Psychotherapy-heavy programs

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I'm going to throw out my thoughts on the matter and am curious if those with more knowledge/experience think I'm off base.

I think I'm leaning to trying to get into a more psychotherapy-based program because I think, for most high-functioning, outpatient-type problems, therapy far exceeds the current state of meds for true personal transformation. Also, med management seems easy enough to learn on your own (or better said, without huge emphasis on the nuance in residency), whereas psychotherapy done well requires a lot of training and supervision and feedback.

Plus, if I were some professional dude with horrible social anxiety, for example, I feel like if I were seeking out a cash-only psychiatrist, I wouldn't want him to talk to me for a half-hour, and throw a first-line SSRI at me and say "see ya in a month". I want someone that would really try and get to the heart of what is wrong with me, and supplement that effort with meds perhaps.

 

[Doctor Bagel]

My thought is that any good psychiatry training should provide solid psychotherapy (in multiple modalities but including psychodynamic) training. So, yeah, your desires are reasonable, and honestly shouldn't be all that hard to find. IMO, this is the harder stuff to learn in your training.

Now things to look for would include a relatively flexible outpatient clinic where you're not stuck doing lots of med management, access to psychodynamically oriented supervisors, preferably some leadership with interest in psychotherapy and a local community supportive of psychotherapy (and by this, I'm still thinking psychodynamic), which can lead to a wealth of resources where you are. A psychoanalytic institute in your town doesn't hurt either.

 

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My thought is that any good psychiatry training should provide solid psychotherapy (in multiple modalities but including psychodynamic) training. So, yeah, your desires are reasonable, and honestly shouldn't be all that hard to find. IMO, this is the harder stuff to learn in your training.

Now things to look for would include a relatively flexible outpatient clinic where you're not stuck doing lots of med management, access to psychodynamically oriented supervisors, preferably some leadership with interest in psychotherapy and a local community supportive of psychotherapy (and by this, I'm still thinking psychodynamic), which can lead to a wealth of resources where you are. A psychoanalytic institute in your town doesn't hurt either.

How does OHSU rate with respect to all this?

 

[Doctor Bagel]

How does OHSU rate with respect to all this?

The downside is you only know where you trained, which limits my perspectives, but I feel pretty supported in having an interest in psychotherapy. Our last PD was analyst, which probably helped. Our university outpatient clinic is pretty flexible in that you can seek out weekly psychodynamic types of cases, but it probably could be better. It's a little harder to seek out cases in the VA clinic, but it seems possible. Our child department is quite psychodynamically oriented, and our child experience is all outpatient, which is great for this (maybe not great if you're a budding child psychiatrist, but I don't know). Our psychotherapy didactics last year were good, and we have a psychodynamic case conference this year run by 3 different analysts. We also have an institute in town, and I'm going to take a class there this year. Most importantly, there are a ton of psychodynamically oriented supervisers you can work with in the community. Actually both my adult and child supervisors are psychodynamically trained, and I think it's going to be great to work with them.

So yeah, we're really not bad. In a perfect world, I'd prefer more time in our university clinic rather than in various VA clinics, but I'm not sure how clinics at other programs work in terms of getting psychotherapy patients. Like everywhere, exposure first year is largely non-existent, but it picks up second year and gets pretty strong 3rd year. Theoretically, I think we're understood as being one of the less biologically oriented programs on the west coast.

 

[vistaril]

I'm going to throw out my thoughts on the matter and am curious if those with more knowledge/experience think I'm off base.

I think I'm leaning to trying to get into a more psychotherapy-based program because I think, for most high-functioning, outpatient-type problems, therapy far exceeds the current state of meds for true personal transformation.

yeah....but that doesnt mean you should be doing the therapy.

When medical students talk about therapy, they need to be more specific.....what kind of therapy do you see yourself doing? How frequently? for what duration?

"pure" analysts are mostly full of crap, and are selling snake oil. By "pure" analysts Im referring to the postww2 types who adhered to rigid principles of what being in analysis has to be. There are very very few of these around anymore, even in larger cities.

People who do psychodynamic therapy but not in a classic analyst model(for example only seeing pts weekly) are more common, and this may be of some benefit in some patients.

 

[splik]

you are correct that psychotherapy requires more time investment and experience that psychopharm, partly because the skillset is somewhat different, and partly becauseit requires 'unlearning' a lot of the BS from medical training. however even if you went to a psychotherapy heavy program you would really only get an introduction to the different modalities and a chance to learn 1 or 2 therapies half-well. You would still need to do further psychotherapy training if you wanted to practice with more of a therapy bent after residency.

