Psychotherapy - how we should be training...

[nitemagi]

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I'm curious for sdn opinions as to how psychiatrists should be trained in therapy.

Right now there's loose requirements for "competence" in "applying supportive, psychodynamic, and cognitive- behavioral psychotherapies to both brief and long- term individual practice, as well as to assuring exposure to family, couples, group and other individual evidence-based psychotherapies."

But that's so loosely defined. Some seem to fall into the camp of believing that biological psychiatry will make psychotherapy obsolete, but I think most of us here see through that fallacy.

So how should we be training? How should it fit into the regular residency curriculum? How much is enough in any one form of therapy? What should be included that isn't required (DBT, hypnosis, group, family, mentalization-based)?

An especially useful point would be hearing from residents and medical students as to what skills they feel they would like at their current level of training (with the caveat that we could always use more at any stage.

Psychologists have their own model, but it seems skewed towards CBT above all else, eschewing anything else as irrelevant, which Yalom calls the "EVT bogeyman." Is a 1000 hours of mostly CBT based therapy too much? Where's the cutoff?

 

[zenman]

I'm curious for sdn opinions as to how psychiatrists should be trained in therapy.

<snip>

Psychologists have their own model, but it seems skewed towards CBT above all else, eschewing anything else as irrelevant, which Yalom calls the "EVT bogeyman." Is a 1000 hours of mostly CBT based therapy too much? Where's the cutoff?

I almost threw up having to study CBT,as well as other forms of therapy. Here's all you need: http://www.thecreativetherapist.com/

 

[BobA]

I'm a PGY3 and quite happy with my psychodynamic and CBT training thus far. My supervisors are great - but it would be nice to have more time.

I'm also offered opportunities to co-lead groups - mostly CBT based.

I think Motivational Interviewing should be stressed much more - perhaps during substance abuse rotations or even given time on the consult service.

 

[dl2dp2]

But that's so loosely defined. Some seem to fall into the camp of believing that biological psychiatry will make psychotherapy obsolete, but I think most of us here see through that fallacy.

CBT/DBT is actually very biologically oriented/mechanistic, much more so than much of psychopharm. Most people believe that behavioral/learning paradigm oriented therapy is quite consistent with neuroscience.

Psychodynamics isn't science. This isn't to say that it's not useful. It's certainly efficacious in some sense.

The issue isn't whether something's "biological" or not, or even scientific or not. That's a false dichotomy. Psychologists do more CBTs and psychiatrist do more psychoanalysis, even though the former is way more "biological". The market forces dictate that as psychopharm and other non-therapy interventions (i.e. brain stim) become more and more complicated, psychiatrists won't have time to do therapy--unless you do psychoanalytic boutique. Hence that part of the training is going to get more and more phased out because of division of labor--it's already QUITE phased out in most of the midwest/western programs. It's very similar to physiatrist and ortho don't do PT/OT and derm don't do facials, and internal medicine docs aren't personal trainers--of course they might learn a thing or two about it, but that's about it. In that regard I think it's probably ok.

I went to a recent talk with Carol Bernstein, the immediate past APA president, and her point really drives this home. In the coming years, as the healthcare system becomes more and more institutionalized, the specialization and division of labor are going to become more prevalent. The current model psychiatrist who spends 1 hr per patient doing both meds and therapy is really going to change to the 15 min per patient primary care model because the rising cost is not going to allow for inefficiencies in the system. You'd have to go outside of the insurance system, and except for a few markets (NYC, Boston, LA, SF), this is pretty much impossible. Unless you can demonstrate that patients do better with non-split treatment than split treatment--which you won't be able to--the role of psychotherapy in psychiatry is only going shrink more and more. I'm fairly conflicted as to whether this is a good thing or not, because I personally enjoy doing it; But I think it's probably best for the system at large because if fewer psychiatrists do therapy maybe more people will be able to get it.

 

[Doctor Bagel]

CBT/DBT is actually very biologically oriented/mechanistic, much more so than much of psychopharm. Most people believe that behavioral/learning paradigm oriented therapy is quite consistent with neuroscience.

Psychodynamics isn't science. This isn't to say that it's not useful. It's certainly efficacious in some sense.

The issue isn't whether something's "biological" or not, or even scientific or not. That's a false dichotomy. Psychologists do more CBTs and psychiatrist do more psychoanalysis, even though the former is way more "biological". The market forces dictate that as psychopharm and other non-therapy interventions (i.e. brain stim) become more and more complicated, psychiatrists won't have time to do therapy--unless you do psychoanalytic boutique. Hence that part of the training is going to get more and more phased out because of division of labor--it's already QUITE phased out in most of the midwest/western programs. It's very similar to physiatrist and ortho don't do PT/OT and derm don't do facials, and internal medicine docs aren't personal trainers--of course they might learn a thing or two about it, but that's about it. In that regard I think it's probably ok.

