Programs known for psychopharm

[Sleaux]

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Does anyone know of solid programs (regardless of region) that emphasize psychopharm more than psychodynamics? Are these programs uncommon? I'm somewhat disenchanted by some of the top-tier schools with websites that boast their psychodynamic focus, with only a passing mention of psychopharm.

Any thoughts?

 

[Doc Samson]

Does anyone know of solid programs (regardless of region) that emphasize psychopharm more than psychodynamics? Are these programs uncommon? I'm somewhat disenchanted by some of the top-tier schools with websites that boast their psychodynamic focus, with only a passing mention of psychopharm.

Any thoughts?

The reason they're boasting their psychodynamic focus is that almost every program will teach psychopharm, while psychodynamics is becoming a rarer thing to find. I doubt that you'd find a top-tier program that doesn't teach psychopharm well. That said, if you're interested in becoming a "psychopharmacologist" (and you won't have to search to far on these threads to find my opinion about that), then Wash U St. Louis is well-known for providing a rigorous psychopharm experience with almost no emphasis on psychodynamic psychotherapy.

 

[Sleaux]

Gotcha. Thanks. I'll check out Wash.

 

[masterofmonkeys]

*smacks head against the wall*

Any 'good' program is going to have great psychopharm teaching. That even includes such psychodynamic stalwarts as Cornell etc.

Looking for a psych program that's a 'psychopharm' program is like looking for an IM program that teaches you to manage CHF, COPD, and HTN.

You can usually throw enough meds at a person to make them stop feeling depressed. But if you fail to address their dysfunctional relationships, emotional traumas, and cognitive-behavioral dysfunctions, you fail to treat the patient, only manage their symptoms.

That said, from the interview trail and scuttlebutt, WUSTL, emory, UCLA, UCSD, and UTSW all come to mind as having reputations for being 'strong in psychopharm', whatever the hell that means.

 

[dianamd]

The other thing about psychopharm vs. dynamics education is the long-term forecast for these approaches.

Psychodynamics is relatively stable, forever (as long as capitalism, etc. are around, at least). People are people -- learning to deal with them, in a very special way, is something that programs emphasize precisely because it is a rarer and rarer skill, as Doc Sampson pointed out.

Psychopharmacology is pretty complicated, at least to me. I feel like there are psychiatrists who feel that they are pretty good with medicines, because it is easy, but they use too much trial and error -- this can lose patients who don't really want to take meds, I would think... If they had a superior psychopharmacology education, I imagine, there would be less trial and error.

However, the psychopharm of tomorrow truly won't be like the psychopharm of today. There will be genetics markers that make our job much easier -- in terms of guessing and predicting which side effects will be less tolerable. The job will truly be easier -- so I think -- although probably require more judgment since the meds get more and more plentiful/powerful.

As for the list of programs that emphasize psychopharm, it is probably accurate, but at least one of those programs (UCLA - Ranked it first!!) has a gigantic faculty and therefore room to learn psychodynamics anyway. I only know of Wash U, and possibly Hopkins, that truly emphasize psychopharmacology over dynamics training -- meaning, at least at Wash U, in my understanding, the dynamics training you need is basically "common sense." This of course is completely ridiculous and cannot lead to a good long-term outcome. (Ex. Using common sense, you would tell someone to stop complaining!)

But the education in pharmacology is fleeting. Medicines in the future will be different, better. We will have improved ways of predicting side effects, etc. The practice of interacting with patients, understanding and treating deeper issues -- those tools you forge in residency can be useful forever.

The other side of this is, neuroscience is the future of psychiatry. At some places, perhaps those that have less of a psychodynamics focus, it is because the future rules the present.

So, this argument is not as philosophical as the debate about which is more effective, the degree to which we medicate society, Freud, etc. But it was my rationale when I wondered why programs didn't advertise their psychopharmacology focus. 👍

 

[nancysinatra]

*smacks head against the wall*

MOM, I hope you are going to a place where they are good at treating traumatic brain injury!

You can usually throw enough meds at a person to make them stop feeling depressed. But if you fail to address their dysfunctional relationships, emotional traumas, and cognitive-behavioral dysfunctions, you fail to treat the patient, only manage their symptoms.

But do you think that actually happens? That is like taking on the whole of American society and all its problems, right there: dysfunctional relationships, emotional traumas, cognitive-behavioral dysfunctions. I'm not arguing with the ideal, but isn't it like parallel to saying that every primary care patient needs to get their weight under control, hit the gym daily, and eat the exact perfect amount of fish oils and no pizza. We can SAY it but that won't just make it happen. Somehow it's not just about the training we receive in residency, it's about the larger health care system we have in place to provide care. I know a lot of people who have been depressed, gone on antidepressants, and somehow, their relationship problems, traumas and other issues did NOT get resolved. In fact, don't most people get treated for depression through primary care doctors anyway?

Plus, let's say you treat the PATIENT for their relationship dysfunctions. Well, the patient's friends and family members still are going to be dysfunctional to some extent, because don't most people have some issues and quirks? So unless you treat every member of the society, what is the practical value of the treatment to the original patient? Won't the insight they gain just sort of make them more depressed since they can't necessarily do a lot with it? Ok, this IS a hypothetical question; I am not devaluing psychodynamic psychotherapy, I am just asking! Don't flame me, please! Hopefully when I get out there and have patients to work with I will see that these goals CAN be realized...

EDIT: I'm sorry for taking this post off topic--but I thought you raised an interesting point, MOM!

 

[sunlioness]

You can usually throw enough meds at a person to make them stop feeling depressed.

