Nice therapy pearls from the guy who wrote the book

[msgeorgeeliot]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

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[PsyDr]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

The book Shrinks also has many good anecdotes about Dr. Frances. Including the story of homosexuality in the DSM.

He smart.

 

[erg923]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

The death of descriptive psychopathology is something I loathe for psychiatry and clinical psychology. Although admit it is often (but not always) adversarial to my current role. You just have to do it right.

Yes, the DSM is there for a reason, and I wish more of us would use it vs our own musing about what's needed to diagnose and render the standard of care. Yes, most psychiatric diagnosis are evolving over time, I agree.

I like the idea of emulating psychological health and well-being for our patients. That should go without saying. I think its silly that he thinks you need to have been a psychiatric patient (or pay for "psychotherapy") to do it though.

I am kinda surprised he is on any kind positive list of yours, considering....

 

[psych.meout]

The death of descriptive psychopathology is something I loathe for psychiatry and clinical psychology. Although admit it is often (but not always) adversarial to my current role. You just have to do it right.

Yes, the DSM is there for a reason, and I wish more of us would use it vs our own musing about what's needed to diagnose and render the standard of care. Yes, most psychiatric diagnosis are evolving over time, I agree.

I like the idea of emulating psychological health and well-being for our patients. That should go without saying. I think its silly that he thinks you need to have been a psychiatric patient (or pay for "psychotherapy") to do it though.

I am kinda surprised he is on any kind positive list of yours, considering....

Yeah, I could be wrong, but I'm not familiarwith any literature that personal psychotherapy is associated with any outcomes of interest.

 

[msgeorgeeliot]

I like the idea of emulating psychological health and well-being for our patients. That should go without saying. I think its silly that he thinks you need to have been a psychiatric patient (or pay for "psychotherapy") to do it though.

I am kinda surprised he is on any kind positive list of yours, considering....

I was trained predominantly by male psychiatrists who I deeply respect. I guess I contain multitudes? [shrug!]

 

[GradStudent2020]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

Thank you for sharing, I enjoyed the entire list. Would love to see prescribers follow some of the advice about medications.

I wholeheartedly agree with #18. I believe that over- inaccurate-diagnoses would be less prevalent if our field wasn’t so damn insistent on attempting to copy a medical model of treatment. Add insurance companies where diagnosis=treatment/reimbursement and lack of diagnosis=lack of reimbursement....and we have a real problem.

 

[erg923]

-

 

[GradStudent2020]

Diagnosis is designed to guide treatment, otherwise we are all operating under false pretenses in this paradigm. There is certainly NOT a lack of diagnostic codes to account for our field's treatments/treatment needs.

However, there is, likely, both a hyper-focus and an under-focus for how diagnosis shapes needs and outcomes in the field. Assessment on the font is is key. Thinking that you have to "have it all figured out" before you can treat the patient is also silly though.

I don’t disagree and think you may have misunderstood my comment.

Diagnosis can help guide treatment (although I would argue that we can conceptualize treatment needs without the DSM). However, many agencies (inappropriately, IMO) demand diagnostic labels (for billing purposes) before adequate information is available. I’ve seen it more in therapy-heavy practices & medical settings than in assessment practices.

 

[erg923]

Thank you for sharing, I enjoyed the entire list. Would love to see prescribers follow some of the advice about medications.

I wholeheartedly agree with #18. I believe that over- inaccurate-diagnoses would be less prevalent if our field wasn’t so damn insistent on attempting to copy a medical model of treatment. Add insurance companies where diagnosis=treatment/reimbursement and lack of diagnosis=lack of reimbursement....and we have a real problem.

Diagnosis is designed to guide treatment, otherwise we are all operating under false pretenses in this paradigm. There is certainly NOT a lack of diagnostic codes to account for our field's treatments/treatment needs.

However, there is, likely, both a hyper-focus and an under-focus for how diagnosis shapes needs and outcomes in the field. Assessment on the font is is key. Thinking that you have to "have it all figured out" before you can treat the patient is also silly though.

 

[erg923]

I don’t disagree and think you may have misunderstood my comment.

Diagnosis can help guide treatment (although I would argue that we can conceptualize treatment needs without the DSM). However, many agencies (inappropriately, IMO) demand diagnostic labels (for billing purposes) before adequate information is available. I’ve seen it more in therapy-heavy practices & medical settings than in assessment practices.

