Psychiatrists doing psychotherapy in settings other than private practice

[woof_iamadog]

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I'm a medical student nearing the end of clerkship year, and I'm leaning towards psychiatry. In particular, I'm most drawn to psych because I really like getting to actually talk to my patients, listen to issues / traumas that they may have never revealed to anyone else, and I liked that in psych I saw my patients as whole people and not just lab values.

I saw firsthand how much good can come out of even a short medication management visit, and how psychiatrists often incorporate supportive psychotherapy into these visits. I've also read about psychiatrists doing longer-duration / more frequent psychotherapy (i.e. psychodynamic psychotherapy) in private practice settings. From what I've read, it seems like psychiatrists can readily carve out their own heavily psychotherapy-focused practices in private practice and occasionally in non-private practice settings...

So how common are these outpatient public sector jobs where you can negotiate doing some psychotherapy along with med management? Would something like this be possible at the VA outpatient? Let's say you really enjoy psychotherapy and are willing to put in extra time to do psychotherapy each week - would most public sector employers allow this, or are there often strict rules separating the roles of psychiatrists, clinical psychologists, licensed clincial social workers, etc?

 

[nexus73]

I think meds plus psychotherapy works great with 40 minute follow up appointments. Most jobs don’t let you do this, typically get 30 minute appointments which is pretty tight.

 

[nitemagi]

There is such a shortage right now, I suspect that psychiatrists could ask for this in their contract if they wanted. Not enough ppl exercise this leverage though when job seeking.

 

[Bartelby]

I think doing 10-20 percent time in therapy is attainable in many settings. As nitemagi says you would need to seek that out. Some employed positions will allow large percentages of time spent doing therapy, but I think that is pretty rare.

I thought doing 10-20 percent formal psychotherapy would be far too little, but now that I'm doing that I find it keeps those skills sharp and lets me hold on to something I love while allowing me to take more of a team leader and E&M approach much of the time. I feel pretty happy with formal therapy being a pretty small portion of my overall practice.

 

[EarlyCareerAcademicPsych]

I work primarily in a VA system where 50% of my clinical work is individual and group psychotherapy and 50% is general outpatient psychiatry. This is unusual and I had to advocate to get it.

The American Psychiatric Association is in support of psychiatrists doing psychotherapy. There is an "APA Psychotherapy Caucus" that you can join, even as a medical student member of APA.

Most hospital systems do not support psychiatrists doing psychotherapy. Some hospital systems are work to exclude both psychiatrists and psychologists from doing psychotherapy and allocate this work only to master's level clinicians (social work, counseling psychology, others). This is simply about money. Administrators do not understand the additional quality that comes from psychiatrists doing psychotherapy, so they are trying to cut costs. That's their job! And it is our job to push back.

 

[futuredo32]

My psychiatrist works as an independent contractor in a clinic. He pretty much dictates what he will do. He does a lot of therapy. I work at a clinic currently a few days a week and my job is to manage medications only. They have a slew of therapists who are in need of patients.

 

[TexasPhysician]

You can negotiate anything, but be prepared to accept less in salary for more therapy time.

 

[Attending1985]

It can be done but I would be prepared to work in private practice. You will be hard pressed to find a traditional hospital based system that will allow this. Maybe in a very underserved, rural area where you have lot of negotiating power but you don't want to limit yourself to that. If you go that route get disability insurance right away when you start residency (hopefully you qualify) otherwise you're gonna be tied to an employer to get it.

 

[futuredo32]

Honestly, I think that no matter what you do, you or should do some therapy even if it's just med management. No, it's not a complete typical therapy, but I think I squeeze some in with all patients, it's hard not to.

 

[Stagg737]

I have an outpatient attending at our VA (urban setting, decent sized) who still does a fair amount psychotherapy with her patients. The VA doesn't really set any time aside for this from what I've gathered, but she still makes it work somehow and has some patient that have more than 30 minutes follow-ups.