Often, but not always. Unless you're using different meds than I'm using. 😉

 

[TheWowEffect]

But do you think that actually happens? That is like taking on the whole of American society and all its problems, right there: dysfunctional relationships, emotional traumas, cognitive-behavioral dysfunctions. I'm not arguing with the ideal, but isn't it like parallel to saying that every primary care patient needs to get their weight under control, hit the gym daily, and eat the exact perfect amount of fish oils and no pizza. We can SAY it but that won't just make it happen. Somehow it's not just about the training we receive in residency, it's about the larger health care system we have in place to provide care. I know a lot of people who have been depressed, gone on antidepressants, and somehow, their relationship problems, traumas and other issues did NOT get resolved. In fact, don't most people get treated for depression through primary care doctors anyway?

Plus, let's say you treat the PATIENT for their relationship dysfunctions. Well, the patient's friends and family members still are going to be dysfunctional to some extent, because don't most people have some issues and quirks? So unless you treat every member of the society, what is the practical value of the treatment to the original patient? Won't the insight they gain just sort of make them more depressed since they can't necessarily do a lot with it? Ok, this IS a hypothetical question; I am not devaluing psychodynamic psychotherapy, I am just asking! Don't flame me, please! Hopefully when I get out there and have patients to work with I will see that these goals CAN be realized...

EDIT: I'm sorry for taking this post off topic--but I thought you raised an interesting point, MOM!

I think you make very good points. I think psychotherapy is a very useful adjunct but often, it is just thrown at patients by an overzealous therapist. Even when a patient may not want it or may not be ready or appropriate for it. I know you can make the same arguement for medications but I totally agree with nancysinatra on this.

 

[watto]

I know, it's crazy. My program, UCLA, is known for being "good for psychopharm," but I'm smack-dab in the middle of an illuminating lecture series tracing the roots of analytic theory from Freud on. Of course, the guys doing the lectures do manage to pimp neuroanatomy at the same time they're discussing "the bad breast."

We're on object relations, not Tara Reid.

 

[nancysinatra]

I think you make very good points. I think psychotherapy is a very useful adjunct but often, it is just thrown at patients by an overzealous therapist. Even when a patient may not want it or may not be ready or appropriate for it. I know you can make the same arguement for medications but I totally agree with nancysinatra on this.

Thanks. I do actually look forward to learning the best possible psychotherapy skills myself in residency, but the subject brings up many interesting questions.

 

[masterofmonkeys]

MOM, I hope you are going to a place where they are good at treating traumatic brain injury!

I was bred to abuse my head, not use it.

But do you think that actually happens? That is like taking on the whole of American society and all its problems, right there: dysfunctional relationships, emotional traumas, cognitive-behavioral dysfunctions.

You have just repeated exactly why I felt like psych was where I could do the most good.

I'm not arguing with the ideal, but isn't it like parallel to saying that every primary care patient needs to get their weight under control, hit the gym daily, and eat the exact perfect amount of fish oils and no pizza. We can SAY it but that won't just make it happen.

Agreed. But a good primary care doc should probably know how to advise their patients in how to live as healthily as possible, whether or not they want, will implement, or are even ready to hear the doc's advice. Likewise, a psychiatrist should be able to handle all of the things I mentioned, whether or not they actually get a chance to do so.

Somehow it's not just about the training we receive in residency, it's about the larger health care system we have in place to provide care. I know a lot of people who have been depressed, gone on antidepressants, and somehow, their relationship problems, traumas and other issues did NOT get resolved. In fact, don't most people get treated for depression through primary care doctors anyway?

That's kind of my point. Depression is a sucky thing and as physicians and psychiatrists we should be able to manage and ameliorate depression with medicine. There is no shame in alleviating symptoms. But the drugs don't change underlying psychosocial stressors. Complete care should involve addressing those as well, if/when the patient desires it or is ready for it or however you want to put it. But you have to know how to look for them and how to address them.

Plus, let's say you treat the PATIENT for their relationship dysfunctions. Well, the patient's friends and family members still are going to be dysfunctional to some extent, because don't most people have some issues and quirks? So unless you treat every member of the society, what is the practical value of the treatment to the original patient? Won't the insight they gain just sort of make them more depressed since they can't necessarily do a lot with it? Ok, this IS a hypothetical question; I am not devaluing psychodynamic psychotherapy, I am just asking! Don't flame me, please! Hopefully when I get out there and have patients to work with I will see that these goals CAN be realized...

That's an important point. But I think understanding how dysfunctional relationships can affect your own mental health is important. And can minimize their hold over you. You undergoing psychotherapy may not help your mother learn to stop being overbearing and pointing out your every flaw, but it can certainly help you see what she's doing, help you realize that she doesn't do it because she hates you, and help you see that your self esteem doesn't have to crash and burn just because she does it. CBT may not change the fact that as a naturally high achiever and perfectionist you feel bad when you fail to reach the standards you set for yourself, but it can certainly help you to not think of yourself as a failure or worthless.

*shrug*

I'm with you that we are not going to get the chance to pursue 'ideal' combination treatment with our patietns and get to do psychotherapy with them until every problem in their life is figured out. Some won't have coverage/won't want to pay, some won't be receptive to the idea, others may find its just too hard to work past certain issues. But I think it's important to know how to maximize the efficiacy of treatment. And for me that means being able to manage their symptoms as well as possible with the meds in my armamentarium, and having enough practice and undertanding of psychotherapeutic modalities to engage the patient in them where possible.

 

[nancysinatra]

But the drugs don't change underlying psychosocial stressors.

But how do you know that psychotherapy can change the underlying psychosocial stressors? After all I think a lot of people would like to have their psychosocial problems solved, and if this were the answer I'm sure more people would run off and get therapy right now.

I am just a med student, and I haven't learned any psychotherapy yet. I haven't even been around psych patients, actually, in several months. What I have been seeing are neuro, ER, surgery and primary care patients, and my own friends and family. In other words the usual range of people with their usual ability to irritate each other and undermine themselves as people so often do. And just from what I can see with that population, I think that people are really hard to change. The larger psychosocial stressors must be even more intractable! So I would not want to walk into day one of residency and say, oh hey, I'm here to change everyone's psychosocial stressors.

