Psychiatrists doing psychotherapy in settings other than private practice

[clausewitz2]

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

Using the same arguments about lack of rural access, I might add.

 

[MBBSMOM]

Using the same arguments about lack of rural access, I might add.

It seems like every profession uses that argument to expand their scope of practice. I know optometrists have used that argument to be able to do some simple eye surgeries.

 

[finalpsychyear]

all these third parties... sigh..

 

[FlowRate]

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.

Coming back to this particular aspect of the discussion because we all touched on it some but I'm curious to think/learn more about it. In my region/training program, dynamic therapy is something that is, in a way, expected to take a while to lead to results. There can be an initial both worsening of symptoms (no longer avoiding difficult emotions) and improvement (stable alliance/feeling held/not alone), but I don't think either really reflects the possible future results. CBT is also not really practiced in the "12 weeks and done" fashion unless you get a patient who responds very quickly to the intervention (rare). So both types of therapy end up being something that goes on for multiple months--sometimes with patient-reported improvement and sometimes not. But also some patients, for their dynamic reasons, would be very reluctant to admit any improvement unless things were way better (depressive PD / transferrence of inadequate prior object.) So how do you use a brief trial to judge effect if the interventions actually tend to take a while and are known to sometimes initially worsen symptoms?

I've had some exposure to experts in ISTDP and even dynamic therapy with "intensive short term" in its name is often expected to take on the order of half a year, or more, for most patients.

 

[WisNeuro]

CBT is also not really practiced in the "12 weeks and done" fashion unless you get a patient who responds very quickly to the intervention (rare).

Definitely depends on the treatment and the population. In my old clinic when I did PTSD treatment, mainly using PE, I'd say the majority of people had pretty significant improvements in avoidance and re-experiencing symptoms by 6-8 weeks. This was a somewhat motivated, treatment seeking sample, but I was still surprised by the consistency of improvements within 1-2 months. I also saw a fair amount of people with panic disorder w and w/o agoraphobia, and those improvements were pretty start, usually even within the first month.

In comparison, doing PE in the VA? Um....not so good, but then we have an incentive seeking population who sees more benefits the sicker they are, so I'd hardly use these as equal comparisons.

 

[dl2dp2]

CBT is also not really practiced in the "12 weeks and done" fashion unless you get a patient who responds very quickly to the intervention (rare). So both types of therapy end up being something that goes on for multiple months--sometimes with patient-reported improvement and sometimes not.

It should be! That's how the treatment is designed and how all the trials are run. It's also not rare at all that people respond very quickly (and 3 months is not all that quick...)

Brief dynamic and IPT were also successfully trialed on a 3 month frame. There's significant literature showing most of therapy's effect are obtained in the first 3 months, regardless of the modality.

There's in fact very little in terms of comparing effect for long vs. short therapy, except in BPD (which I mentioned above)--and by extension other personality disorders, and in infrequent maintenance for relapse prevention (some literature on monthly-bimonthly maintenance CBT treatment).


I'm not saying that your training has problems per se, I'm saying that the statements that are made in the training are not scientifically justified. This is almost normative at this point, since psychotherapists, and many of those who are in charge of training people for psychotherapy, don't care about the science and the data. Which is fine--but when third parties start to screw you, you end up getting screwed badly. This is literally what's playing out right now. Therapists are generally IMO screwed much harder than MDs/"prescribers" since the rise of managed care. LCSWs are getting paid $50 an hour (if that). PhDs not much better. These people know they are screwed and don't even know how to appropriately protect their turf, because they can't speak the language with numbers, efficacy, cost-benefit analyses, etc. Patients who are paying out of pocket also care about expectations. They don't want to play a game without knowing the rules. People are paying me 5x as much as what they are paying their ex-PhD therapists years and years of ineffective treatment for doing 12-week manual-driven CBT. Am I profiting from this weird phenomenon? Sure. But IMO this is insane on a systemic level.

