Psychiatry and Psychotherapy?

[Healthinfo104]

I know that psychiatrists as a whole tend not to utilize psychotherapy as often as they used to years ago because their services in terms of medication management and such are more valued... therefore the therapy is often done by psychologists and social workers.

With that said, I read that some psychiatry residencies are doing away with teaching psychoanalysis in their programs and others want to do away with psychotherapy training all together and instead implement more neuroscience didactics since there has been an explosion in neurosciences understanding of mental health.

Is that true? Some programs want to do away with psychotherapy training?

Do you think they should and that it is a good or bad idea?

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[Shikima]

You'll need training in motivational interviewing in addition to neurosciences.

 

[nitemagi]

ACGME requires competency in 5 psychotherapies. So, no.

 

[WisNeuro]

ACGME requires competency in 5 psychotherapies. So, no.

As in 5 different types of therapy? Most psychiatrists that I know have some knowledge of CBT, maybe psychodynamic, and that's about it. What are the ACGME requirements, and how do they define competency?

 

[Healthinfo104]

ACGME requires competency in 5 psychotherapies. So, no.

Yes currently, but if u noted in ny post I said I read that they are trying to change that and elminate psychotherapy training from residencies... they just want to provide a basic understanding of the modalities so psychiatrists can collaborate with psychotherapists and thats it

 

[nitemagi]

Yes currently, but if u noted in ny post I said I read that they are trying to change that and elminate psychotherapy training from residencies... they just want to provide a basic understanding of the modalities so psychiatrists can collaborate with psychotherapists and thats it

You wrote "some residencies." ACGME dictates policy, and the residencies have to follow that.

 

[hamstergang]

I read that some psychiatry residencies are doing away with teaching psychoanalysis in their programs and others want to do away with psychotherapy training all together and instead implement more neuroscience didactics since there has been an explosion in neurosciences understanding of mental health.

Can you link to where you read this?

 

[wannabie]

ACGME requires competency in 5 psychotherapies. So, no.

You wrote "some residencies." ACGME dictates policy, and the residencies have to follow that.

ACGME dictates policy; they do not dictate reality. And in reality, they dictate a checklist, which program directors are incentivized to check off. The level of competence (if any) varies from program to program. I'm sure that the top programs teach psychotherapy well. As for the rest, who knows.

 

[nitemagi]

ACGME dictates policy; they do not dictate reality. And in reality, they dictate a checklist, which program directors are incentivized to check off. The level of competence (if any) varies from program to program. I'm sure that the top programs teach psychotherapy well. As for the rest, who knows.

Getting into a debate about the definition of competency is a straw man argument. My point was that ACGME requires training in psychotherapy, so it doesn't matter if individual residencies are considering phasing out training -- they don't have a choice, currently.

 

[Healthinfo104]

Getting into a debate about the definition of competency is a straw man argument. My point was that ACGME requires training in psychotherapy, so it doesn't matter if individual residencies are considering phasing out training -- they don't have a choice, currently.

Is the ACGME trying to get rid of the necessity for psychotherapy training in psych residencies?

 

[WisNeuro]

I am still curious as to the aspect of competency in 5 therapies? If this is so, I have yet to meet a single person in any profession who is anywhere near competent in 5 separate therapy modalities? Did you mean 5 techniques?

 

[nitemagi]

Is the ACGME trying to get rid of the necessity for psychotherapy training in psych residencies?

You have yet to post any evidence to support this and no one here has claimed any such thing. Therefore I'm not sure where this claim comes from.

 

[nitemagi]

I am still curious as to the aspect of competency in 5 therapies? If this is so, I have yet to meet a single person in any profession who is anywhere near competent in 5 separate therapy modalities? Did you mean 5 techniques?

It's not specified and a reasonable question, though not germane to the original question of the post -- what qualifies as "competence."
https://www.acgme.org/Portals/0/PFA...atry_2017-07-01.pdf?ver=2017-05-25-083803-023
"must demonstrate competence in: ...
managing and treating patients using both brief and long-term supportive, psychodynamic, and cognitive-behavioral psychotherapies; (Outcome) "

This most recent change looks like it has dialed back from the list of 5 to 3.

 

[WisNeuro]

Well, supportive therapy isn't really therapy. A dog wearing a fake vest can deliver "supportive therapy." So, more like 2. Seems more on par with what I've seen in terms of what people have been exposed to.