 

[SourceOfDenial]

I’m only 20% clinical, but all my follow ups are an hour and news are 90 min in the VA. Everyone gets psychotherapy.

 

[woof_iamadog]

Super helpful replies - thanks everyone. It seems based on these responses that it certainly is possible to work in the public sector while still doing some psychotherapy, although this will require self-advocacy and earning less. It also seems very workplace-dependent, even from one VA to another.

I really like that psychodynamic psychotherapy in particular is so "operator-dependent" (just finished my surgery rotation ha) / skill-based and has such a potential to do good for people. I'm glad potential new psychiatry students like myself still have hope to practice this skill and incorporate it into our careers.

Please keep the replies coming - all perspectives are helpful.

 

[dl2dp2]

Not disagreeing with what people are saying, but in general I'm less bullish on psychotherapy being done by MDs--even though I do a lot of therapy but in private practice. The psychotherapy market is highly fragmented. If you are clever you can carve out a niche but generally psychotherapy providers are non-MDs, and they work a lot and don't get paid well. They also don't often provide "real" therapy. There's also lots of other issues (most therapists women, most people who can't find a therapists are probably men, lots of issues re: where money is, etc).

I think the baseline expectation of you in a public job is NOT psychotherapy. It's POSSIBLE if you bend over backward, but this kind of work is probably done in private--which is fine to me.

 

[FlowRate]

I have an interview with a large medical group coming up and I plan to ask this question (not sure whether the recruiter will know the answer tho.) Will circle back with the results. I'd like to do 5-8 hours of therapy per week, which is what I'm doing in residency.

 

[WisNeuro]

Not disagreeing with what people are saying, but in general I'm less bullish on psychotherapy being done by MDs--even though I do a lot of therapy but in private practice. The psychotherapy market is highly fragmented. If you are clever you can carve out a niche but generally psychotherapy providers are non-MDs, and they work a lot and don't get paid well. They also don't often provide "real" therapy. There's also lots of other issues (most therapists women, most people who can't find a therapists are probably men, lots of issues re: where money is, etc).

Heck, in many medical systems, they don't even want to pay PhDs to do therapy, why would they pay more for MDs to do it? Over the years, more and more of this (on the institutional level) is being given over to midlevels. I don't see that trend changing. Private practice will be the last real refuge for doctoral level practitioners practicing therapy as time goes on.

 

[nitemagi]

Heck, in many medical systems, they don't even want to pay PhDs to do therapy, why would they pay more for MDs to do it? Over the years, more and more of this (on the institutional level) is being given over to midlevels. I don't see that trend changing. Private practice will be the last real refuge for doctoral level practitioners practicing therapy as time goes on.

It's a unique position for psychiatrists right now because there's such a shortage, we have a bit more bargaining power in terms of asks in a job negotiation. Think of it like a job perk.

 

[MBBSMOM]

Heck, in many medical systems, they don't even want to pay PhDs to do therapy, why would they pay more for MDs to do it? Over the years, more and more of this (on the institutional level) is being given over to midlevels. I don't see that trend changing. Private practice will be the last real refuge for doctoral level practitioners practicing therapy as time goes on.

This is the same as how I feel except as an MD . The hospital I work at still has psychiatrists doing mostly inpatient and php. Many hospital systems have replaced psychiatrists with psych nps at the inpatient/php level and outpatient level. I feel as time goes on most of us will also be forced into private practice.

 

[WisNeuro]

It's a unique position for psychiatrists right now because there's such a shortage, we have a bit more bargaining power in terms of asks in a job negotiation. Think of it like a job perk.

I'm sure that in some places, that shortage does indeed increase bargaining power. Our sister hospital was trying to recruit a psychiatrist, took too long, so they just hired 2 NPs instead. YMMV depending on local trends, but I can't imagine anyone being able to carve out any sizable chunk of psychotherapy time as a psychiatrist in our system.