Though I do look forward to becoming convinced that therapy has a lot to offer, and if that happens to include changing psychosocial stressors, then all the better. It's just that I will wait to learn about the therapies themselves before suspending my disbelief I guess.

You undergoing psychotherapy may not help your mother learn to stop being overbearing and pointing out your every flaw, but it can certainly help you see what she's doing, help you realize that she doesn't do it because she hates you, and help you see that your self esteem doesn't have to crash and burn just because she does it.

But aren't you making some assumptions here? How do you know the patient's mother DOESN'T hate the patient? And as the patient gains a more realistic view of her mother and comes to depend on her mother's approval less for her own self esteem, why do you assume this will NOT lead to a different type of "crash and burn?" Maybe she'll feel a new kind of loss due to seeing her mother in a more jaded light. I'm just saying I don't see how every psychotherapy scenario necessarily entails a happy ending. Of course, the same scenario without psychotherapy might not have a happy ending either.

 

[Doc Samson]

But how do you know that psychotherapy can change the underlying psychosocial stressors? After all I think a lot of people would like to have their psychosocial problems solved, and if this were the answer I'm sure more people would run off and get therapy right now.

I am just a med student, and I haven't learned any psychotherapy yet. I haven't even been around psych patients, actually, in several months. What I have been seeing are neuro, ER, surgery and primary care patients, and my own friends and family. In other words the usual range of people with their usual ability to irritate each other and undermine themselves as people so often do. And just from what I can see with that population, I think that people are really hard to change. The larger psychosocial stressors must be even more intractable! So I would not want to walk into day one of residency and say, oh hey, I'm here to change everyone's psychosocial stressors.

Though I do look forward to becoming convinced that therapy has a lot to offer, and if that happens to include changing psychosocial stressors, then all the better. It's just that I will wait to learn about the therapies themselves before suspending my disbelief I guess.



But aren't you making some assumptions here? How do you know the patient's mother DOESN'T hate the patient? And as the patient gains a more realistic view of her mother and comes to depend on her mother's approval less for her own self esteem, why do you assume this will NOT lead to a different type of "crash and burn?" Maybe she'll feel a new kind of loss due to seeing her mother in a more jaded light. I'm just saying I don't see how every psychotherapy scenario necessarily entails a happy ending. Of course, the same scenario without psychotherapy might not have a happy ending either.

If you're going into Psychiatry for happy endings, then you're going to be pretty disappointed (as everyone knows, you should go to massage parlors for happy endings). Seriously though, psychotherapy isn't supposed to make you happier, it's supposed to clarify internal and external distortions so that you can figure out what you do and do not have control over. This may or may not make you happy, what it will do is stop you spinning your wheels wasting psychic energy on things you can't change.

 

[dianamd]

But aren't you making some assumptions here? How do you know the patient's mother DOESN'T hate the patient? And as the patient gains a more realistic view of her mother and comes to depend on her mother's approval less for her own self esteem, why do you assume this will NOT lead to a different type of "crash and burn?" Maybe she'll feel a new kind of loss due to seeing her mother in a more jaded light. I'm just saying I don't see how every psychotherapy scenario necessarily entails a happy ending. Of course, the same scenario without psychotherapy might not have a happy ending either.

Of course it is totally possible that the patient's mother hates the patient, and that this realization will lead to another type (perhaps an even more dramatic type) of crash and burn.

My experience is, psychotherapy certainly results in seeing some things in a different light. Maybe it is a jaded light, but definitely something more detached.

I guess my assumption is that understanding ourselves, understanding our relationshps, the dynamics, the motivations behind what we do and what "happens" to us -- this understanding is a good in and of itself. It may lead to more unhappiness and more happiness, that's not the point.

We don't always know what makes us happiest. Something that is terrible today can end up being the most useful experience five years later -- we make that terrible event into a useful experience in the future -- and so we can strive to increase self-awareness and understanding for our patients, and then hope for the best!

just my two cents

 

[billypilgrim37]

How about we get back to "psychotherapy X has great evidence for psychopathology Y, alone or in combination with pharmacotherapy" and leave all this hippy burn out talk to the undergrads talking about their philosophy homework at 3 AM? 😉

(yes, I'm kidding.)

(pass the bong, please?)

 

[nancysinatra]

If you're going into Psychiatry for happy endings, then you're going to be pretty disappointed (as everyone knows, you should go to massage parlors for happy endings).

I've heard of people having bad endings involving massage parlors.

Thanks everyone. I hope I didn't give the wrong impression with my question. Just to clarify, I was curious how we look at the risks and benefits of psychotherapy. I have heard people compare it to surgery in terms of its invasiveness. So this makes me wonder, well, what are the risks of the therapy itself, what are the alternatives, how do we "consent" the patient, etc. (There can't be NO risks. There is at least whatever risk the patient incurs by transporting themselves to the therapist's office each session.) We cover these things in med school when we are looking at other invasive therapies, so I was curious about psychotherapy too. Also, I was wondering how you might track the patient's progress or a cohort of patients' progress over time. If you have a concrete problem like a phobia that seems pretty straightforward but if you are talking about "clarity" I think that would be harder.

I know my scenario was a bit silly but I couldn't think of anything else off the top of my head.

Sorry for hijacking the thread, although the original question seems to have been answered.

 

[nancysinatra]

How about we get back to "psychotherapy X has great evidence for psychopathology Y, alone or in combination with pharmacotherapy" and leave all this hippy burn out talk to the undergrads talking about their philosophy homework at 3 AM? 😉

(yes, I'm kidding.)

(pass the bong, please?)

I know you're kidding but I don't think it's that stupid of a question to ask, even if I can totally understand why this would be a very annoying line of questioning. I feel like med students (especially those who apply for psych residency) are expected to take the value and mechanism of psychotherapy on faith whereas we are indoctrinated to demand evidence and memorize pathways and side effects when it comes to every other therapy we might use.