 

[SmallBird]

As in 5 different types of therapy? Most psychiatrists that I know have some knowledge of CBT, maybe psychodynamic, and that's about it. What are the ACGME requirements, and how do they define competency?

The psychiatrists you know might not have gone to good residencies or if they did, failed to access the resources available. I consider myself to have had an average degree of commitment to therapy during residency, and yet had extensive supervision and clinical experience in CBT, dynamic, family and play therapy, and now routinely provide and bill for these services. My colleagues who went into addictions have skills in MI rather than play therapy and others who chose to get the exposure during 4th year have competencies in DBT.

How to define competency is a good question (number of supervised cases? Specific outcomes?) but it is not based on what won't spark incredulity in a psychologist.

 

[WisNeuro]

The psychiatrists you know might not have gone to good residencies or if they did, failed to access the resources available. I consider myself to have had an average degree of commitment to therapy during residency, and yet had extensive supervision and clinical experience in CBT, dynamic, family and play therapy, and now routinely provide and bill for these services. My colleagues who went into addictions have skills in MI rather than play therapy and others who chose to get the exposure during 4th year have competencies in DBT.

How to define competency is a good question (number of supervised cases? Specific outcomes?) but it is not based on what won't spark incredulity in a psychologist.

My incredulity was about the 5 different types of therapy comment. Competency is an amorphous thing. I imagine some of us view therapy competency for some psychiatry residencies the same way that some psychiatrists view prescribing competency for RxP. Just a difference of opinion, of which neither of our professions has good outcome data to bolster our arguments either way.

 

[Shikima]

Yeah, the interrater reliability is low in psych.

 

[WisNeuro]

Yeah, the interrater reliability is low in psych.

And, supervision requirements vary wildly. How many years? How many supervisors? Cases? Live supervision, video, audiotape, etc?

 

[Shikima]

And, supervision requirements vary wildly. How many years? How many supervisors? Cases? Live supervision, video, audiotape, etc?

My issues for any of the mental health disciplines is if one doesn't know how to diagnose correctly, how do you know what the treatment plan is? And if we're doing the psychotherapy as a check box item, this is dangerous and ought to be abandoned as a practice.

 

[WisNeuro]

My issues for any of the mental health disciplines is if one doesn't know how to diagnose correctly, how do you know what the treatment plan is? And if we're doing the psychotherapy as a check box item, this is dangerous and ought to be abandoned as a practice.

I wholeheartedly agree. I see "Bipolar" in the chart a great deal of the time, but when I start asking about manic symptoms and episodes, they seem to be almost wholly absent in any meaningful way. Too often, diagnoses are made in 5-10 minute conversations, with people not asking the right questions. "the patient reported not sleeping for several days, must be a manic episode." Oh yeah? Follow up and ask how they felt after barely sleeping for several days, chances are, they felt terrible, tired, sluggish, etc. We're a healthcare system of checkboxes and no nuance these days. So far, I consider myself lucky in that I still get an hour to do my interview/intake for a npsych eval and insurance companies/medicare haven't tried to knock that back to a 15 minute convo.

 

[splik]

many of the crappier programs do not provide training in one or more modalities of psychotherapy but I have not noticed a decline in psychotherapy training over the past 10 years (30 or 40 yrs, certainly) except at programs that were particularly psychotherapy heavy and have been trying to balance the training a bit better.

In the 1990s, the supposed decade of the brain, in the shadow of the SSRIs and the wake of managed care, many programs did do away with psychotherapy. some people even had the temerity to decree that psychotherapy was dead! This was extremely unpopular with medical students who tend to be turned off by an overly biological view of psychiatry, and in fact many programs were forced to close or dramatically shrink, and despite increases in training slots and new programs in recent years, we still havent returned to the numbers in the early 90s. since the early 2000s there has been more emphasis on psychotherapy training even as fewer psychiatrists do psychotherapy or spend a smaller proportion of their time doing so. Ironically, there were no major advances in "biological" treatments for mental disorders in the 90s, but many psychotherapeutic treatments were developed.

Even the MD/PhD applicants seem particularly interested in getting strong psychotherapy training. It is among the essential skills of the psychiatrist.

Well, supportive therapy isn't really therapy. A dog wearing a fake vest can deliver "supportive therapy." So, more like 2. Seems more on par with what I've seen in terms of what people have been exposed to.