 

[Sushirolls]

This is the same as how I feel except as an MD . The hospital I work at still has psychiatrists doing mostly inpatient and php. Many hospital systems have replaced psychiatrists with psych nps at the inpatient/php level and outpatient level. I feel as time goes on most of us will also be forced into private practice.

Our system will eventually fracture, not completely, but definitely a large crack based upon ARNP vs doctor. Big box vs small practices [and possibly with this real quality...]

 

[dl2dp2]

Our system will eventually fracture, not completely, but definitely a large crack based upon ARNP vs doctor. Big box vs small practices [and possibly with this real quality...]

Indeed, did you see the new Walmart Health price list? Google it. I'm damn sure no MD is doing that.

 

[Sushirolls]

Indeed, did you see the new Walmart Health price list? Google it. I'm damn sure no MD is doing that.

Those numbers are very low, and very low even with ARNPs.

This excerpt at the bottom of the PDF, might show that this is misleading and the likely range of out of pocket costs after submitting to insurance and not the actual fee schedule:
"*Charges shown are the average prices customers are expected to pay for these specific services, but actual cost will be determined on a case by case basis"

But if they are indeed the actual prices they may be trying to subsidize to further get people into their stores due to competition with Target, and especially Costco. They may be trying the long haul play of get people in the door and once they get more market share, then jack up the prices.

 

[downwithDTB]

But if they are indeed the actual prices they may be trying to subsidize to further get people into their stores due to competition with Target, and especially Costco. They may be trying the long haul play of get people in the door and once they get more market share, then jack up the prices.

Your hypothesis is strong. Alternatives/additional things would be making money on testing and/or pharmacy (likely with unnecessary ordering); contracting with pretty much every insurance company so that they only take out of pocket hits on the uninsured and hiring the cheapest/worst possible providers; and also using the very, very cheap providers for their health insurance such that their 1.5 million employees (and their families) can only get care from them, massively driving down their health insurance expenditures (the same model that academic health centers use, except that some of them still have decent MDs).

So in my model, they provide cheap care to the uninsured while getting them into the store (your idea), they make money off of insurance companies by testing excessively, giving everyone who is a little sad pristiq, everyone with a cold a zpack and referring everyone else to an urgent care with 5 min max visits, and forcing all of their employees into substandard care for dirt cheap.

... so if any multinational corporations need a CEO and want to make some more money, I've got ideas... just saying...

 

[clausewitz2]

I'm sure that in some places, that shortage does indeed increase bargaining power. Our sister hospital was trying to recruit a psychiatrist, took too long, so they just hired 2 NPs instead. YMMV depending on local trends, but I can't imagine anyone being able to carve out any sizable chunk of psychotherapy time as a psychiatrist in our system.

Our system has a couple of psychiatrists who still do a good chunk of psychotherapy, but at least one of them has significant psychotherapy research funding that she brings to the table (Holly Swartz) which obviously helps. IPSRT ("go to bed, no, seriously, go to bed") is also probably not what most people think of when they think about wanting to do psychotherapy, so there's that as well.

 

[dl2dp2]

Our system has a couple of psychiatrists who still do a good chunk of psychotherapy, but at least one of them has significant psychotherapy research funding that she brings to the table (Holly Swartz) which obviously helps. IPSRT ("go to bed, no, seriously, go to bed") is also probably not what most people think of when they think about wanting to do psychotherapy, so there's that as well.

I would argue that this is the only kind of therapy most patients would benefit from: evidence-based, manually driven, behaviorally oriented treatment. IPT or MBT technically not behaviorally oriented, but they work great so I'll allow it 🙂.

Sadly, it's shocking how few LCSWs and PhDs do it when you refer out. So as an MD I end up doing this kind of "psychotherapy" which perhaps in many ways are designed to be not done by me.

I had experiences where PhD therapists tell me that they don't do CBT because they have "philosophical qualms" with it. I have had PhD therapists sending me nasty letters because I "stole their patients" because the patient got fed up with their drawn-out analysis of their childhood and confessional rituals. Clinicians in the community are often not doing the very basics of evidence-based care.

