Psychotherapy Case Conference

[prominence]

I dont know if it's just at my program, but does anyone else find psychotherapy case conference a complete waste of time (especially for PGY-1 psych residents to listen in on)?

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[Anasazi23]

I have to admit that psychotherapy cc is probably my least favorite class...though at our residency it's referred to as continuing case conference.

 

[outofhere]

I think the success of a psychotherapy case conference is completely dependent on the teacher. In my training experience, we actually had monthly psychotherapy conferences, and it isn't a continous case. Rather, it is a snapshot into various patients. Then, there is a course for short-term psychotherapy, where a senior resident presents a case, in real-time, for 12 weeks. The case terminates as the class ends. I thought it was a great, fantastic experience. Not only was our teacher fabulous, the input from my peers were great too.

That being said, I have attended case conferences where the teachers are so lame, so narrow minded, and don't allow any topics other than what they themselves want to discuss, and I think, it is because the teachers are so anxious about the residents asking them questions they don't know how to answer, and such defensiveness makes the experience a waste of time.

 

[Anasazi23]

In our teacher/professor's defense, he is quite an open fellow and allows full discussion amongst the residents and offers some good insights. But, he, like many others in my residency program, have a heavy analytic hand. Therefore, all cases are viewed in an analytic light. At best, more psychodynamic theory is applied, but the prevailing theme remains clear. This isn't necessarily a bad thing...just that some of the residents have extensive psychoanalytic training, and present/discuss the cases using complex psychoanalytic language. If you're aren't completely privy to this mode of case formulation, you can feel left out in the cold. Or, if you understand most of the concepts but aren't completely devoted to putting cases into this light, it can drag.

 

[50960]

Why is the therapy end of psychiatry still so entrenched in psychoanalysis?? Especially when there is little if any EBM data to support its efficacy in treating most disorders.

 

[nitemagi]

Why is the therapy end of psychiatry still so entrenched in psychoanalysis?? Especially when there is little if any EBM data to support its efficacy in treating most disorders.

Agreed. In some ways I think it's a lot like surgery-- "Because that's the way we've always done it."

 

[Anasazi23]

I don't think many outpatients can be categorized into having a 'disorder' per se. Many that are in the clinic have some sort of problem either with relationships, or work, or have pervasive personality problems that hinder them.

I guess the thinking is that CBT is easy to learn, while psychoanalytic skills can take a lifetime to perfect. While I don't see myself practicing any type of hardcore psychodynamic therapy when I'm an attending, it does help with case forumulation in many ways.

 

[maranatha]

I don't think many outpatients can be categorized into having a 'disorder' per se. Many that are in the clinic have some sort of problem either with relationships, or work, or have pervasive personality problems that hinder them.

I guess the thinking is that CBT is easy to learn, while psychoanalytic skills can take a lifetime to perfect. While I don't see myself practicing any type of hardcore psychodynamic therapy when I'm an attending, it does help with case forumulation in many ways.

Sazi, or anyone else, how does psychoanylsis help with case formulation? Also, even though you don't plan on doing "hardcore psychodynamic therapy", do you think it is valid as a therapy? Any one?

 

[50960]

CBT is easy to learn, but not at all easy to do. However, psychoanalysis is hard to learn, but not too hard to do.

 

[Pterion]

Sazi, or anyone else, how does psychoanylsis help with case formulation? Also, even though you don't plan on doing "hardcore psychodynamic therapy", do you think it is valid as a therapy? Any one?

For me, psychodynamic conceptualizations include the broader systemic issues that CBT has conveniently left out. It is a formalized way to include the long-standing effects of family of origin issues, relational recapitulations, and character style. I distinguish "psychodynamic" from "psychoanalytic". They have the same parents, but very different evolutions. Not that CBT doesn't have a place. And of course, neither is the be-all-end-all. Anyone who says otherwise has an agenda.

It is a valid therapy, done appropriately. If your case formulation includes more references to "penis" than a urology consult, you may be missing something.😉

There are numerous sources you can tap for these answers, which I think are more complex than can be adequately addressed in an internet forum. Best of luck

 

[50960]

LOL...well put, and I totally agree.

