat the crap out of everyone is now calmly talking. We all do this and people with good social skills do it unconsciously.

I must admit I am still regularly amazed at the skills of a good therapist who can attune themselves to a patient to the degree that they can subtly steer that patient's regulation towards something more akin to a healthier, more balanced response. There have been plenty of times I've gone into session feel very flat, not in the mood to talk, overwhelmed, drained etc, and I spend the first quarter of the session wondering why I even bothered to waste an appointment spot, because neither of us are saying much, but by the end of the session the conversation's flowing and I'm feeling way more of a sense of being emotionally balanced. It's often not until I've left the appointment and had a few hours, or even a few days to go back and analyse what happened that I actually realise, "Oh, hey, wait a minute, I see wha you did there...damn, nice work!"

I wish more people who doubted the effectiveness and power of psychotherapy could have the opportunity of sitting in on a session with a therapist who actually knows what they're doing. I wonder how attitudes towards therapy might be changed for the better.

And YAY Mirror Neurons.

 

[tr]

Typical staff misattunements often lead to us being called in to talk to the patient and then half hour later the patient who was withdrawn and uncommunicative is now engaged in conversation and the patient who was threatening to beat the crap out of everyone is now calmly talking. We all do this and people with good social skills do it unconsciously.

Absolutely. Actually this is one of the experiences that drew me to psychiatry - while on my IM rotation in med school we had a belligerent uncooperative patient. Psych fellow was called in, happened to be someone who had this skill, had patient eating out of his hand in 20 minutes. I was amazed.
I'm quite good at this myself by now but it was definitely a learned - and learnable! - skill.

 

[smalltownpsych]

Absolutely. Actually this is one of the experiences that drew me to psychiatry - while on my IM rotation in med school we had a belligerent uncooperative patient. Psych fellow was called in, happened to be someone who had this skill, had patient eating out of his hand in 20 minutes. I was amazed.
I'm quite good at this myself by now but it was definitely a learned - and learnable! - skill.

Not something I really knew about before I chose this path, but definitely a skill I like and one of the few times others get to see why we are essential. The rest of the time they just make fun of us for being so touchy-feely.

 

[Merovinge]

Absolutely. Actually this is one of the experiences that drew me to psychiatry - while on my IM rotation in med school we had a belligerent uncooperative patient. Psych fellow was called in, happened to be someone who had this skill, had patient eating out of his hand in 20 minutes. I was amazed.
I'm quite good at this myself by now but it was definitely a learned - and learnable! - skill.

Yup, same thing that drew me in after I already thought I was going a different direction. CL work can be really sexy, at least to me.

 

[sgardner1414]

blueadams, this is really quite a welcoming place and people here tend to be very helpful. Don't get put off by a couple of snide remarks.

I was in your situation not so long ago myself.

Yes psychiatrists do talk therapy. And you can make a very decent living (100k+) taking insurance and doing talk therapy.

http://www.usnews.com/health/family...iatrists-talk-therapy-falling-by-wayside.html

Recent survey for some info.

Here's a short, but far from exhaustive list of reasons for why talk therapy is falling by the wayside. The pharma push and the medicalization of psychiatry. Increased incidence of psychiatric disorders. Increased symptomatic management of same by PCPs who are not trained in psych. Increase in number of psychiatry programs without a strong psychotherapist faculty contingent. Decline in quality of individuals entering psychiatry. Adverse compensation (thank you medicare!). Sociocultural issues regarding psych stigma (if its a biochemical issue you need a pill for, that's not really your fault. If it's a biopsychosocial problem at least partially rooted in your experiences, and reaction to them, and requires work on your part to correct, then it's your fault, you weak person!)

30% is nothing to sneeze at. And I daresay there's no reason the number couldn't be higher. It's just that there's a combination of training programs who don't care about psychotherapy as well as residents who don't care to learn it to go along with societal and economic pressures.

Myself, I still plan on becoming a psychiatrist who thinks of himself as a psychotherapist. I can take a small economic hit, or supplement with some high-paying clients. If I were in it for the money, I wouldn't have gone into psych in the first place lol.