This is not saying I'm against psychodynamics or insight, but everything has a time and a place. Nor is it saying that psychiatrists don't have the same problems. I wish I didn't have to de-prescribe everyone off their lamictal.

 

[WisNeuro]

@sluox are you on a coast? Or a location with a high degree of diploma mills (e.g., Argosy/Alliant)? Those are usually the hotbeds of people doing mostly dynamic and non-empirically supported work with patients. I'm with you about finding good therapists, though. I have a fairly short list of people I will refer out to for therapy or people who I either know personally, or have vetted their training background.

 

[deleted736562]

I'm not sure what people are calling evidence-based or empirically driven.

Are we saying CBT is evidence-based but not psychodynamic? By evidence, is it studies supporting efficacy?

 

[clausewitz2]

Are we saying CBT is evidence-based but not psychodynamic?

I mean...is there a part of that description that you object to?

 

[Stagg737]

I had experiences where PhD therapists tell me that they don't do CBT because they have "philosophical qualms" with it.

I'm curious as to what those philosophical qualms with it are...

 

[WisNeuro]

I'm curious as to what those philosophical qualms with it are...

Most likely that they were poorly trained and don't understand it. Any program worth a damn trains people in CBT and psychodynamic therapy. Most of us from those programs have at least 1-2 years of supervised experience in both just during the grad school years. Some, less than reputable programs, train in very limited ways.

 

[FlowRate]

I mean...is there a part of that description that you object to?

So you're saying psychodynamic is not evidence-based?

 

[Stagg737]

Most likely that they were poorly trained and don't understand it. Any program worth a damn trains people in CBT and psychodynamic therapy. Most of us from those programs have at least 1-2 years of supervised experience in both just during the grad school years. Some, less than reputable programs, train in very limited ways.

It's pretty scary to me that a PhD program in psychology wouldn't have adequate training in CBT. LCSW not having the proper training I could see, but a full Phd? That's just not right.

 

[MBBSMOM]

It's pretty scary to me that a PhD program in psychology wouldn't have adequate training in CBT. LCSW not having the proper training I could see, but a full Phd? That's just not right.

The PhD psychologists I work with are very sharp and all of them have adequate training in CBT. It’s usually the PsyDs who are improperly trained.

 

[WisNeuro]

It's pretty scary to me that a PhD program in psychology wouldn't have adequate training in CBT. LCSW not having the proper training I could see, but a full Phd? That's just not right.

Some coastal PhDs are somewhat outdated in that way. And, as mentioned, PsyDs tend to have poor training models beyond a handful of reputable programs.

 

[dl2dp2]

I'm not sure what people are calling evidence-based or empirically driven.

Are we saying CBT is evidence-based but not psychodynamic? By evidence, is it studies supporting efficacy?

Psychodynamic psychotherapy is proven [as] effective. However, the mode with which they are delivered in real life are not evidence based.

Let me explain: both fluoxetine and sertraline are evidence based. You try fluoxetine, if it doesn't work you move on to sertraline.

It's fine if you want to start for a 3 month trial of Brief Dynamic, and assess for response. If not effective then switch to IPT or CBT, or perhaps schema therapy or TFP, etc.

It's definitely NOT evidence based to keep trying something that doesn't work.

Secondarily, since I'm on my soap box, LOTS of therapists purport to be doing psychodynamic psychotherapy but are actually doing nothing. Good psychodynamic psychotherapy is really challenging to do, and when I reviewed some of these cases it's CRAZY what's going on in these rooms. There are therapists who actively sabotage medication-assisted therapy for substance use disorders, for example, because they think that the reason patients are not motivated is because of ... "defenses". This is not uncommon--I bet lots of people here can relate to episodes of this type. So I'm kind of like, omg if you don't know what you are doing, you need to just go down to the basics and follow a manual. They do hocus pocus, and I'm not their boss so I can't be like your patient hates you. Then the patient comes in our regular med mgmt appt and be like I don't like this therapy thing, what do you suggest, I say okay maybe let's just buy a manual off Amazon. 3 months later the patient is in remission. #Science!