 

[Anasazi23]

Sazi, or anyone else, how does psychoanylsis help with case formulation? Also, even though you don't plan on doing "hardcore psychodynamic therapy", do you think it is valid as a therapy? Any one?

I should make more of a distinction between psychoanalysis and psychodynamic therapy and forumulation to be sure. Relatively speaking, few psychiatrists or psychologists practice psychoanalysis in the traditional sense of the term. Where I train, the psychodynamic prevailance is quite strong...much of this psychodynamic case formulation comes from analytic roots. Though there is much overlap and one feeds the other, they are different in practice.

I'll give a case example off the top of my head. A patient comes to you, at 33 years old, with complaints of what initially sound like low grade panic attacks. She has had a few such episodes, and has been living at home since she returned from college, apparently unable to "get it together" enough to hold down a full-time job and support herself.

It is conceivable that a purely cognitive-behavioral therapist might not, due to various 'resistance' or other issues, fail to recognize that the complaint is not the panic attack per se, but the faulty dynamics that exist between her mother, with whom she lives, and the residual hostility from her parents divorce 7 years ago.

If you approach this patient with "Ok, now think of a big red stop sign when you start to feel really anxious, then keep a diary and we'll go over it," you'll entirely miss the boat. A psychodynamic therapist can help fetter out these "issues" and through self-exploration, help the patient on a grander scale.

To say that CBT is not hard to do, and that psychoanalysis or psychodynamic therapy is easy is walking on thin ice, and an argument can certainly be made to refute this. If easy you (psisci) refer to sitting on the couch and listening to a patient in psychoanalysis - yes, that's easy. It's the broader formulation and conceptualization of the case that is difficult. For CBT, there are literal cookbooks on how to treat various disorders. I too am simplifying, but the point is the same.

 

[OldPsychDoc]

For me, psychodynamic conceptualizations include the broader systemic issues that CBT has conveniently left out. It is a formalized way to include the long-standing effects of family of origin issues, relational recapitulations, and character style. I distinguish "psychodynamic" from "psychoanalytic". They have the same parents, but very different evolutions. Not that CBT doesn't have a place. And of course, neither is the be-all-end-all. Anyone who says otherwise has an agenda.

It is a valid therapy, done appropriately. If your case formulation includes more references to "penis" than a urology consult, you may be missing something.😉

There are numerous sources you can tap for these answers, which I think are more complex than can be adequately addressed in an internet forum. Best of luck

I always found psychodynamic conferences to be good entertainment at the very least. And I think CBT/DBT/IPT all go a bit better if you can understand a little about the developmental antecedents of the various cognitive distortions you meet.

 

[50960]

I said that CBT was easy to learn, not easy to do. Sure there are cookbook approaches, but have you ever tried these with real patients...it never goes the way it is supposed to. CBT would be easy if pts did what the book says they will, but they rarely do. I use CBT, but by no means exclusively. My point is that many non-psych MD's get taught that CBT is easy, so they try to do it themselves and feel that they are..then they do not refer, the pt gets worse, then gets 20 mg prozac, then has SE's, then stops taking the med and sees a new PCP.Repeat.

 

[Anasazi23]

What non-psych MD is doing cognitive behavioral therapy?

 

[Pterion]

What non-psych MD is doing cognitive behavioral therapy?

Sadly, every family practice doc I have met so far. By their own label, you understand. The problem of course is that when the patient is finally appropriately referred to a competent psychiatrist who appropriately approaches CBT, the patient has some well-developed resistance.

I had one dinosaur even tell me that REBT was the only "true" form of psychotherapy out there. The greatest enemy of good psychiatry is family practice. (slips into asbestos undies)....

 

[Anasazi23]

Sadly, every family practice doc I have met so far.

I've never come across this in my 7 years of medical training, including months spent in primary care offices in various places. If by CBT you mean, pat-on-the-back, listening for 5-10 minutes, and pep talk, then ok. True CBT? No way.

 

[whopper]

For better or worse, if you don't give a damn about psychotherapy--it usually won't hurt your standing in a program. So many docs don't seem to care about it much these days.

I do think we need to learn about it--but I also think its more of an experiental thing than a thing that can be easily taught in class with the exception of CBT.

 

[50960]

Sazi, read some family practice literature.