But I will say that a funny thing has happened since I started residency (i'm an intern right now). Namely that I've got a reputation for knowing my psychopharm. Which I actually got annoyed with for a while. Because psychotherapy and lifestyle intervention have been what I wanted to do since I was 15 or so. And then i wasn't so annoyed. Psychiatric disorders after all are BioPsychoSocial, and thus treatment needs to hit all of these areas. It's now become a goal of mine to become as good at psychopharm as possible, because that'll only make me a better clinician.

I'll also say that on the inpatient wards, every patient with insight gets the psychotherapy available in my at the moment limited armamentarium. Whether supportive, motivational interviewing, cognitive-behavioral chunks, or mindfulness exercises.

In short, there is plenty of opportunity for a psychiatry resident to learn plenty of psychotherapy and to do it.

Hello! I'll be a first year non-traditional medical student this Fall. How are you doing now? Your sentiment echos mine exactly. Now that you're done with residency how is the work force treating you? Have you changed your mind about psychotherapy? I'm hoping you're still on SDN, I would love to hear back from you or someone similar!

 

[sgardner1414]

Please excuse the barely coherent tirade that follows.

It is time for the completely inane mind-brain dualism to die a fast, painless death. I am so sick of hearing about biological psychiatry vs. psychotherapy.

One of my greatest laments is that basic sciences in medical education is biased toward memorization rather than theory formulation and concept recognition. I majored in neuroscience in undergrad, knowing I wanted to go on to do psychotherapy. Why? Because if psychotherapy makes a difference (and it does, with equivalent efficacy and arguably superior relapse rates), then it does so through changing the brain.

Nerves that fire together wire together. The Hebbian synapse. A core principle of basic neuroscience. And a principle that can inform the way we think about how thought patterns arise, are maintained, and extinguished.

What is cognitive-behavioral therapy if not identifying a maladaptive thought pattern, showing it to be false, and then forcibly extinguishing it? Stopping the nerves that wrongly fire together from doing so. What is DBT if it isn't helping the patient to gain awareness over their destructive behavioral responses to emotional distress? And in doing so, extinguish the strength of this synaptic connection?

Furthermore, while a lot of different psychotherapies have been shown to be about as effective as each other for a number of different disorders, and it's been argued that the therapeutic alliance is the common bond, it can also be argued that one thing all of these modalities share is that they teach the patient insight. One could argue since that's a central goal of all psychotherapies, it shouldn't be terribly surprising that they all work.

Psychotherapies ultimately work on the substrate of the brain, and produce their therapeutic benefits through changes in long-term potentiation and synaptic networks. They do this by changing thoughts and improving behavioral/emotional control. Which are products of the brain and its neurons. This should be the null hypothesis, to be disproven, rather than proven. To hold any other position is to essentially invoke Cartesian dualism. Which I am for various reasons not OK with.

Another thing to consider is that most DSM diagnoses are syndromes. I.e. collections of symptoms. Not diseases in and of themselves. Our treatments have been designed to target the relief of these symptoms rather than at specific underlying etiologies. A reduction in symptoms, whether measured by DSM criteria or the GAF (bleh), thus reveals to us nothing but how effective the medication is at relieving symptoms. You can take enough morphine to not feel any pain after you've herniated a disc. Doesn't change the fact that you herniated a disc...

The point I'm trying to make is that while psychopharm works, and psychotherapy works, that in and of itself does not make a very good case for which one is actually fixing the underlying pathophysiology.

As I mentioned earlier, psychotherapies do appear to have better relapse rates than medications alone for depression and anxiety, and we all know that the combination of both is superior. Could the superior relapse rate have to do with therapies, by the development of insight and prevention of maladaptive behaviors, thoughts, and emotional responses, reduce the likelihood of the long-term potentiation and synaptic network changes associated with mood and anxiety disorders? Could it be that combination therapy is beneficial because antidepressants provide symptomatic relief and thus de-stress the brain enough to heal?