 

[nitemagi]

yeah....but that doesnt mean you should be doing the therapy.

When medical students talk about therapy, they need to be more specific.....what kind of therapy do you see yourself doing? How frequently? for what duration?

"pure" analysts are mostly full of crap, and are selling snake oil. By "pure" analysts Im referring to the postww2 types who adhered to rigid principles of what being in analysis has to be. There are very very few of these around anymore, even in larger cities.

Actually there's a wide variety of "pure" analysts, depending on the specific school of psychoanalysis. You don't seem to be able to discriminate between them, so I'd guess you're not really trained in the differences. Your comments seem mostly directed towards classical ego psychology psychoanalysts. That is a minority, but if you go to any psychoanalytic institute, telling non-ego psychology based analysts they're not "pure" analysts would just show you're stuck in 1980's (or earlier) thinking. That ship sailed, buddy. It's a broader field than you apparently have an understanding of. Funny that you comment about analysis and psychodynamic therapy as if those are the only forms of psychotherapy. CBT, DBT, IPT, ISTDP, hypnotherapy, mentalization therapy, so many options. Open your mind, Mr. Quaid.

 

[MrJiggles]

Actually there's a wide variety of "pure" analysts, depending on the specific school of psychoanalysis. You don't seem to be able to discriminate between them, so I'd guess you're not really trained in the differences. Your comments seem mostly directed towards classical ego psychology psychoanalysts. That is a minority, but if you go to any psychoanalytic institute, telling non-ego psychology based analysts they're not "pure" analysts would just show you're stuck in 1980's (or earlier) thinking. That ship sailed, buddy. It's a broader field than you apparently have an understanding of. Funny that you comment about analysis and psychodynamic therapy as if those are the only forms of psychotherapy. CBT, DBT, IPT, ISTDP, hypnotherapy, mentalization therapy, so many options. Open your mind, Mr. Quaid.

Though truthfully in medical school, we have learned absolutely nothing about therapy/analysis, just that there are different types that have different foci, for the sake of the shelf exam. I wish I knew more, I feel my own "biological psych" leaning, whatever that may mean, is out of that ignorance.

I think this is where alot of med student's negative assumptions about psychiatry come from, we can quickly learn the requisite pharmacology and feel that the scope of the field is limited to that, which drive med students away who feel their intellects could be better used in something more challenging. One of the reasons psych may be so unpopular among medical students is that therapy cannot be well demonstrated in a 4 week clerkship period.

 

[nitemagi]

Though truthfully in medical school, we have learned absolutely nothing about therapy/analysis, just that there are different types that have different foci, for the sake of the shelf exam. I wish I knew more, I feel my own "biological psych" leaning, whatever that may mean, is out of that ignorance.

I think this is where alot of med student's negative assumptions about psychiatry come from, we can quickly learn the requisite pharmacology and feel that the scope of the field is limited to that, which drive med students away who feel their intellects could be better used in something more challenging. One of the reasons psych may be so unpopular among medical students is that therapy cannot be well demonstrated in a 4 week clerkship period.

I agree, as medical students there is a paucity of training on different psychotherapies. Vistaril purports to be a 4th year resident so should have a relatively sophisticated understanding of the different therapies. Or not.

 

[splik]

Though truthfully in medical school, we have learned absolutely nothing about therapy/analysis, just that there are different types that have different foci, for the sake of the shelf exam. I wish I knew more, I feel my own "biological psych" leaning, whatever that may mean, is out of that ignorance.

I think this is where alot of med student's negative assumptions about psychiatry come from, we can quickly learn the requisite pharmacology and feel that the scope of the field is limited to that, which drive med students away who feel their intellects could be better used in something more challenging. One of the reasons psych may be so unpopular among medical students is that therapy cannot be well demonstrated in a 4 week clerkship period.

This is largely true, but it definitely is possible for med students to get a bit more exposure to the principles and practice of psychotherapy. My medical students have to spend 30-60 minutes with their patients everyday, essentially providing some level of supportive psychotherapy and learning about alliance building. They get an hour of supervision each week to talk about how things are going with the patient, to develop a better understanding of themselves, to become aware of how transference and counter-transference operate.

In addition, they learn the basics of case formulation from the biomedical, psychodynamic, cognitive, behavioral, sociocultural and social constructivist perspectives. They are expected to demonstrate a basic understand of two different psychological formulations as evidenced in their case formulation in their notes.