I don't do inpatient. But there are any number of codes to use if some needs treatment. Companies/business need to have some sort of metric, and some sort of threshold for releasing monetary disbursement for services.

 

[GradStudent2020]

I don't do inpatient. But there are any number of codes to use if some needs treatment. Companies/business need to have some sort of metric, and some sort of threshold for releasing monetary disbursement for services.

What codes do you use that insurance companies reimburse that are not diagnoses?

I don’t know the solution, but feel our current approach is problematic. Why isn’t it sufficient for clinicians to identify functional impairment, move forward (with reimbursement), and diagnosis /label when appropriate?

 

[erg923]

What codes do you use that insurance companies reimburse that are not diagnoses?

I don’t know the solution, but feel our current approach is problematic. Why isn’t it sufficient for clinicians to identify functional impairment, move forward (with reimbursement), and diagnosis /label when appropriate?

I don't have a traditional clinical practice at this time.

Often, clinicians ask for "more" (services/visits) when what they are doing isn't working. This has no empirical backing.

 

[GradStudent2020]

I don't have a formal clinical practice at this time.

Often, clinicians ask for "more" when what they are doing isn't working. This has no empirical backing.

I don’t understand how that relates to over-diagnosis?

 

[erg923]

I don’t understand how that relates to over-diagnosis?

It doesn't. That wasn't the point of my post. Over-utilization was. Closely related.

 

[psych.meout]

What codes do you use that insurance companies reimburse that are not diagnoses?

I don’t know the solution, but feel our current approach is problematic. Why isn’t it sufficient for clinicians to identify functional impairment, move forward (with reimbursement), and diagnosis /label when appropriate?

To play devil's advocate a bit, one argument may be that functional impairment doesn't always necessitate therapy with a mental health professional. Yes, a psychologist, psychiatrist, or mid-level provider could certainly help people across the spectrum from SMI to problems of living not rising to psychopathology, but does that mean they should? Maybe some problems interfering with functioning are better suited to being ameliorated in other settings and means, e.g., support groups, clergy, individual social network. To have highly trained mental health professionals be reimbursed for these levels of problems is an inefficient use of scarce, expensive resources. Requiring a diagnosis is one way to assure that these professionals are working on problem rising to their level of expertise. This is not to say it is an ideal method of doing so, but there needs to be some way of efficiently delineating which services should and shouldn't be reimbursed. It would be nice if the professionals did this themselves voluntarily, but financial demands, competition, and other factors often lead them astray.

 

[msgeorgeeliot]

Gee. In starting this thread, I was kind of hoping to chat about wisdom-based aphorisms about the mechanics of effective psychotherapy. But ugh, I guess we lack RCTs about the value of psychotherapists engaging in their own psychotherapy? Color me shocked.

 

[psych.meout]

Gee. In starting this thread, I was kind of hoping to chat about wisdom-based aphorisms about the mechanics of effective psychotherapy. But ugh, I guess we lack RCTs about the value of psychotherapists engaging in their own psychotherapy? Color me shocked.

Isn't psychology supposed to be a science? Shouldn't we be operating based on where the evidence is, not "wisdom-based aphorisms?"

 

[msgeorgeeliot]

Isn't psychology supposed to be a science? Shouldn't we be operating based on where the evidence is, not "wisdom-based aphorisms?"

Gee, smartypants, have you graduated yet? Nope? That’s what I thought.

 

[msgeorgeeliot]

The book Shrinks also has many good anecdotes about Dr. Frances. Including the story of homosexuality in the DSM.

He smart.

I also really like the book of clinical aphorisms compiled by Elvin Semrad’s students. I find it very moving.

 

[psych.meout]

Gee, smartypants, have you graduated yet? Nope? That’s what I thought.

Huh, that seems a bit uncalled for. Maybe we could use a thread about welcoming all perspectives and how being "rude" or "aggressive" is unhelpful and keeps people from participating.

 

[msgeorgeeliot]

Huh, that seems a bit uncalled for. Maybe we could use a thread about welcoming all perspectives and how being "rude" or "aggressive" is unhelpful and keeps people from participating.