I went to a recent talk with Carol Bernstein, the immediate past APA president, and her point really drives this home. In the coming years, as the healthcare system becomes more and more institutionalized, the specialization and division of labor are going to become more prevalent. The current model psychiatrist who spends 1 hr per patient doing both meds and therapy is really going to change to the 15 min per patient primary care model because the rising cost is not going to allow for inefficiencies in the system. You'd have to go outside of the insurance system, and except for a few markets (NYC, Boston, LA, SF), this is pretty much impossible. Unless you can demonstrate that patients do better with non-split treatment than split treatment--which you won't be able to--the role of psychotherapy in psychiatry is only going shrink more and more. I'm fairly conflicted as to whether this is a good thing or not, because I personally enjoy doing it; But I think it's probably best for the system at large because if fewer psychiatrists do therapy maybe more people will be able to get it.

You just depressed me right there. I will say, though, that I'm at a west coast program that seems to place decent emphasis on psychodynamic training. And I know recent grads here (not in LA, SF, etc.) who are setting up their own practices doing primarily psychotherapy and doing OK.

Anybody else with a different perspective?

As for the original question, I've got no idea. I enjoy my psychotherapy didactics, but I'm a 2nd year, so I don't know enough to compare it to other programs or to what really would be beneficial. To give you a breakdown of our 2nd year training (and I might have to get a little vague here, too), we have two didactic sessions weekly for psychotherapy. One is an E&M class, which is basically just a chance to discuss the basics of seeing outpatients, talk about our individual patients and do some pretty general readings. Not a ton of formal teaching but an awesome hour for lots of other reasons. We also have a more formal type of class where we do different modules throughout the year on different types of psychotherapy. We're completed supportive psychotherapy and are now on CBT (which I'm unfortunately missing due to being on nightfloat). Psychodynamic is coming after that, I think.

 

[nitemagi]

I almost threw up having to study CBT,as well as other forms of therapy. Here's all you need: http://www.thecreativetherapist.com/

This brings up an interesting perspective -- weighing one form of psychotherapy over another. While I like the idea of "creative therapy," especially one that uses Ericksonian techniques, neglecting exposure to any of the main techniques I think is a disservice to the trainee. At least know what you're rejecting before you reject it.

 

[nitemagi]

I went to a recent talk with Carol Bernstein, the immediate past APA president, and her point really drives this home. In the coming years, as the healthcare system becomes more and more institutionalized, the specialization and division of labor are going to become more prevalent. The current model psychiatrist who spends 1 hr per patient doing both meds and therapy is really going to change to the 15 min per patient primary care model because the rising cost is not going to allow for inefficiencies in the system. You'd have to go outside of the insurance system, and except for a few markets (NYC, Boston, LA, SF), this is pretty much impossible. Unless you can demonstrate that patients do better with non-split treatment than split treatment--which you won't be able to--the role of psychotherapy in psychiatry is only going shrink more and more. I'm fairly conflicted as to whether this is a good thing or not, because I personally enjoy doing it; But I think it's probably best for the system at large because if fewer psychiatrists do therapy maybe more people will be able to get it.

Market forces exist, but we choose how we want to respond to them. I believe that plenty of others could create therapy-based practices if they made that a priority rather than maximizing $$ only. As for split treatment being inferior to non-split treatment -- no one's studied it, but there is a little paper suggesting split care is less cost effective for anyone that needs meds. While this wouldn't address the shortage of psychiatrists and could in fact worsen it, I think our profession is lessened by neglecting proper training in psychotherapy. And frankly I get sick of the "leaders" of our field predicting how things will change in the next 10-20 years. Didn't they also predict the human genome would be curing every disease by now?

We're the ones shaping our field because we're the ones practicing it. Ceding leadership to "leaders" means you abdicate any dislike for where the field ends up.

 

[Therapist4Chnge]

I think Motivational Interviewing should be stressed much more - perhaps during substance abuse rotations or even given time on the consult service.

This is a great point. I think MI is gaining traction in the Primary Care setting (smoking cessation, sub abuse, diabetes management, etc). Unfortunately the lunch seminar presentations are not sufficient enough to teach it, but I am glad to see more people are at least asking about it.

 

[digitlnoize]

I've interviewed at a couple of places so far, and one place uses Webcams to observe therapy and have faculty review the tape with you after the session. Another place uses one-way mirrors, which pretty much serves the same effect, but seems more of a temporal headache...