 

[downwithDTB]

It should be! That's how the treatment is designed and how all the trials are run. It's also not rare at all that people respond very quickly (and 3 months is not all that quick...)

We don't have great long term RTC data on most meds, either.

Regarding CBT (ect.) trials, they are great at saying that the average person gets y BDI points better after 12 weeks, but say nothing about what to do for the large percentage of non-responders and the plaurality of partial responders. To answer these questions, we really need large trials with, for example, SMART designs.

What do you do when someone started CBT and went from severe MDD to moderate MDD over 12 weeks? Say, congratulations, you got the expected BDI improvement but now since there is no adequate clinical trial to inform us on what to do we'll stop the CBT?

 

[dl2dp2]

We don't have great long term RTC data on most meds, either.

Regarding CBT (ect.) trials, they are great at saying that the average person gets y BDI points better after 12 weeks, but say nothing about what to do for the large percentage of non-responders and the plaurality of partial responders. To answer these questions, we really need large trials with, for example, SMART designs.

What do you do when someone started CBT and went from severe MDD to moderate MDD over 12 weeks? Say, congratulations, you got the expected BDI improvement but now since there is no adequate clinical trial to inform us on what to do we'll stop the CBT?

Agree with everything you say. Sadly, NIH is not interested in funding this type of study at the moment. They are more interested in receptors and MRI...

For one thing, NIMH has no existing framework to do large pragmatic trials on depression (or any other garden variety outpatient psychiatric complaint). Unlike say the NCI/NIHLB, where you can raise money to do these large multi-sites. Be my guest if you want to advocate for this kind of thing, since you'd be stepping on some pretty powerful people's toes.

Also, frankly the field itself is kind of moving away from this. The relevant entities are all trying to automate CBT. The debates are not gonna be relevant when the standard of care will be an app in 10 years. IMO, LCSWs and below should really start to worry about OUTSOURCING as a real problem for insurance-driven care in the next decade.

 

[pediatric_psydoc]

We don't have great long term RTC data on most meds, either.

Regarding CBT (ect.) trials, they are great at saying that the average person gets y BDI points better after 12 weeks, but say nothing about what to do for the large percentage of non-responders and the plaurality of partial responders. To answer these questions, we really need large trials with, for example, SMART designs.

With partial response it usually means that treatment needs to be augmented, such as with psychopharmacology. There is nothing magical about 12 exact sessions (note that it is 12 sessions that is typically published in the literature, not 12 weeks, as sometimes it is only feasible for patients to come in biweekly) and studies usually offer the range of measurable improvement being seen over 12-16 CBT sessions. If you’re seeing no response over 12 sessions, using another evidence based treatment is likely indicated. The patient could just not be motivated as well, which is a possibility that needs to be considered.

What do you do when someone started CBT and went from severe MDD to moderate MDD over 12 weeks? Say, congratulations, you got the expected BDI improvement but now since there is no adequate clinical trial to inform us on what to do we'll stop the CBT?

Consider augmenting treatment with the involvement of a psychiatrist.



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[clausewitz2]

Definitely depends on the treatment and the population. In my old clinic when I did PTSD treatment, mainly using PE, I'd say the majority of people had pretty significant improvements in avoidance and re-experiencing symptoms by 6-8 weeks. This was a somewhat motivated, treatment seeking sample, but I was still surprised by the consistency of improvements within 1-2 months. I also saw a fair amount of people with panic disorder w and w/o agoraphobia, and those improvements were pretty start, usually even within the first month.

In comparison, doing PE in the VA? Um....not so good, but then we have an incentive seeking population who sees more benefits the sicker they are, so I'd hardly use these as equal comparisons.

Still not the norm or robustly supported yet in the English language literature, but there is a camp pushing E/RP in an intensive four day program (the Bergen format for those interested). They claim to actually get response rates not entirely dissimilar to more traditional E/RP for OCD.

So under the right circumstances these therapies can be very short indeed.