Lol! Let’s call this a social experiment in which I am a female psychologist who is your professional superior. (This is obviously what is really happening, but for the sake of collective suspension of disbelief, I’ll continue with the hypothetical.)

You’re clearly a know-it-all graduate student. Permit me to emulate the smooth moves of my masculine brethren in suggesting that you’re all hat, no cattle in this discussion. Maybe try to listen more and talk less? Just a suggestion, no RCT to back it up. Shrug!

 

[psych.meout]

Lol! Let’s call this a social experiment in which I am a female psychologist who is your professional superior. (This is obviously what is really happening, but for the sake of collective suspension of disbelief, I’ll continue with the hypothetical.)

You’re clearly a know-it-all graduate student. Permit me to emulate the smooth moves of my masculine brethren in suggesting that you’re all hat, no cattle in this discussion. Maybe try to listen more and talk less? Just a suggestion, no RCT to back it up. Shrug!

Huh, that sounds a bit like "dismissiveness" and a "condescending reality check." Weird....

 

[msgeorgeeliot]

Huh, that sounds a bit like "dismissiveness" and a "condescending reality check." Weird....

My conceptualization appears to be quite sound. Good night, junior.

 

[psych.meout]

My conceptualization appears to be quite sound. Good night, junior.

Alright, you've convinced me. Psychologists should definitely get their own psychotherapy.

 

[erg923]

Lol! Let’s call this a social experiment in which I am a female psychologist who is your professional superior. (This is obviously what is really happening, but for the sake of collective suspension of disbelief, I’ll continue with the hypothetical.)

You’re clearly a know-it-all graduate student. Permit me to emulate the smooth moves of my masculine brethren in suggesting that you’re all hat, no cattle in this discussion. Maybe try to listen more and talk less? Just a suggestion, no RCT to back it up. Shrug!

Lol. what?

 

[AcronymAllergy]

Mod Note: Let's try to remain on topic. If you have thoughts related to another thread, you can address them in that thread.

 

[GradStudent2020]

To play devil's advocate a bit, one argument may be that functional impairment doesn't always necessitate therapy with a mental health professional. Yes, a psychologist, psychiatrist, or mid-level provider could certainly help people across the spectrum from SMI to problems of living not rising to psychopathology, but does that mean they should? Maybe some problems interfering with functioning are better suited to being ameliorated in other settings and means, e.g., support groups, clergy, individual social network. To have highly trained mental health professionals be reimbursed for these levels of problems is an inefficient use of scarce, expensive resources. Requiring a diagnosis is one way to assure that these professionals are working on problem rising to their level of expertise. This is not to say it is an ideal method of doing so, but there needs to be some way of efficiently delineating which services should and shouldn't be reimbursed. It would be nice if the professionals did this themselves voluntarily, but financial demands, competition, and other factors often lead them astray.

I agree with you that functional impairment does not always require mental health services, individuals can experience impairment in a multitude of ways. I also can see how we as a field got to where we are in terms of over-reliance on diagnosis. IMO, that doesn’t mean there aren’t serious issues with the status quo.

 

[Pragma]

Gee, smartypants, have you graduated yet? Nope? That’s what I thought.

Wow?

 

[deleted106747]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

I love this list. One of my favorites:
42. Read widely, especially the great classic novels, and see psychologically astute movies and plays.

Gee, smartypants, have you graduated yet? Nope? That’s what I thought.

Ms. George, you know I love what you are bringing to this message board, but when you post like this you're becoming your enemy. Student perspectives are welcome, even if they go in a different direction. I do get the disappointment of discussing the art as well as the science of our field landing on deaf ears.

 

[msgeorgeeliot]

I love this list. One of my favorites:
42. Read widely, especially the great classic novels, and see psychologically astute movies and plays.

Ms. George, you know I love what you are bringing to this message board, but when you post like this you're becoming your enemy. Student perspectives are welcome, even if they go in a different direction. I do get the disappointment of discussing the art as well as the science of our field landing on deaf ears.

I agree, and thanks for the feedback.

Sorry, @psych.meout.

 

[deleted106747]

I agree, and thanks for the feedback.

Sorry, @psych.meout.

You're awesome. It's unusual to see someone on here who doesn't just double down.