Actually, you are right, it is hippy burn out talk. But that is more fun than board score talk or call hours talk!

 

[billypilgrim37]

It's a great question to ask!

My way of thinking, people mix up the questions of "does psychotherapy work?" and "how does psychotherapy work." The answer to the first question is, "yes, and here's the evidence." Period. But people frequently jump to the second question before they every consider the importance of the first. Because the second question doesn't matter at all if the first one isn't properly addressed. This of course becomes a little hairier with some dynamic therapies, because our general epidemiologic model of evidence doesn't treat them very kindly, but evidence-based medicine, as we all know intuitively, is much more than just journal articles on Pubmed. Patient values and clinical experience (even collective experience) are just as important for good EBM.

The goal of psychiatry is not self-actualization. But, it seems to be that the pursuit of self-actualization is generally an efficacious treatment for many of the medical disorders we treat. I think that's an important distinction.

 

[nancysinatra]

My way of thinking, people mix up the questions of "does psychotherapy work?" and "how does psychotherapy work." The answer to the first question is, "yes, and here's the evidence." Period. But people frequently jump to the second question before they every consider the importance of the first. Because the second question doesn't matter at all if the first one isn't properly addressed. This of course becomes a little hairier with some dynamic therapies, because our general epidemiologic model of evidence doesn't treat them very kindly, but evidence-based medicine, as we all know intuitively, is much more than just journal articles on Pubmed. Patient values and clinical experience (even collective experience) are just as important for good EBM.

The goal of psychiatry is not self-actualization. But, it seems to be that the pursuit of self-actualization is generally an efficacious treatment for many of the medical disorders we treat. I think that's an important distinction.

It would be helpful if med schools taught public health, epidemiology, and some of the primary care stuff with psychiatry in mind.

My other question is how do you rule out a patient for psychotherapy. Like MOM's example patient--if he's treated with meds for depression and no longer has symptoms (say he goes to a PCP and just gets meds, no psychotherapy). Ok, so now say he's indistinguishable from a normal person and you could not pick him out from a lineup as being depressed. Yeah you might want to change his psychosocial stressors, but everyone else in the lineup probably has psychosocial stressors too, so would you really do anything just for HIM?

Now in medicine you have labs and vital signs with ranges of normal values. So in medicine you could look at those and conclusively say this person has or has not been ruled out for needing further therapy. What is there in psychiatry to tell you that a patient is "normal" enough and may not need, say, psychotherapy? I ask because I could envision some therapist wanting or agreeing to treat every patient indefinitely with therapy because there IS that ideal of self-actualization out there, somewhere.

Admittedly, a lot of my concerns are pretty overblown--they come from growing up on a diet of Woody Allen movies where I thought that the role of analysts was to make their patients more neurotic! That made me want to stay FAR away from psychiatry and everything to do with it... When I get to residency and am surrounded by real life psychiatry again this will stop being a problem, I promise! 🙂

 

[michaelrack]

It's a great question to ask!

My way of thinking, people mix up the questions of "does psychotherapy work?" and "how does psychotherapy work." The answer to the first question is, "yes, and here's the evidence." .

How do you measure "does psychotherapy work" if it's not clear what psychotherapy is supposed to do (make you happy vs "clarify internal and external distortions")??

 

[billypilgrim37]

How do you measure "does psychotherapy work" if it's not clear what psychotherapy is supposed to do (make you happy vs "clarify internal and external distortions")??

The same way you measure whether any treatment works, with imperfect HAM-Ds and BDIs and MADRSSs and all that fun stuff.

It's clear what psychotherapy is supposed to do: improve symptoms. We don't require that medications make you happy or clarify distortions. We require that they decrease symptoms that are distressing or inhibit reasonable function. If they decrease symptoms BY these "mechanisms," then okay, that's well and good, and should be the subject of further research and practice. But the mechanism is a secondary consideration.

By no means am I saying I'm not interested in the mechanisms by which psychotherapy is an effective treatment for various disorders. I'm saying that if we confuse the question of mechanism with the question of efficacy, we sound stupid.

 

[dianamd]

How do you measure "does psychotherapy work" if it's not clear what psychotherapy is supposed to do (make you happy vs "clarify internal and external distortions")??

I always had the impression that clarifying distortions in one's life will make you most happy, by freeing you.

And yes, you can use all sorts of metrics, tests (BDI, PSQI etc.) or even suicide rates, hospital rates (which are bound to be highly biased) -- all the usual half-BS ways to measure things in medicine.

There was a study in the fall of 2008: how long-term psychotherapy is superior to short-term for people with complex mental disorders... here is a brief newspaper article about it that links to the study.

http://latimesblogs.latimes.com/booster_shots/2008/09/long-term-psych.html

It was a German meta-analysis of 23 psychotherapy studies. It made news all over, as a big contributor to the evidence base of psychiatry.

However, if you read it, it is actually a meta-analysis of meta-analyses. The authors compared smaller numbers of papers on specific disorders -- eg 5 papers about depression, 3 papers about anorexia, etc. -- and then summarized those results. Whatever the statistical P-values, etc., say, the paper is far weaker than it was acclaimed to be.

That said, I do think that understanding yourself and the world around you has the potential to make you address your weaknesses, think more deeply about others, and generally develop a stronger ego that will lead to greater happiness. It may not make you happy like a drug, or sex, or some crazy thrill -- but it is a more long-term happiness. At least I hope so...... 👍👍 🙂

Just to clarify, When I say develop a stronger ego, I also believe that this can apply to a somewhat vapid person who has conflicts with her friends. Just by talking to a therapist, thinking about her relationships, perhaps taking a low dose of some medicine (for her anxiety etc), she will probably be "happier" even in the short term. Just did not want to sound like some nut...

 

[michaelrack]

The same way you measure whether any treatment works, with imperfect HAM-Ds and BDIs and MADRSSs and all that fun stuff.