I also do a demonstration on a willing and highly hypnotizable resident of some hypnotic phenomena (eye lid catalepsy, full body catalepsy, time distortion, amnesia, anesthesia) and they learn Meichenbaum's progressive relaxation and the principles of anxiety management training which they are expected to apply.

They are also expected to attend a DBT group and describe what happens is DBT, and they could also describe what happens in sessions for trauma-focussed CBT for PTSD and CBT for bipolar disorder. Finally, they learn the stages of change model, and the principles of motivational interviewing.

In a month or two you are not going get lots of exposure to psychotherapy, especially more long term work but there are plenty of opportunities that interested students can seek out, and residents and faculty can do a lot to expose students to the tenets of different therapies and the basic theories.

Finally, it is possible to do psychotherapy electives at some places. Austen Riggs used to offer such an elective, not sure if they still do.

 

[Doctor Bagel]

I agree, as medical students there is a paucity of training on different psychotherapies. Vistaril purports to be a 4th year resident so should have a relatively sophisticated understanding of the different therapies. Or not.

I'm guessing he trains at one of those programs that isn't too into psychotherapy of any type. Or he's been too busy moonlighting to learn.

 

[vistaril]

Actually there's a wide variety of "pure" analysts, depending on the specific school of psychoanalysis. You don't seem to be able to discriminate between them, so I'd guess you're not really trained in the differences. Your comments seem mostly directed towards classical ego psychology psychoanalysts. That is a minority, but if you go to any psychoanalytic institute, telling non-ego psychology based analysts they're not "pure" analysts would just show you're stuck in 1980's (or earlier) thinking. That ship sailed, buddy. It's a broader field than you apparently have an understanding of. Funny that you comment about analysis and psychodynamic therapy as if those are the only forms of psychotherapy. CBT, DBT, IPT, ISTDP, hypnotherapy, mentalization therapy, so many options. Open your mind, Mr. Quaid.

dont see any reason why a physician level provider would be doing some of these.....a well trained lcsw or lpc should suffice, and in many cases do a better job than a psychologist/psychiatrist.

as for hypnotherapy, I prefer to deal in evidence based medicine

 

[vistaril]

I'm guessing he trains at one of those programs that isn't too into psychotherapy of any type. Or he's been too busy moonlighting to learn.

eh....some people are more into it than others.....

I think some types of therapy has a place and in many cases moreso than medications depending on the presentation. Im just not interested in doing it

 

[nitemagi]

dont see any reason why a physician level provider would be doing some of these.....a well trained lcsw or lpc should suffice, and in many cases do a better job than a psychologist/psychiatrist.

as for hypnotherapy, I prefer to deal in evidence based medicine

🙄

And your evidence based approach tells you that LPC's do a better job than psychologists and psychiatrists? Care to cite such evidence? I'll tell you straightaway there is no evidence to support that, whatsoever.

 

[vistaril]

🙄

And your evidence based approach tells you that LPC's do a better job than psychologists and psychiatrists? Care to cite such evidence? I'll tell you straightaway there is no evidence to support that, whatsoever.

"in many cases" means that some do, some don't. Some psychiatrists are better "in many cases" than lpcs and lcsws as well......

For most modes of therapy, there is probably little difference between a psychiatrist and midlevels. As we all know the most important factor in therapy in many cases is the patient feeling that the therapist really cares about the pt and that bond, which enables us to provide a corrective emotional experience. That's not something that one needs an md to do......

Quality of therapist varies widely between individual psychologists, psychiatrists, and midlevels.....so in other words, if a psychiatrist happens to be a lot better therapist than an lpc it probably has nothing to do with them and their title but more that they just suck at therapy. And likewise if an lpc is a much better therapist in some cases than a psychiatrist that doesnt speak for all psychiatrists or lpcs either.

Patients(or insurers) are free to pay whatever they want as frequently(or infrequently) as they want.....in some cases it may make sense to see an MD therapist because they could also manage the meds at the very end.....

Im not going to do therapy, and I feel pretty darn good about that.

 

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"in many cases" means that some do, some don't. Some psychiatrists are better "in many cases" than lpcs and lcsws as well......

For most modes of therapy, there is probably little difference between a psychiatrist and midlevels. As we all know the most important factor in therapy in many cases is the patient feeling that the therapist really cares about the pt and that bond, which enables us to provide a corrective emotional experience. That's not something that one needs an md to do......

Quality of therapist varies widely between individual psychologists, psychiatrists, and midlevels.....so in other words, if a psychiatrist happens to be a lot better therapist than an lpc it probably has nothing to do with them and their title but more that they just suck at therapy. And likewise if an lpc is a much better therapist in some cases than a psychiatrist that doesnt speak for all psychiatrists or lpcs either.