Literally, this happens all the time. And literally I had multiple therapists on the phone yelling at me because I "stole" their patients. One therapist told me that I need to insist that the patient goes back to her even though she hates her! Maybe it's splitting, but when remission happens so "quickly" (really not, this is just all consistent with the findings that 80% of whatever in remission with meds+therapy) when the quote-unquote right thing was done, I really don't think a personality disorder is what's going on here.

Shockingly, for my intakes, perhaps only about 10% of patients ever had a real manual driven treatment. And since I see relatively sick patients, they almost always had previous significant exposure to mental health. It's not rare where after 3 months patients tell me that this helped them more than the years of therapy they had in the past because, shock of all shocks, I insisted that they do homework. Literally the only thing that helps.

And yes, maybe this is a coastal thing. I have a vague feeling this has to do with private pay therapists have ulterior conflict of interest. My sources in the VA and in the Midwest tell me that in large systems this is unusual. Therapists start with CBT more often using a program. Problems is sicker people who need real long term treatment (DBT/TFP/schema, etc) then get dropped off, and they have a lot of sick people.

 

[clausewitz2]

So you're saying psychodynamic is not evidence-based?

Not at all, but I suppose I did not assume CBT being evidence-based meant other approaches couldn't be evidence-based as well.

EDIT: I see the trouble. I did not realize fpsychdoc was eliding something like "but psychodynamic is not" and thought he was saying that CBT was not a psychodynamic approach...which seems uncontroversial.

 

[watto]

My beef: the therapist who advocates for time off from work due to stressors there "because symptoms are likely to worsen in that environment." Absolutely no time spent addressing reaction to stressors, how to reframe conflicts, how to DEAL WITH LIFE. Learn how to be assertive, how to set boundaries, how to ask for your needs to be met rather than crumple any time you are faced with a stressor...ugh.

And thank you for teaching deep breathing techniques, but the patient is going to need more than that to address how they approach interpersonal conflict.

 

[deleted736562]

Psychodynamic psychotherapy is proven [as] effective. However, the mode with which they are delivered in real life are not evidence based.

Let me explain: both fluoxetine and sertraline are evidence based. You try fluoxetine, if it doesn't work you move on to sertraline.

It's fine if you want to start for a 3 month trial of Brief Dynamic, and assess for response. If not effective then switch to IPT or CBT, or perhaps schema therapy or TFP, etc.

It's definitely NOT evidence based to keep trying something that doesn't work.

Secondarily, since I'm on my soap box, LOTS of therapists purport to be doing psychodynamic psychotherapy but are actually doing nothing. Good psychodynamic psychotherapy is really challenging to do, and when I reviewed some of these cases it's CRAZY what's going on in these rooms. There are therapists who actively sabotage medication-assisted therapy for substance use disorders, for example, because they think that the reason patients are not motivated is because of ... "defenses". This is not uncommon--I bet lots of people here can relate to episodes of this type. So I'm kind of like, omg if you don't know what you are doing, you need to just go down to the basics and follow a manual. They do hocus pocus, and I'm not their boss so I can't be like your patient hates you. Then the patient comes in our regular med mgmt appt and be like I don't like this therapy thing, what do you suggest, I say okay maybe let's just buy a manual off Amazon. 3 months later the patient is in remission. #Science!

Literally, this happens all the time. And literally I had multiple therapists on the phone yelling at me because I "stole" their patients. One therapist told me that I need to insist that the patient goes back to her even though she hates her! Maybe it's splitting, but when remission happens so "quickly" (really not, this is just all consistent with the findings that 80% of whatever in remission with meds+therapy) when the quote-unquote right thing was done, I really don't think a personality disorder is what's going on here.