It is unfortunate that "supportive therapy" is often used in this way, but supportive psychotherapy as psychiatry residents are supposed to learn it is a brief dynamically oriented therapy that avoids much in the way of confrontation, interpretation, free association etc, and focuses on empathic validation, praise, supporting non-dysfunctional defenses, problem solving, and tackling one or two specific problems. The case formulation is based on a narrower framwork using the core conflictual relationship theme. so no, a dog could not deliver it but if i had to choose between a dog and a therapist, the dog would win every time. and a cat would beat the dog

 

[WisNeuro]

Well, we definitely agree on the cat issue.

 

[nitemagi]

You cat people.

 

[SmallBird]

I imagine some of us view therapy competency for some psychiatry residencies the same way that some psychiatrists view prescribing competency for RxP. Just a difference of opinion, of which neither of our professions has good outcome data to bolster our arguments either way.

That is a false equivalency. Psychiatrist have provided therapy for decades, and whatever recent trends may be it remains a core part of our training. I would say that about half of my training was either providing psychotherapy or in psychotherapy supervision. Most of my dynamic supervisors were psychiatrists who have been providing outpatient dynamic therapy and analysis for 30 years. You are right that there is no good data to know who is trained well and what constitutes competency but to suggest that a psychiatrist providing therapy is anywhere close to being similar to RxP is not accurate.

 

[WisNeuro]

That is a false equivalency.

Matter of opinion, really. I see them as very similar in the current climate. From what I've seen, I'm not sure "core" describes what many people get, especially considering the depth that is seen in other training settings.

 

[Mad Jack]

I wholeheartedly agree. I see "Bipolar" in the chart a great deal of the time, but when I start asking about manic symptoms and episodes, they seem to be almost wholly absent in any meaningful way. Too often, diagnoses are made in 5-10 minute conversations, with people not asking the right questions. "the patient reported not sleeping for several days, must be a manic episode." Oh yeah? Follow up and ask how they felt after barely sleeping for several days, chances are, they felt terrible, tired, sluggish, etc. We're a healthcare system of checkboxes and no nuance these days. So far, I consider myself lucky in that I still get an hour to do my interview/intake for a npsych eval and insurance companies/medicare haven't tried to knock that back to a 15 minute convo.

I feel like 90% of the patients I've ever come across with a "bipolar" diagnosis are actually just borderline personality disorder. It's sad, really.

 

[WisNeuro]

I feel like 90% of the patients I've ever come across with a "bipolar" diagnosis are actually just borderline personality disorder. It's sad, really.

Happens quite a bit. That or just a smattering of subclinical Axis II stuff going on.

 

[thoffen]

It is unfortunate that "supportive therapy" is often used in this way, but supportive psychotherapy as psychiatry residents are supposed to learn it is a brief dynamically oriented therapy that avoids much in the way of confrontation, interpretation, free association etc, and focuses on empathic validation, praise, supporting non-dysfunctional defenses, problem solving, and tackling one or two specific problems. The case formulation is based on a narrower framwork using the core conflictual relationship theme. so no, a dog could not deliver it but if i had to choose between a dog and a therapist, the dog would win every time. and a cat would beat the dog

One of my pet peeves as well. Supportive psychotherapy requires a framework of the mind from other disciplines and differs in that it favors supportive over interpretive interventions. You shouldn't imagine competence in it because you imagine yourself as capable of being supportive for others.

As a general comment on the idea of doing away with psychotherapeutic training for psychiatrists, it's utter hogwash. A psychiatrist need not engage in psychotherapy with patients, but the success of treatment depends heavily on treatment relationship with patients, and we need more attention to this not less. Would be interested to hear from patients on this topic. If you've had good or bad experience with psychiatry, was it due to medication choice or something else?

 

[EarlyCareerAcademicPsych]

Great question.

For context, I'm writing here as an Associate Program Director of a Psychiatry Residency where I am the director of psychotherapy training, a member of the AADPRT Psychotherapy Committee & a member of the APA Psychotherapy Caucus. I work at a VA hospital where I do psychotherapy as well as work as clinician educator (supervision, didactics).