It's clear what psychotherapy is supposed to do: improve symptoms.

I happen to agree with you- I think that the efficacy of psychotherapy, at least that psychotherapy performed or prescribed by medical doctors, should be measured by symptomatic improvement in medical (psychiatric) illness. In other words, when I read about psychotherapy results in a psychiatric/medical journal, I want to know about the decrease in symptoms of a DSM 4 illness (improvement in depression as measured by the HAM D or other rating scale, decrease in number of panic attacks, etc).

There are some forms of psychotherapy, including pscychoanalysis and long-term psychodynamic psychotherapy that have aims that include (in part) insight and clarification of distortions and finding the meaning of life. Any type of research looking at those aims belongs in psychology or social work journals and not psychiatry journals.

 

[nancysinatra]

But aren't some people in psychotherapy for treatment of Axis II problems and only Axis II problems? Including not just borderline personality disorder with its measurable symptoms of cutting and suicide attempts, but also narcissistic personality disorder and schizoid personality disorder, and paranoid personality disorder? And the others... I know they do not present usually as perfectly formed disorders but still, aren't there some patients in therapy with psychiatrists for these problems? And if so, would you really be able, say with a schizoid patient, to quantitatively measure symptomatic improvement in the same way you would with a medical illness or with Axis I depression or panic disorder? Can a severely schizoid patient actually DO much beyond achieve better "clarity?"

I should read more about the treatment for schizoid PD but I thought it was hard to treat and so I wondered what would happen to a patient who, say, gained insight into their illness, but then got stalled when it came to actually changing anything about their personality. That's why I wondered earlier if people might just sometimes become somewhat MORE depressed as they gained greater insight. Also, sometimes don't Axis II patients (borderlines aside) present for treatment in middle age when their problems catch up with them, when it is too late to go back and relive their earlier, mispent years? There again I see a situation where insight could be disheartening. And these are Axis II DSM conditions so this is not just "psychology" or "meaning of life."

I know money is an issue for treating Axis II problems but I am asking about the ideal world, perfect case scenario in which insurance is not involved. These problems are in the DSM and the traits, if not the full blown personality disorders themselves, I thought were rampant among people in general so it seems relevant to psychiatry.

 

[tr]

I feel like med students (especially those who apply for psych residency) are expected to take the value and mechanism of psychotherapy on faith whereas we are indoctrinated to demand evidence and memorize pathways and side effects when it comes to every other therapy we might use.

Then your teachers are not serving you well.

I agree that the results of the analytic and some dynamic approaches don't lend themselves well to measurement (hence why I'm personally less interested in those than in more concrete, behaviorally oriented techniques). But CBT/DBT strategies do quite well when subjected to the same evidence requirements as medications. The pathways are mostly out of our reach at the moment but the side effects are nil!

Rathod et al., J Psychiatr Pract. 2008 Jan;14(1):22-33. Cognitive-behavioral therapy for medication-resistant schizophrenia: a review.
http://www.ncbi.nlm.nih.gov/pubmed/18212600

Tarrier N., Psychother Psychosom. 2005;74(3):136-44. Cognitive behaviour therapy for schizophrenia -- a review of development, evidence and implementation.
http://www.ncbi.nlm.nih.gov/pubmed/15832064

Covin et al., J Anxiety Disord. 2008;22(1):108-16.
A meta-analysis of CBT for pathological worry among clients with GAD.
http://www.ncbi.nlm.nih.gov/pubmed/17321717

Oei et al., J Affect Disord. 2008 Apr;107(1-3):5-21. The effectiveness of group cognitive behaviour therapy for unipolar depressive disorders.
http://www.ncbi.nlm.nih.gov/pubmed/17716745

Etc, etc, etc. But you can do your own PubMed search.

 

[nancysinatra]

Then your teachers are not serving you well.

It's not at the MS1, 2 or clerkship level that I noticed this, it was on the interview trail, where programs will often espouse their support for psychotherapy training. This sounds great! But then I ask myself, how can I, as a med student with 6 or 10 weeks of psych experience total, truly appreciate the inherent dichotomy that clearly lies behind this "support?" Even worse, how can I choose a camp myself, when I haven't even gone through residency yet and LEARNED about both the psychopharm and the psychotherapy camps? I would side with learning more as opposed to learning less, and with wanting to spend time with my patients, and being able to talk to them. But that's hardly scientific.

Thanks for the references!

 

[tr]

Why a "dichotomy?" Therapy and meds aren't opposed. For most psychiatric disorders, the optimal approach is a combination of meds and therapy - typically more effective than either alone.

I don't see this need to choose a "camp." This isn't about taking sides. You can learn to use all of the tools in your arsenal.

 

[nancysinatra]

Why a "dichotomy?" Therapy and meds aren't opposed. For most psychiatric disorders, the optimal approach is a combination of meds and therapy - typically more effective than either alone.

I don't see this need to choose a "camp." This isn't about taking sides. You can learn to use all of the tools in your arsenal.

Why a "dichotomy?" Look, I never said anything about choosing meds vs. therapy for an individual PATIENT (except in the utterly hypothetical, non-real world scenario I was mentioning about a depressed person above.) I was talking about the larger culture of psychiatry. This very thread starts out with someone saying this:

"Does anyone know of solid programs (regardless of region) that emphasize psychopharm more than psychodynamics? Are these programs uncommon? I'm somewhat disenchanted by some of the top-tier schools with websites that boast their psychodynamic focus, with only a passing mention of psychopharm."

If students, who don't KNOW what they need to learn from residency yet, are able to pick and choose what they WILL learn, this certainly suggests that there is a dichotomy out there to me! I myself interviewed at some programs where I was told that psychotherapy training had to be aggressively sought out. Some people even told me it wasn't financially sustainable. At other programs it was clearly a great strength and pride of the program. And don't tell me there aren't dozens of threads on this board along the lines of "which programs are strong in psychodynamic psychotherapy?" None seem to be weak in psychopharm but it is the psychotherapy training that appears to vary. I doubt if you go over to the surgery board you will find such a polarization along the lines of "which residency programs will teach me laparoscopic surgery and which won't require to learn that at all because I'm just not into that?"