 

[Justanothergrad]

Perhaps this thread is worth some further consideration in the other thread on the unique dismissiveness and aggressiveness of male posters.

::Shrug::

 

[msgeorgeeliot]

Perhaps this thread is worth some further consideration in the other thread on the unique dismissiveness and aggressiveness of male posters.

::Shrug::

I’m loath to break the fourth wall, but yes, my rude bluster is largely a performance to gauge differential responses to similar types of content. Irony really is dead.

I say that not to discount the reality that, at times, I can definitely behave in dismissive and aggressive ways. I work sincerely to improve my character in recognizing these less appealing sides of myself.

Anyway, I’m going take Dr. Frances’s advice (39. Have a rich, varied, and satisfying personal life) and go do some awesome stuff. Have a nice rest of your weekend.

 

[Justanothergrad]

I’m loath to break the fourth wall, but yes, my rude bluster is largely a performance to gauge differential responses to similar types of content. Irony really is dead.

I say that not to discount the reality that, at times, I can definitely behave in dismissive and aggressive ways. I work sincerely to improve my character in recognizing these less appealing sides of myself.

Anyway, I’m going take Dr. Frances’s advice (39. Have a rich, varied, and satisfying personal life) and go do some awesome stuff. Have a nice rest of your weekend.

So you were intentionally rude, insulting, and dismissive without provocation or reason, knowing it would be a problem? And the real problem is someone else? Ok.

Enjoy your weekend and your thread.

 

[AbnormalPsych]

I’m loath to break the fourth wall, but yes, my rude bluster is largely a performance to gauge differential responses to similar types of content. Irony really is dead.

So you were intentionally rude, insulting, and dismissive without provocation or reason, knowing it would be a problem? And the real problem is someone else? Ok.

Enjoy your weekend and your thread.

Agreed. I've been following along in the other main thread, and several others. I've appreciated the dialogue, but not all of it. There is something real to walking the walk. I haven't seen that from several and it disappoints me. Some posts have felt disingenuous and at times contradictory. Follows along with the 'antagonistic' tone the first thread was started in.

I just want to call some attention to this - and this specific example.

Sorry, not sure how to transfer this post to the other thread.

Also, really cool link and list! I enjoyed reading it.

 

[Pragma]

Here’s a new article from Allen Frances, chair of the DSM-IV task force, on advice he‘d give to new psychiatrists. Lots of good and applicable fodder for psychotherapists in general. Which ones speak to you? My favorites tonight:

2. No meeting with any patient is ever routine for them; so it should never be routine for you.

18. Diagnosis should almost always be written in pencil—especially in the young and the old. Always err on the side of underdiagnosis—it is easy to later up-diagnose; almost impossible to erase a diagnostic error that can haunt the patient for life.

19. Use DSM, but don't worship it. I equally distrust clinicians who do not know DSM and those who only know DSM.

40. Embark on a personal psychotherapy to help understand yourself better, solve any problems you may have, correct biases based on your personality and experiences, and discover what it is like to be a patient.

49. Be yourself—and grow into an even better version of yourself as you enjoy the special privilege of helping others also better themselves.

Advice to Young Psychiatrists From a Very Old One

Here it is—the 50 most important things Allan Frances, MD, has learned in over 50 years studying psychiatry.

www.psychiatrictimes.com

Ignoring the other stuff from this thread...

I liked #2. It’s how I try to approach things. Everyone needs heuristics but clinic work should never be too formulaic.

Also a mistake I see people make in practice. Too busy being the expert and wanting to demonstrate their expertise with patients. Instead, recognizing that patients are experts on their own lives and believing you always have something to learn is a more productive (and genuinely empathetic - not faux-empathy) attitude, IMO.

 

[futureapppsy2]

I’m loath to break the fourth wall, but yes, my rude bluster is largely a performance to gauge differential responses to similar types of content. Irony really is dead.

I say that not to discount the reality that, at times, I can definitely behave in dismissive and aggressive ways. I work sincerely to improve my character in recognizing these less appealing sides of myself.

Anyway, I’m going take Dr. Frances’s advice (39. Have a rich, varied, and satisfying personal life) and go do some awesome stuff. Have a nice rest of your weekend.

Addressing this to everyone: This forum is not a venue for social experiments. Post professionally and genuinely about topics that you legitimately want to discuss.