Shockingly, for my intakes, perhaps only about 10% of patients ever had a real manual driven treatment. And since I see relatively sick patients, they almost always had previous significant exposure to mental health. It's not rare where after 3 months patients tell me that this helped them more than the years of therapy they had in the past because, shock of all shocks, I insisted that they do homework. Literally the only thing that helps.

And yes, maybe this is a coastal thing. I have a vague feeling this has to do with private pay therapists have ulterior conflict of interest. My sources in the VA and in the Midwest tell me that in large systems this is unusual. Therapists start with CBT more often using a program. Problems is sicker people who need real long term treatment (DBT/TFP/schema, etc) then get dropped off, and they have a lot of sick people.

OK so what you're saying is that psychodynamic therapy in the wrong hands suck. I mean, that's probably true for all therapies. And I'd also argue that even if you follow the "manual", you can still suck. Therapy is an art however you dice it. The literature suggests that they work equally well in the right hands, and I think that would be the fair conclusion from the actual "evidence" we have. Unless by "evidence" people mean closely tracking progress through symptom scales; which is a fair point, but there's nothing stopping you from tracking symptom progress in psychodynamic therapy; perhaps not weekly, but who said we need to do this weekly? May be quite counterproductive.

The problem is that I've seen many who hold their collective nose whenever psychodynamic is mentioned because it is supposedly not "evidence-based" like manualized treatments such as CBT or CPT. I think there's a sort of assurance to know you're following a manual rather than improvising in the hour and I guess that's where the "evidence-based" is coming in, but the irony is that's actually not evidence-based.

From my experience I found that psychodynamic therapy can complement CBT and sometimes it's badly needed. People hold on to their maladaptive thoughts/core beliefs for a reason and no matter how much evidence they or you throw at them, those beliefs don't always budge unless you unravel the developmental/dynamic factors underneath.

 

[FlowRate]

real manual driven treatment

As an aside, I've found it really interesting that none of the (very good) CBT supervisors that I've had have actually advocated using treatment manuals. As if no one performs CBT in its "evidence-based" form, either.

I did not assume CBT being evidence-based meant other approaches couldn't be evidence-based as well.

Ah, I think I was inferring from how some people use "evidence-based" therapy as a synonym for CBT and to imply that psychodynamic is not evidence-based.

 

[dl2dp2]

OK so what you're saying is that psychodynamic therapy in the wrong hands suck. I mean, that's probably true for all therapies. And I'd also argue that even if you follow the "manual", you can still suck.

Sure, but I find it problematic that people making assumptions (that my particular therapy with a particular patient is working) without actively assessing for concrete symptoms, and when concrete symptoms improve, don't continue to assess for necessity for further treatment.

When you talk about "evidence-based", it doesn't just mean that you are using a procedure that's shown to work. It means that you are practicing medicine with the intent to follow an application of the scientific method. Otherwise why bother doing science? Just do whatever voodoo that you feel like works, and when it doesn't work, just say that in my opinion it'll work better later.

Now, this point is controversial in the sense that many therapists don't think of themselves as practicing a applied science in the sense of being analogous to what a surgeon or a car mechanics does. They think of it as "an art" in a true sense of the word, like playing the violin or something. Which I suppose is fine, when the stakes are low. And I think they know that too--because they screen out people who are really sick and refer them back to me for "therapy".

 

[downwithDTB]

Sure, but I find it problematic that people making assumptions (that my particular therapy with a particular patient is working) without actively assessing for concrete symptoms, and when concrete symptoms improve, don't continue to assess for necessity for further treatment.

When you talk about "evidence-based", it doesn't just mean that you are using a procedure that's shown to work. It means that you are practicing medicine with the intent to follow an application of the scientific method. Otherwise why bother doing science? Just do whatever voodoo that you feel like works, and when it doesn't work, just say that in my opinion it'll work better later.