 

[Pterion]

I've never come across this in my 7 years of medical training, including months spent in primary care offices in various places. If by CBT you mean, pat-on-the-back, listening for 5-10 minutes, and pep talk, then ok. True CBT? No way.

Agreed. Family Practice texts (I'll need to go find the reference for the one we're supposed to buy for this rotation) give a lame and infantile introduction to CBT. More than pep talking, but not true CBT. There is also a statement in the Depression chapter that says something along the lines of "if your patient does not improve within three years on medical management, consider referral to a psychiatrist". Frightening and frustrating at the same time.

In short, your experience in training has included better FP clinicians than mine has. These guys/gals really think there's nothing to it.

 

[Anasazi23]

Agreed. Family Practice texts (I'll need to go find the reference for the one we're supposed to buy for this rotation) give a lame and infantile introduction to CBT. More than pep talking, but not true CBT. There is also a statement in the Depression chapter that says something along the lines of "if your patient does not improve within three years on medical management, consider referral to a psychiatrist". Frightening and frustrating at the same time.

In short, your experience in training has included better FP clinicians than mine has. These guys/gals really think there's nothing to it.

Disturbing to be sure. Although, I think things are changing. I went to an Astra-Zeneca Dinner the other day that was a round table discussion with IM and FP docs. I was the only psychiatrist (resident). The leader of the discussion was an IM doc that also did primary care in an office, and he had talking points which, to his credit (and I guess Zeneca's) weren't bad. The point was that primary care docs should at least recognize symptoms of bipolar II disease and refer to psychiatry as soon as possible. Surpsisingly, they weren't really pushing Seroquel too much - just pushing the referral. They went over the diagnostic criteria of bipolar disorder, and most of the docs were privy to the bipolar III problem and how they are reluctant to prescribe certain ADs when they suspect bipolar.

With black box warnings, and warnings over manic switching on ADs, PCPs might be more reluctant to prescribe to this population without better evaluations. They passed out some rudimentary screening tools to help the PCPs.

Guess we'll see.

 

[50960]

Well I see this drug company stuff as a big part of the problem. Rudimentary screening materials are totally useless unless you have a clue what it is you are assessing. Do you think most FP docs have a clue what the diff is between Bipolar 12 or 3?? No. Yes they will refer to psychiatry if they have a viable option to do so, but in many places they do not. These simple screening things, and articles teaching FP docs that asking a pt if they have automatic thoughts associated with their chronic pain-fibromyalgic-referred/nerve-pain syndrome= CBT. It is this kind of dummying-down of psych in general that leads to lack of referrals to you and to me, and poor pt care. I have a feeling one of these days you and Sazi will find ourselves on the same expert panel in front of alot of students etc.....disagreeing😉

 

[Anasazi23]

Well I see this drug company stuff as a big part of the problem. Rudimentary screening materials are totally useless unless you have a clue what it is you are assessing. Do you think most FP docs have a clue what the diff is between Bipolar 12 or 3?? No. Yes they will refer to psychiatry if they have a viable option to do so, but in many places they do not. These simple screening things, and articles teaching FP docs that asking a pt if they have automatic thoughts associated with their chronic pain-fibromyalgic-referred/nerve-pain syndrome= CBT. It is this kind of dummying-down of psych in general that leads to lack of referrals to you and to me, and poor pt care. I have a feeling one of these days you and Sazi will find ourselves on the same expert panel in front of alot of students etc.....disagreeing😉

I don't know what bipolar 12 is, but I'll tell you that every one of the FPs knew of the switching effect of SSRIs in the undiagnosed bipolar patient. We discussed the percentages of actual switching, compared to rumor and misunderstanding, and they knew a surprising amount of differences between the SSRIs and their related side effects. They prescribe more psych meds than you ever can suggest - FPs are responsible for close to 80% of psychotropic prescribing...which isn't surprising. They prescribe many more cardio meds than cardiologists, many more anti-rheumatological than rheumatologists, and more gastrointestinal medications than GI docs.