What this whole issue shows is a silly bias in the medical profession. If it's delivered through pill or needle, if we physically cut into you and rearrange things, then, it's biological. If it happens through a change in behavior, action, or thought, then it's not. It's that kind of thinking that leads to the loss of empowerment and the medicalization of everyday life.

And to conclude my nonsensical rant, one final thought experiment. If psychotherapy is not a biologic treatment, and it works, then is the illness not biological?

Wow, I really appreciate that insight. Thank you.

 

[Attending1985]

I wanted to add this on to my last post...but my laptop battery died...

It seems almost as though the psychologist should be to the psychiatrist as the general practitioner is to the specialist.

EMERGENCY: If someone is brought to a large hospital with a potentially fatal gun shot wound (or something similar), he is rushed straight to a surgical specialist of some sort. If someone is brought to a large hospital absolutely out of control because of a mental problem, he is rushed straight to a psychiatrist and given the proper medication asap.

NON-EMERGENCY: If someone notices a potentially cancerous lump (or something similar), they go to their general doctor for a closer inspection, and if necessary, are then recommended to a specialist of some sort. If a functional person is feeling depressed, they SHOULD go to a psychologist for some non-pharm therapy sessions (I would imagine at least ten or so to really get to the root of the problem...couldn't hurt) to determine if drugs would be appropriate/helpful.

If an investment banker is depressed because he hates his job, he shouldn't go straight to a psychiatrist and ask for drugs, and that psychiatrist should not prescribe him drugs after a thirty minute interview. That investment banker should first have ten or so non-pharm psychotherapy sessions...be it with a psychologist or psychiatrist...to identify if the problem is biological and needs drug treatment, or social and needs behavioral adjustments.

If he has a serious chemical imbalance, then yes, he should take drugs of some sort to counteract that. But its more likely that he hates his job because he works 70+ hours a week, feels that it is meaningless, he is constantly stressed out, and he has no time for friends, family or leisure. With such business world experience, he would certainly have other options. Maybe he could take an executive position at an NGO or something. Work less hours. Change the world for the better. Be under less stress. Spend more time with his friends and family. Take some time to see if the difference in money is really worth the difference in lifestyle quality. If he does all that, and he is still having serious depression problems, THEN he should go see a psychiatrist, and THEN he should be prescribed medications.

But in the real world, that's not how it works, is it!? In the real world, that first psychiatrist he sees and asks for a prescription...he is probably going to give him that prescription. And nothing that should really change will really change.

It depends on the quality of psychiatrist he sees. I don’t always prescribe meds and I often reduce or taper them off while recommending other interventions. But all in all you are very right that the use of medications, namely antidepressants, is a knee jerk reaction in medicine. People with mild to moderate depression and anxiety would be much better served by a course of therapy before considering medications. This is commonsensical but common sense is lacking in mental health treatment. Buyer beware.

 

[splik]

1) I never said that psychotherapy only affects the cortex. Rather, I'm saying that psychotherapy isn't always a useful form of treatment because not all mental disease states are related to the cortex.

Ex. There are two types of anxiety: cortex-based or amygdala-based anxiety. An amygdala-based panic attack could be sparked by an association the amygdala has paired a neutral stimulus from to a bad situation.
(Ex. Getting raped and Rolling Stones song playing in background.)

Now said patient may go to therapy and not understand why they experienced this panic attack, and furthermore psychotherapy will not be very effective BECAUSE the amygdala is not logical. But, by understanding how amydala-based anxiety develops, you can detach the neutral stimulus from a bad experience and solve the problem.

I dont think you understand psychotherapy. I'm not sure what the hell "amygdala-based anxiety" is but it is precisely those patients with limbic hyperreactivity and S-S or S-R conditioning you describe that I would treat with psychotherapy. panic, phobia, PTSD, hysteria - these are all potentially curable with psychotherapy

 

[MADD!!!]

I dont think you understand psychotherapy. I'm not sure what the hell "amygdala-based anxiety" is but it is precisely those patients with limbic hyperreactivity and S-S or S-R conditioning you describe that I would treat with psychotherapy. panic, phobia, PTSD, hysteria - these are all potentially curable with psychotherapy

Loll something I read in a book.