Now, this point is controversial in the sense that many therapists don't think of themselves as practicing a applied science in the sense of being analogous to what a surgeon or a car mechanics does. They think of it as "an art" in a true sense of the word, like playing the violin or something. Which I suppose is fine, when the stakes are low. And I think they know that too--because they screen out people who are really sick and refer them back to me for "therapy".

Some points... 1) "evidence based" should refer to a specific intervention in a specific population (i.e. disease). As far as I'm aware, neither CBT nor any dynamic treatment is evidence based for treating everyone in a clinic. For some diseases there are specific adaptations of both with fair evidence.

2) To your point about symptom tracking: I'm not sure that, generally, this is an evidence based intervention. For it to be, you would need a clinical trial with multiple randomizations. For example, randomize pts with MDD to dynamic vs. CBT, after 16 weeks, divide into responder and non-responder groups and re-randomize. Very few therapy (and med) trials adequately answer the when to stop, change or augment question and if symptom tracking can meaningfully influence that decision. Please share examples if you think I'm wrong. I have seen a few "more CBT is not always better for the average person with disease x" studies but they don't necessarily focus on non-responders specifically.

3) Therapy studies, especially manualized ones are often not done by so called "experts" (i.e. highly experienced clinicians), and very rarely with experts on both "sides" implementing their own intervention. A few studies that have tried to show benefit for the "gold standard" manual based care (DBT, prolonged exposure) have failed to beat highly experienced clinicians doing their secret sauce (or secret sauce and sertraline):

Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up - PubMed

One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants...

www.ncbi.nlm.nih.gov

Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT01524133.

www.ncbi.nlm.nih.gov

Both of the above studies showed great benefit from psychiatists doing essentially secret sauce therapy plus med management that was non significantly better than the trained manual based approaches (i.e. at least as good).

 

[FlowRate]

Both of the above studies showed great benefit from psychiatists doing essentially secret sauce therapy plus med management that was non significantly better than the trained manual based approaches (i.e. at least as good).

And the best evidence is that common factors are the biggest component of success of any therapy. I have a hard time thinking of a good way to abstract therapeutic alliance from therapeutic modality.

 

[WisNeuro]

And the best evidence is that common factors are the biggest component of success of any therapy. I have a hard time thinking of a good way to abstract therapeutic alliance from therapeutic modality.

This is actually debatable, given the ways that broad swaths of treatments were collapsed into very heterogeneous categories in this research body. Common factors are definitely important, but the effect of common factors most likely varies quite a bit across different treatments and different conditions.

 

[dl2dp2]

3) Therapy studies, especially manualized ones are often not done by so called "experts" (i.e. highly experienced clinicians), and very rarely with experts on both "sides" implementing their own intervention. A few studies that have tried to show benefit for the "gold standard" manual based care (DBT, prolonged exposure) have failed to beat highly experienced clinicians doing their secret sauce (or secret sauce and sertraline):

Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up - PubMed

One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants...

www.ncbi.nlm.nih.gov

Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT01524133.

www.ncbi.nlm.nih.gov

Both of the above studies showed great benefit from psychiatists doing essentially secret sauce therapy plus med management that was non significantly better than the trained manual based approaches (i.e. at least as good).

This is actually exactly my point: that it's relatively solid science now that you don't need to be an expert with secret sauce if/when you use a manual. When things don't work, maybe you should try a manual. But people resist this because they think their particular secret sauce will work better than a manual.

Someone who reports all of the depression symptoms for 5 years and in therapy in the entire duration has never tried a manual driven treatment with no symptomatic improvement, IMO, has not been served well by evidence-base medicine.

 

[WisNeuro]

Someone who reports all of the depression symptoms for 5 years and in therapy in the entire duration has never tried a manual driven treatment with no symptomatic improvement, IMO, has not been served well by evidence-base medicine.

"Manual driven" being the key phrase. No one should be doing therapy from a manual when they haven't learned the intricacies of the underlying theories, be they CBT, dynamic, 3rd-wave, etc. The manual is merely a reference point/road map, it still takes a lot of skill to adapt it to the context of the individual patient and work on the fly for issues that arise within that therapeutic framework.