Patients(or insurers) are free to pay whatever they want as frequently(or infrequently) as they want.....in some cases it may make sense to see an MD therapist because they could also manage the meds at the very end.....

Im not going to do therapy, and I feel pretty darn good about that.

What's your long-term plan? What would be your ideal future practice set-up. And what kind of coin do you think you'll be getting from it?

 

[vistaril]

What's your long-term plan? What would be your ideal future practice set-up. And what kind of coin do you think you'll be getting from it?

high volume community inpatient mixed with suboxone clinic on the side. +/- some C-L contract depending on how many inpatient beds Im covering in addition to my suboxone clinic.

I plan on making about 250-280k from this.

 

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high volume community inpatient mixed with suboxone clinic on the side. +/- some C-L contract depending on how many inpatient beds Im covering in addition to my suboxone clinic.

I plan on making about 250-280k from this.

Why inpatient instead of outpatient?

And what kind of hours a week do you anticipate for that amount of dough?

 

[vistaril]

Why inpatient instead of outpatient?

And what kind of hours a week do you anticipate for that amount of dough?

I just like inpatient better.

around 50...maybe 55

 

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I just like inpatient better.

around 50...maybe 55

Figure out a way to get that number to 350, or drop your hours to 40, and I think you might have a plan.

 

[vistaril]

Figure out a way to get that number to 350, or drop your hours to 40, and I think you might have a plan.

well I mean yeah...thats what we would all like.....Im going to try to make as much as reasonably possible in as few hours possible while practicing ethical and professional psychiatry......if it happens that I can make 280 working 40 hrs a week I will be glad. I just dont see that happening.

 

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well I mean yeah...thats what we would all like.....Im going to try to make as much as reasonably possible in as few hours possible while practicing ethical and professional psychiatry......if it happens that I can make 280 working 40 hrs a week I will be glad. I just dont see that happening.

do you think you would make more by swapping inpatient for outpatient? i understand you're not interested in doing that, but just for my own edification.

 

[BobA]

do you think you would make more by swapping inpatient for outpatient? i understand you're not interested in doing that, but just for my own edification.

It Depends.

In many outpatient practices you're paid by what you collect, not by what you bill. So it can depend on what type of payment your clients will be using. If you practice in an area where self-pay is an option then you might make some good money doing outpatient work. It can take some time to build up a high-volume self-pay clinic. If you're in an outpatient clinic where you take medicaid, you're not going to make much money period. Also, outpatient clinics can vary by their structure - some psychiatrists are able to take a cut of what the therapist bills for, or have a PA. All this is to say that there is a lot of variety in outpatient jobs and varied pay.

Most inpatient jobs, on the other hand, are salaried positions (although some can be collections-based as well). These jobs can be well-paid (I'm looking at 180-190K with minimal to no call), and low risk.

At this point in my life, though, money isn't the deciding factor. I could never to 10minute med checks even if it did pay 250K. I'm much more interested in enjoying my work. I didn't go into psychiatry to make money - that wouldn't been a lot easier to do in other fields of medicine.

 

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It Depends.

In many outpatient practices you're paid by what you collect, not by what you bill. So it can depend on what type of payment your clients will be using. If you practice in an area where self-pay is an option then you might make some good money doing outpatient work. It can take some time to build up a high-volume self-pay clinic. If you're in an outpatient clinic where you take medicaid, you're not going to make much money period. Also, outpatient clinics can vary by their structure - some psychiatrists are able to take a cut of what the therapist bills for, or have a PA. All this is to say that there is a lot of variety in outpatient jobs and varied pay.

Most inpatient jobs, on the other hand, are salaried positions (although some can be collections-based as well). These jobs can be well-paid (I'm looking at 180-190K with minimal to no call), and low risk.

At this point in my life, though, money isn't the deciding factor. I could never to 10minute med checks even if it did pay 250K. I'm much more interested in enjoying my work. I didn't go into psychiatry to make money - that wouldn't been a lot easier to do in other fields of medicine.

Good point. I obviously want to do good by my patients (or maybe that's not so obvious), but I struggle with maximizing my income, like most of us.

A ~200k/yr job @ 40hrs a week would be nice, then I could do whatever I wanted in my free-time to tack on more income. I guess that was the point with the suboxone. Easy way to add 50-80k.

 

[nitemagi]

200+ for 40 hours isn't that hard if you're willing to move or look around. Once you put your name out there with recruiters, you will routinely get mailings about positions for 230+, though they're often in the south.