Psychologists complaining about every single screening tool not performed and interpreted by them as being "useless" unless they are trained for 7 years to understand them and take a class in structural equation modeling is bogus. Face validity amounts for something, and can be useful - if for nothing else than to make gross screens. I looked at the screening tool. It was quick, easy to understand, and hit on a lot of key points that are meant to spark further discussion. No one is handing in a piece of paper to a psychiatrist and claiming that they've diagnosed bipolar disorder. Just as a PSA is a screen meant for further investigation, so are rudimentary "waiting room" screening tools. There's no harm in them. If anything, I'd think they would open up doors that were previously unexplored.

By the way, I have no lack of referrals.
😉

 

[50960]

You have not heard of bipolar 12??? And I thought you were cool....... Bipolar 1,2 you x-file geek..🙂 Everyone knows about SSRI switching potential. My argument had nothing to do with training in psychometrics at all, but that FP docs given a form they think is testing, getting a silly result, and then feeling fully able to tx with socratic questioning is dangerous. I am not suffering from referrals either as I see all the psychopharm folks who don't want to wait 6 months to see your cohort in CO. BTW, the psychiatrist I work with is supportive of me continuing medication management, and I have privileges at the local hospital to manage meds!!! Watch out SAZI...PS. all this is true but I am just saying it to get you riled!!!

 

[Pterion]

Disturbing to be sure. Although, I think things are changing. I went to an Astra-Zeneca Dinner the other day that was a round table discussion with IM and FP docs. I was the only psychiatrist (resident). The leader of the discussion was an IM doc that also did primary care in an office, and he had talking points which, to his credit (and I guess Zeneca's) weren't bad. The point was that primary care docs should at least recognize symptoms of bipolar II disease and refer to psychiatry as soon as possible.

It is my sincerest hopes that 1.) FP's in this area get to see this information and 2.)act on it accordingly. I confess that my hopes are not high for #2. At least not this far south of the Mason-Dixon line.

They passed out some rudimentary screening tools to help the PCPs.

I'm actually ok with this. The problem isn't that PCP's have the tools, it's whether they are used. As an example, the BDI is pretty easy to administer and score. But if the FP doesn't think to include it when the patient is having mood disturbance there is frequently also no consideration of referral. The BDI is horribly face-valid, I know, but it was an easy example. Insert your own.

It is this kind of dummying-down of psych in general that leads to .... poor pt care.

I agree. Unfortunately, as Anasazi points out:

FPs are responsible for close to 80% of psychotropic prescribing...which isn't surprising. They prescribe many more cardio meds than cardiologists, many more anti-rheumatological than rheumatologists, and more gastrointestinal medications than GI docs.

This is fact. I see it myself, as a lowly third year. I am frequently biting my tongue during patient consultations where these things occur. A great difficulty - not unique to psychiatry - is the stigma of specialty. To the lay public there is the simple question of why go see some smart-anus specialist when I can get the same drugs from Harvey here, who I trust and who has been treating me for my {depression/RA/SLE/AVNRT/Crohn's/COPD/etc} for the last 3 years? In other words, I see cases where the FP and the patient collude to avoid referral. To each his/her own agenda. Ultimately: poorer outcomes. I'll stop now in order to avoid an unrestrained and incoherent rant on the state of primary care in the South.

I have a feeling one of these days you and Sazi will find ourselves on the same expert panel in front of alot of students etc.....disagreeing

Good! Science cannot progress without dissent.😀

 

[Anasazi23]

You have not heard of bipolar 12??? And I thought you were cool....... Bipolar 1,2 you x-file geek..🙂 Everyone knows about SSRI switching potential. My argument had nothing to do with training in psychometrics at all, but that FP docs given a form they think is testing, getting a silly result, and then feeling fully able to tx with socratic questioning is dangerous.

I guess my point here was that something is better than nothing, if we truly have patient care and access to care as a global concern for patients.

I am not suffering from referrals either as I see all the psychopharm folks who don't want to wait 6 months to see your cohort in CO. BTW, the psychiatrist I work with is supportive of me continuing medication management, and I have privileges at the local hospital to manage meds!!! Watch out SAZI...PS. all this is true but I am just saying it to get you riled!!!

It doesn't get me riled, as my career is set, with infinite practice options as a fully licensed physician (paperwork is being processed). 😀 I'm just saying this to get your goat....

Here, this if for you. You might need it.
😉

 

[50960]

That made me laugh...good one sazi!!! I get your points. I actually use the MDQ as a f/u measure as well as other such only face-valid scales.