I did not make this dichotomy up out of thin air so please don't insinuate that I did. I also don't think it's nice to respond to my earlier post by suggesting that I was taught poorly by my medical school faculty. If you have a problem with my comments then you can take me to task but you cannot infer from one post that the faculty of my school did a poor job. I was referring to the apparent cultural situation in psychiatry as seen by a med student and not to individual patient care.

If someone goes to a program where psychotherapy training is skimpy, how will they learn to take care of patients who can ONLY be treated with psychotherapy, like some of the Axis II patients I asked about earlier, or a somatoform patient or malingerer, say. If someone goes to a program that is strong in psychotherapy, but they make that decision as a med student when they are not yet steeped in the theories behind these therapies, and so their reason for going to such a program is essentially just personal interest, is there a chance that their underlying enthusiasm for psychotherapy will make them overly zealous in applying it later on? That is my larger question here, and yes I am just an unschooled medical student so you can hack away at it. I am wary of continuing to post about this however.

 

[Tradewind]

Why a "dichotomy?" Therapy and meds aren't opposed. For most psychiatric disorders, the optimal approach is a combination of meds and therapy - typically more effective than either alone...I don't see this need to choose a "camp." This isn't about taking sides. You can learn to use all of the tools in your arsenal.

I agree with this completely.

Some programs may emphasize one more than the other, or say that other programs don't emphasize one enough, but in the end, you need both. I think most psychiatrists would agree with that. So maybe it's a matter of terminology... Rather than saying "dichotomy" we should say "emphasis" or "philosophy" or some other more neutral term that won't exclude one method over the other.

Using a surgical analogy, I'd hedge a bet that different programs will emphasize different surgical methods.

 

[nancysinatra]

I agree with this completely.

Some programs may emphasize one more than the other, or say that other programs don't emphasize one enough, but in the end, you need both. I think most psychiatrists would agree with that. So maybe it's a matter of terminology... Rather than saying "dichotomy" we should say "emphasis" or "philosophy" or some other more neutral term that won't exclude one method over the other.

Using a surgical analogy, I'd hedge a bet that different programs will emphasize different surgical methods.

That's because the statement by TR is a truism and no one would disagree with it. But it doesn't explain the things people SAY about psychodynamic psychotherapy training being almost non-existent at WashU, for example (see Post #2 of this thread), or the interview comments I myself encountered where attendings told me psychodynamic psychotherapy is not financially sustainable, or the myriad comments I have heard (including on this board) about psychotherapy being turned over to psychologists in some parts of the country.

I believe surgery residencies are required to provide residents a certain minimum number of cases in each major type of surgery, and beyond that there may be room for "emphasis." I could be wrong but I doubt their governing body leaves much to philosophy.

 

[tr]

If students, who don't KNOW what they need to learn from residency yet, are able to pick and choose what they WILL learn, this certainly suggests that there is a dichotomy out there to me! I myself interviewed at some programs where I was told that psychotherapy training had to be aggressively sought out. Some people even told me it wasn't financially sustainable. At other programs it was clearly a great strength and pride of the program... I did not make this dichotomy up out of thin air so please don't insinuate that I did.

This is going to sound nitpicky, but a 'dichotomy' is defined as any splitting of a whole into exactly two non-overlapping parts. (A 'false dichotomy' consists of a supposed dichotomy which fails one or both of the conditions: it is not jointly exhaustive or not mutually exclusive.)

So by saying there is a 'dichotomy' between meds and therapy, you imply that the two cannot be taught or used simultaneously. If that's not what you meant, perhaps you could find a different word that would better express your intended meaning.

The mere fact that some programs don't teach therapy well (which is true) does not imply the existence of a dichotomy.

I also don't think it's nice to respond to my earlier post by suggesting that I was taught poorly by my medical school faculty. If you have a problem with my comments then you can take me to task but you cannot infer from one post that the faculty of my school did a poor job. I was referring to the apparent cultural situation in psychiatry as seen by a med student and not to individual patient care.

Sorry if I offended you. It wasn't meant as an insult. But when you say "I feel like med students... are expected to take the value and mechanism of psychotherapy on faith," that does suggest that you haven't been exposed to the evidence base for psychotherapeutic approaches. Am I wrong?

If someone goes to a program where psychotherapy training is skimpy, how will they learn to take care of patients who can ONLY be treated with psychotherapy, like some of the Axis II patients I asked about earlier, or a somatoform patient or malingerer, say.

They will probably do a worse job of it than someone who had more appropriate training in how to care for that type of patient.

If someone goes to a program that is strong in psychotherapy, but they make that decision as a med student when they are not yet steeped in the theories behind these therapies, and so their reason for going to such a program is essentially just personal interest, is there a chance that their underlying enthusiasm for psychotherapy will make them overly zealous in applying it later on?

There will always be some practitioners who push therapy to the last possible second, avoiding meds like the plague - and others who reach for the pills without so much as a "tell me about your mother." "Overly zealous" is hard to define, and ultimately probably a matter of individual opinion.

 

[Tradewind]

That's because the statement by TR is a truism and no one would disagree with it...I believe surgery residencies are required to provide residents a certain minimum number of cases in each major type of surgery, and beyond that there may be room for "emphasis." I could be wrong but I doubt their governing body leaves much to philosophy.

Okay, my point is that you are misusing the word dichotomy. What TR said is true, and yet, a fair number of medical students and residents still describe this debate in terms of dichotomy. So, I don't think what he said was trivial or obvious, especially for someone who just wrote what you wrote.

I'm not sure what you're saying regarding surgery. The analogy still holds, in my opinion.