I think the key is observation and feedback. The details of how this is done seems slightly less important. The techie in me likes the fancy-shmancy webcams, but the low-tech mirror is probably more reliable...

Any other ways programs handle this that I haven't seen yet?

 

[dl2dp2]

Market forces exist, but we choose how we want to respond to them. I believe that plenty of others could create therapy-based practices if they made that a priority rather than maximizing $$ only. As for split treatment being inferior to non-split treatment -- no one's studied it, but there is a little paper suggesting split care is less cost effective for anyone that needs meds. While this wouldn't address the shortage of psychiatrists and could in fact worsen it, I think our profession is lessened by neglecting proper training in psychotherapy. And frankly I get sick of the "leaders" of our field predicting how things will change in the next 10-20 years. Didn't they also predict the human genome would be curing every disease by now?

We're the ones shaping our field because we're the ones practicing it. Ceding leadership to "leaders" means you abdicate any dislike for where the field ends up.

I have to say I do agree with what you are saying, and the AJP paper is an interesting read. It appears that the mental health team based treatment model is likely going to change in unexpected ways in the next few decades and nobody really knows what's gonna happen. This argues that a psychiatry resident should strive to be able to provide at least a baseline number of therapies: supportive, psychodynamic, CBT, combining meds with therapy as ACGME stipulates. This kind of baseline competency insures that you are protected for being able to do the most. Even if specific residency programs differ in terms of the amount of supervision/didactics etc., I think you can make it up on your own.

 

[loveoforganic]

As a first year, my opinion obviously is coming not so much from experience as foresight, so take it for what you will.

I met with a psychiatry PD prior to starting about ways to learn psychotherapeutic technique during med school (particularly MI), and the advice came down to finding a mentor during clinical years with skill in the area and a desire to teach, but that residency and beyond were really the times when that would be readily available. That seems somewhat unfortunate to me, although I can't say it was surprising. 3rd and 4th year (4th year in particularly) seem like perfect opportunities to invest significant time in picking up some skill in a psychotherapy. Your patient load is low and your responsibility toward the overall medical care of the pt is fairly low. So while the time is available to sit and spend a little extra time with a patient, when your mind isn't burdened with being "in charge" of the medical affairs of the patient, when the medical knowledge you're picking up may or may not be directly applicable to whatever field you may go into, invest some resources in learning skills that will help in whatever field it is you go into.

Some more structured training in this time period would be great.

Now back to learning CBT.. er... CFUs and HSCs...

Edit: And maybe I've just gotten a bad shake with psychodynamic, and I'm certainly not up on the lit, but doesn't psychodynamic tend to come out pretty lackluster for most things relative to other modalities? Seems to be either poorer outcomes or longer tx to the same outcome. Has seemed to me like the persisting force of psychodynamics in psychiatry is just tradition, not so much evidence-based. Obviously open to correction here though.

 

[nitemagi]

Edit: And maybe I've just gotten a bad shake with psychodynamic, and I'm certainly not up on the lit, but doesn't psychodynamic tend to come out pretty lackluster for most things relative to other modalities? Seems to be either poorer outcomes or longer tx to the same outcome. Has seemed to me like the persisting force of psychodynamics in psychiatry is just tradition, not so much evidence-based. Obviously open to correction here though.

There's definitely less research total on psychodynamic therapy. I would keep in mind that psychoanalysis and psychodynamic therapy are continually evolving fields. I also found it funny that when I went to the Beck institute for training, they talked about while the 16 session limit is used for simple anxiety disorder or isolated depression, any co-morbidities often double or triples the number of sessions at least. And they openly expect treatment of a personality d/o to require several years of CBT. So while the hype is great for CBT, the real world execution for the patients we all see doesn't fit into the usual time-limited treatment period.

 

[roubs]

Acceptance/mindfullness based approaches and Interpersonal psychotherapy are also taught in many clinical psych programs and have empirical support. I'd also point out that using MI techniques doesn't exclude pursuing CBT or another approach later or concurrently. Approaching all initial therapy sessions with a MI framework has really helped in the rapport building department.

edit: I'd be willing to bet therapy skills also come in handy for psychiatrists when having to deal with medication noncompliance. There's your CBT target right there 😛

 

[splik]

I think psychotherapy training should be based on the well-supported premise that there is more that unites the different psychotherapies than divides them. The so-called 'dodo bird verdict' is well known. Even the formulations have some similarities- internal working models, schemas, objects all describe similar concepts.