The ACGME Psychiatry RRC requires competency in three frames of psychotherapy to complete graduation (supportive psychotherapy, cognitive-behavioral psychotherapy and psychodynamic psychotherapy). Agree with splik & thoffen above re: supportive psychotherapy -- this is a form of psychotherapy, developed as a part of psychodynamic work, which helps patients to shore up or bolster their defenses, rather than interpret them for insight. During a crisis, do you really want to know how your coping style came from your mom's relationship with her father and got passed down to you in some way? No - you want to get through it. That is what supportive psychotherapy is for. It is unfortunate that it has been marginalized in this way, simply because the name appears easy to understand. There is a lot more to it (check out books by Henry Pinsker and colleagues, if you are interested)

As a whole, psychiatry residencies are not trying to do away with psychiatrists doing psychotherapy - this is a larger issue for the field of psychiatry as a whole. There are established practicing psychiatrists - well trained in psychotherapy - who are shifting their practices in response to insurance companies payments.

The APA Psychotherapy Caucus (currently lead by Erik Plakun) is working to push back. IMO, there are some situations where the degree and training program is not relevant to the psychological treatment, where psychiatrist, psychologist and social workers have no advantage over one another (except based on their own individual level of training and experience, which is vital for the development of a psychotherapist). There are some other situations where there is a clear advantage to have a single clinician who can do psychotherapy and prescribe medications, as indicated.

Happy to answer other questions on the topic, as it is a major work area for me.

 

[Evidence Based]

The APA Psychotherapy Caucus (currently lead by Erik Plakun) is working to push back. IMO, there are some situations where the degree and training program is not relevant to the psychological treatment, where psychiatrist, psychologist and social workers have no advantage over one another (except based on their own individual level of training and experience, which is vital for the development of a psychotherapist). There are some other situations where there is a clear advantage to have a single clinician who can do psychotherapy and prescribe medications, as indicated.

Thanks for posting here! I'm applying in psych right now and am interested in hearing more about this. In what areas do you think it's advantageous to having a single clinician doing therapy and prescribing meds? Any data around this?

 

[thoffen]

Thanks for posting here! I'm applying in psych right now and am interested in hearing more about this. In what areas do you think it's advantageous to having a single clinician doing therapy and prescribing meds? Any data around this?

I'll let @EarlyCareerAcademicPsych respond, but I'll take his/her point farther. There are many times where I think medical and psychiatric residency experience would be important to the treatment regardless of whether you are prescribing meds. Sometimes you need to pay attention to medical morbidity or your knowledge of medicine or psychiatric practice or comfort level with severely medically or mentally ill/suicidal/substance using patients pays dividends. Plus, psychoanalytic type of thinking, while open to other disciplines, is still largely connected to medicine and would be far less common among other providers.

 

[nitemagi]

Great question.

For context, I'm writing here as an Associate Program Director of a Psychiatry Residency where I am the director of psychotherapy training, a member of the AADPRT Psychotherapy Committee & a member of the APA Psychotherapy Caucus. I work at a VA hospital where I do psychotherapy as well as work as clinician educator (supervision, didactics).

The ACGME Psychiatry RRC requires competency in three frames of psychotherapy to complete graduation (supportive psychotherapy, cognitive-behavioral psychotherapy and psychodynamic psychotherapy). Agree with splik & thoffen above re: supportive psychotherapy -- this is a form of psychotherapy, developed as a part of psychodynamic work, which helps patients to shore up or bolster their defenses, rather than interpret them for insight. During a crisis, do you really want to know how your coping style came from your mom's relationship with her father and got passed down to you in some way? No - you want to get through it. That is what supportive psychotherapy is for. It is unfortunate that it has been marginalized in this way, simply because the name appears easy to understand. There is a lot more to it (check out books by Henry Pinsker and colleagues, if you are interested)

As a whole, psychiatry residencies are not trying to do away with psychiatrists doing psychotherapy - this is a larger issue for the field of psychiatry as a whole. There are established practicing psychiatrists - well trained in psychotherapy - who are shifting their practices in response to insurance companies payments.

The APA Psychotherapy Caucus (currently lead by Erik Plakun) is working to push back. IMO, there are some situations where the degree and training program is not relevant to the psychological treatment, where psychiatrist, psychologist and social workers have no advantage over one another (except based on their own individual level of training and experience, which is vital for the development of a psychotherapist). There are some other situations where there is a clear advantage to have a single clinician who can do psychotherapy and prescribe medications, as indicated.

Happy to answer other questions on the topic, as it is a major work area for me.

Glad to see you here.