 

[Kazema]

There is some degree of "emphasis" within surgery programs - mostly related to the presence or absence of surgeons who specialize in certain types of surgeries.

For example, I have a friend at a pretty prestigious orthopedic surgery program. One of his complaints about his program is that pretty much none of the surgeons really use the computer navigation systems when doing total knee replacements, and he feels like he's going to graduate residency without really being comfortable using those systems.

 

[nancysinatra]

This is going to sound nitpicky, but a 'dichotomy' is defined as any splitting of a whole into exactly two non-overlapping parts. (A 'false dichotomy' consists of a supposed dichotomy which fails one or both of the conditions: it is not jointly exhaustive or not mutually exclusive.)

So by saying there is a 'dichotomy' between meds and therapy, you imply that the two cannot be taught or used simultaneously. If that's not what you meant, perhaps you could find a different word that would better express your intended meaning.

The mere fact that some programs don't teach therapy well (which is true) does not imply the existence of a dichotomy.

Ok, thanks. I was using the word loosely, but I must say that what a med student on the interview trail sees and what a resident or attending sees will be different things. We were getting sales pitches on the interview trail about PROGRAMS (not patient care protocol). Sales pitches tend to exaggerate things. If you can believe me about that part of it, you might understand why I chose the word dichotomy. I'm only talking about appearances, since I certainly don't claim to know the reality of what goes on. I also haven't been posting on this board about the "psychopharm/psychotherapy" debate in the past. I'm not all worked up about it. But in interviewing and ranking programs, I felt I sometimes was over my head in the propaganda of the profession related to this debate. It's gotta be true in any profession when you go out and interview that there's some showmanship that does happen. I then also wondered, well if there possibly IS a difference in what some programs are teaching residents, won't this trickle DOWN to patient care somehow? Patients don't know in advance which doctors have been trained with which emphasis after all. They just make appointments and show up. This is why I suppose it sounds like I am asking if there is a "dichotomy" between meds and therapy... Because whatever difference affects residency programs, if in fact it's even real, will affect patients who see those doctors, won't it?

Then I found this thread where others at my level were proclaiming their "views" (somewhat anyway) about psychotherapy and it baffled me: how can an MSIV be anything other than a little confused at this point?

Sorry if I offended you. It wasn't meant as an insult. But when you say "I feel like med students... are expected to take the value and mechanism of psychotherapy on faith," that does suggest that you haven't been exposed to the evidence base for psychotherapeutic approaches. Am I wrong?

I was exposed to evidence for many psychotherapies, like CBT and DBT, but with others, like psychoanalysis, or maybe psychodynamic psychotherapy, we learned what they are and were exposed to lots of interesting background and theory, but I don't recall going into detail about evidence or clinical trials, in the same way that we might have been lectured to about, say, a hypertension drug. I think that would be a bit arcane to expose all medical students to those debates, seeing as I can't even stir up much of a discussion on this board about those things right now!

At interviews I heard about psychoanalytic institutes we could apply to. I'm all up for that. But again, I have no idea why I'm all up for that, other than personal interest. For all I know psychoanalysis has no use at all! That's why I'm saying there is a faith-based component to this.

Anyway, I just took it for granted that people would not criticize their medical school faculty on this board. That would be extraordinarily rude! (And untrue in my case.)

My point is just that I went on interviews, professed my own opinions, realized they were basically bunk, and now I'm skeptical and eager to learn. That's all.

They will probably do a worse job of it than someone who had more appropriate training in how to care for that type of patient.

Epidemiologically, doesn't that have an effect on how well able we are to control the rates of these illnesses in the society? Isn't there some governing body that monitors whether graduating residents can actually care competently for all types of psychiatric patients? How can programs not provide "appropriate training" for a certain "type" of psychiatric patient? I don't understand that. There will be patients of that type that might go to that doctor. Do they have to provide a statement saying "since I didn't get trained in type of therapy X I cannot treat disease Y, even if it is urgent or debilitating?"

 

[Doc Samson]

Coming out of med school I was pretty much in the same boat, so I chose the residency that I thought would expose me to the most eclectic mix possible figuring that I couldn't dismiss something unless I'd tried it. I absolutely agree that as a medical student you're incapable of being able to realistically weigh all the evidence pro and con psychotherapy (or anything else) since your knowledge and experience base isn't broad enough yet. As far as psychotherapy is concerned, if you go to a "psychopharm only" program for residency it never will be.

 

[psychattending]

The reason they're boasting their psychodynamic focus is that almost every program will teach psychopharm, while psychodynamics is becoming a rarer thing to find. I doubt that you'd find a top-tier program that doesn't teach psychopharm well. That said, if you're interested in becoming a "psychopharmacologist" (and you won't have to search to far on these threads to find my opinion about that), then Wash U St. Louis is well-known for providing a rigorous psychopharm experience with almost no emphasis on psychodynamic psychotherapy.

It depends on what you mean by psychodynamic psychotherapy. If by psychodynamic you mean something akin to psychoanalytical training, then I would agree that we do not emphasize training in that area of psychotherapy. However, we do provide our residents with very good training in those psychotherapies that have data supporting their use as treatment for a clinical illness. Given the training our residents receive in psychotherapies coupled with the depth of pharmacology training our residents receive and the breadth of patients we treat, our residents perform exceedingly well when they enter clinical practice. They are just as talented clinically as those who are trained at other top notch programs. I would encourage any applicant, who thinks he/she might be interested in training with us but are hesitant to do so because of rumors, to come and see firsthand how we train our residents to practice psychiatry.

Nuri B. Farber, M.D.
Director, Psychiatry Residency Training Program
Washington University
http://www.psychiatry.wustl.edu/

 

[masterofmonkeys]

My other question is how do you rule out a patient for psychotherapy. Like MOM's example patient--if he's treated with meds for depression and no longer has symptoms (say he goes to a PCP and just gets meds, no psychotherapy). Ok, so now say he's indistinguishable from a normal person and you could not pick him out from a lineup as being depressed. Yeah you might want to change his psychosocial stressors, but everyone else in the lineup probably has psychosocial stressors too, so would you really do anything just for HIM?