 

[finalpsychyear]

Our system will eventually fracture, not completely, but definitely a large crack based upon ARNP vs doctor. Big box vs small practices [and possibly with this real quality...]

We really should have protected our turf better. Can you imagine lawyers having to compete with some type of Nurse equivalent lawyer in their field.
Medicine is truly going to fracture catastrophically but it won't happen anytime before 10 years from now. I can imagine walmart/amazon all hiring 100's of NPs per store as they will soon get all 50 states on board being 100% independent. Work hard now so your tears will be for your future colleagues and not yourself.

 

[downwithDTB]

Can you imagine lawyers having to compete with some type of Nurse equivalent lawyer in their field.

Paralegal Practiconers? You can pass the bar and practice in many states without a JD. Law is actually oversaturated as is; the difference is that there are lots of wealthy firms/ companies willing to pay a premium for good talent and hustlers who can make money on contingency cases. That's why you have far more rich lawyers than doctors but also plenty of public defenders and divorce lawyers, lawyers working for the common person, who make less than an RN.

Imagine if we did away with health insurance and medicare and Medicaid would only pay if you were literally bankrupt and then at a fraction of market rate to whoever really needed business. A few docs would crush it and the rest, well... yikes.

 

[MBBSMOM]

We really should have protected our turf better. Can you imagine lawyers having to compete with some type of Nurse equivalent lawyer in their field.
Medicine is truly going to fracture catastrophically but it won't happen anytime before 10 years from now. I can imagine walmart/amazon all hiring 100's of NPs per store as they will soon get all 50 states on board being 100% independent. Work hard now so your tears will be for your future colleagues and not yourself.

Law is a bad comparison as the market is oversaturated. The only way to get a good job as a lawyer right now is by going to a T-14 law school. Unlike medicine where we have a shortage of certain specialties. NP/PA were created to help alleviate the shortage. The nursing lobby claimed that NPs would help alleviate the shortage in rural areas. Which is why NPs were given independent practice. Even though NPs do not tend to practice in rural areas. Now PAS are also jumping onto the independent practice train.

 

[clausewitz2]

Paralegal Practiconers? You can pass the bar and practice in many states without a JD. Law is actually oversaturated as is; the difference is that there are lots of wealthy firms/ companies willing to pay a premium for good talent and hustlers who can make money on contingency cases. That's why you have far more rich lawyers than doctors but also plenty of public defenders and divorce lawyers, lawyers working for the common person, who make less than an RN.

Imagine if we did away with health insurance and medicare and Medicaid would only pay if you were literally bankrupt and then at a fraction of market rate to whoever really needed business. A few docs would crush it and the rest, well... yikes.

Paralegals offering independent legal advice does not happen in the United States (outside of Washington State, it appears). Paralegals are not really a lawyer replacement or legal mid-level. The enormous surplus of lawyers does the job of suppressing their wages just fine by itself.

The white-shoe firms offer big salaries because they get paid so much by their clients. The deals and situations they are involved.in have much higher monetary stakes than anything a typical physician will ever be involved with. The industry is not very similar in structure to ours.

 

[downwithDTB]

Paralegals offering independent legal advice does not happen in the United States (outside of Washington State, it appears). Paralegals are not really a lawyer replacement or legal mid-level.

"Paralegal Practiconers" was a joke answering the question "can you imagine some type of nurse midlevels in law suggesting that adding the word practioner would make them a lawyer replacement. I think a few years ago people would have said "nurses are not really a physician replacement or medical mid-level" until they became physician replacements.

 

[Sushirolls]

"Paralegal Practiconers" was a joke answering the question "can you imagine some type of nurse midlevels in law suggesting that adding the word practioner would make them a lawyer replacement. I think a few years ago people would have said "nurses are not really a physician replacement or medical mid-level" until they became physician replacements.

Dentistry is also trying out a dental hygienist who can drill and fill.