Sorry for the late reply. Two weeks post-op from wrist surgery and my right hand finally feels like a hand again.

I'm neither a psychiatrist nor a strength coach yet, but I'm working on both. But it seems to me that mood/anxiety/panic/emotion are very similar to somatic pain. In that the are symptoms of a problem and not necessarily a problem in and of themselves.

One of the concepts I've taken from my most important strength coaching role model--Eric Cressey--is the idea of waiting to reach threshold. Dysfunction is not always symptomatic. But dysfunction, over time, will lead to symptoms. We can address the symptoms (NOT TREAT ARGH!) in a number of ways that can restore you to an asymptomatic level. In MSK, this can be done through anti-inflammatories, pain pills, or steroid injections, or even just RICE. But this symptomatic management does little to address the underlying dysfunction.

We can make their symptoms go away, but unless we remove the underlying dysfunction they will return.

Another thing that is stressed in the dealing of MSK dysfunction by strength coaches (who come from a kinesiology and exercise science background, and who are trained to address rehabilitation, not just fitness), is finding the source of the pain. A painful shoulder doesn't mean that the source of the pain is in the shoulder. Usually the first thing I check is the upper back. Excessive kyphosis and weak scapular stabilization are far more likely to be the ultimate culprits in shoulder pain than what the patient points to. Or lower back pain often being linked to abdominal or pelvic issues.

I personally address posture and biomechanics in EVERYONE I train, regardless of current perceived pain. And funnily enough every one of them tells me their back, neck, and joints feel better. And the majority of them reported no pain or MSK issues when I started working with them in the first place.

IMO, you address dysfunction if its there. Particularly if it has resulted in or contributed to symptomatic syndromes. You can manage the symptoms of depression and anxiety with medicine, and perhaps by decreasing the psychic pain, allow them the space they need to deal with emotional issues in a more healthy way, but if you don't address the unhealthy aspects of cognition and psychosocial stress response, you really haven't done anything to change the likelihood of them developing depression again.

 

[masterofmonkeys]

It's clear what psychotherapy is supposed to do: improve symptoms. We don't require that medications make you happy or clarify distortions. We require that they decrease symptoms that are distressing or inhibit reasonable function. If they decrease symptoms BY these "mechanisms," then okay, that's well and good, and should be the subject of further research and practice. But the mechanism is a secondary consideration.

The question of efficacy implies that the only therapies or treatment modalities worth considering are those that actually change symptoms or measured lab values. What should I tell an obese patient with a poor diet and no physical activity who has normal FBG, chol, trig, BP, and no MSK issues? "Come back when you have a medical issue"?

As I mentioned in my above post, addressing dysfunction is a good goal in and of itself, regardless of its impact in current symptomatology. And it can be argued that in fact the mechanism of improvement in symptoms is improvement. As those that improve symptoms by addressing dysfunction do have lower relapse/recurrence rates across all aspects of medicine and health. Whether it's the better long term results of posture-movement training/physical therapy/weight loss in MSK, or the lower relapse/recurrence rates for psychotherapies alone or in combination, that's pretty clear.

 

[TheWowEffect]

It depends on what you mean by psychodynamic psychotherapy. If by psychodynamic you mean something akin to psychoanalytical training, then I would agree that we do not emphasize training in that area of psychotherapy. However, we do provide our residents with very good training in those psychotherapies that have data supporting their use as treatment for a clinical illness. Given the training our residents receive in psychotherapies coupled with the depth of pharmacology training our residents receive and the breadth of patients we treat, our residents perform exceedingly well when they enter clinical practice. They are just as talented clinically as those who are trained at other top notch programs. I would encourage any applicant, who thinks he/she might be interested in training with us but are hesitant to do so because of rumors, to come and see firsthand how we train our residents to practice psychiatry.

Nuri B. Farber, M.D.
Director, Psychiatry Residency Training Program
Washington University
http://www.psychiatry.wustl.edu/

Dear Dr. Farber,

Thank you so much for this post. Your program has been getting an unfair rap on this board for being so called "pharmacology oriented". I am glad you are doing great service to psychiatry by doing what your doing there. Keep it up!

Disclaimer- I have no affiliation with the Washu program.

 

[Doc Samson]

It depends on what you mean by psychodynamic psychotherapy. If by psychodynamic you mean something akin to psychoanalytical training, then I would agree that we do not emphasize training in that area of psychotherapy. However, we do provide our residents with very good training in those psychotherapies that have data supporting their use as treatment for a clinical illness. Given the training our residents receive in psychotherapies coupled with the depth of pharmacology training our residents receive and the breadth of patients we treat, our residents perform exceedingly well when they enter clinical practice. They are just as talented clinically as those who are trained at other top notch programs. I would encourage any applicant, who thinks he/she might be interested in training with us but are hesitant to do so because of rumors, to come and see firsthand how we train our residents to practice psychiatry.

Nuri B. Farber, M.D.
Director, Psychiatry Residency Training Program
Washington University
http://www.psychiatry.wustl.edu/

To quote Gabbard:

Psychodynamic psychiatry is an approach to diagnosis and treatment characterized by a way of thinking about both patient and clinician that includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations and that integrates these elements with contemporary findings from the neurosciences.

So while it's not psychoanalysis, it certainly incorporates some major psychoanalytic themes. As has been discussed in other threads, evidence base for this style of treatment is hard to come by since it's impossible to standardize the therapy from patient to patient.

No-one's doubting the talent of your trainees or commenting on the training you provide in other forms of therapy. The OP asked for a recommendation of a program that provided strong psychopharm training without emphasis on psychodynamic psychotherapy. I think we agree that your program fits the bill.