I would start with a 'Principles of Psychotherapeutics' course in PGY-1 focussing on the non-specific factors in psychotherapy: empathy, reflection, active listening, building positive expectancy, genuineness, a process group to think psychologically (and not necessarily dynamically) about different cases, and role playing and videoing of interviewing)

I also think all psych interns should become proficient in motivational interviewing.

In PGY-2 I would have a course 'Evidence-Base for Psychotherapy' looking at how to study efficacy of psychotherapy, biological effects of psychotherapy, evidence for and against psychoanalytic theories (there is a lot of evidence supporting attachment theory from cognitive psychology, developmental psychology, developmental neurobiology, and neuropsychoanalysis is an emerging field), evidence-base for different psychological treatments (psychodynamic therapy, CBT, DBT, mindfulness, IPT/IPSRT, mentalization-based treatment, EMDR, psychoeducation, family-focussed therapy), computer-aided psychotherapy, and considering what factors make psychotherapy effective

I would also have a course 'Practice of Psychotherapy' building on the 'Principles of Psychotherapy' course and residents having at least one psychodynamic case which they see from PGY2-4, at least one case of CBT for depression, and at least one case of CBT for an anxiety disorder with supervision and didactics

In PGY-3 I would have a course 'Psychotherapy: a lifespan approach' considering lifespan development and family systems theories and psychopathology, and issues of psychotherapy with children, adolescents, and the elderly as well as issues of mother-infant psychotherapy and psychotherapy at the end of life. At least 2 family therapy cases, a DBT group experience, and learn hypnosis and Ericksonian approaches (which are great for working with families and for C/L psychiatry)

In PGY-4 I would have a 'Clinical Psychopharmacology and Psychotherapeutics' course considering the psychological effects of psychotropic medication, effectively combining psychopharmacology and psychotherapeutics, working with resistance to medication, approaches to patients who use psychotropic medication as a way of avoiding engaging psychologically with their problems, and issues of the placebo effect, contextual healing, building positive expectancy, the 'meaning' of psychiatric intervention.
In addition to whatever therapy cases they have residents should have to choose to learn CBT, psychodynamic psychotherapy, or family systems therapy in more depth and take one at least one case that is more challenging
Further residents should opt to learn an evidence-based therapy e.g. IPT, EMDR, problem-solving therapy, mentalization-based treatment with at least one case

By the end of residency I think all residents should have worked psychotherapeutically with all the following: depression, bipolar disorder (family therapy/CBT/IPSRT), schizophrenia (family therapy/CBT), panic disorder (exposure therapy), OCD (ERP), PTSD (CBT/EMDR), substance abuse/eating disorder (MI), borderline personality disorder, and conversion disorder and everyone should have experience with working with families, couples and groups.

Neuroscience and psychiatric genetics do not spell the end of psychotherapy - if anything we are learning how the developing brain is affected by early experience, the neural basis of psychotherapeutic effects, and genetic predictors of response to psychotherapy similar to pharmacogenetics. Sadly some psychiatrists are pill pushers, but most of us don't want to be pill pushers and most of our patients don't want that either. As psychologists seek to expand the scope of their practice, why should we seek to limit ours?

 

[nitemagi]

I think psychotherapy training should be based on the well-supported premise that there is more that unites the different psychotherapies than divides them. The so-called 'dodo bird verdict' is well known. Even the formulations have some similarities- internal working models, schemas, objects all describe similar concepts.

I would start with a 'Principles of Psychotherapeutics' course in PGY-1 focussing on the non-specific factors in psychotherapy: empathy, reflection, active listening, building positive expectancy, genuineness, a process group to think psychologically (and not necessarily dynamically) about different cases, and role playing and videoing of interviewing)

I also think all psych interns should become proficient in motivational interviewing.

In PGY-2 I would have a course 'Evidence-Base for Psychotherapy' looking at how to study efficacy of psychotherapy, biological effects of psychotherapy, evidence for and against psychoanalytic theories (there is a lot of evidence supporting attachment theory from cognitive psychology, developmental psychology, developmental neurobiology, and neuropsychoanalysis is an emerging field), evidence-base for different psychological treatments (psychodynamic therapy, CBT, DBT, mindfulness, IPT/IPSRT, mentalization-based treatment, EMDR, psychoeducation, family-focussed therapy), computer-aided psychotherapy, and considering what factors make psychotherapy effective

I would also have a course 'Practice of Psychotherapy' building on the 'Principles of Psychotherapy' course and residents having at least one psychodynamic case which they see from PGY2-4, at least one case of CBT for depression, and at least one case of CBT for an anxiety disorder with supervision and didactics

In PGY-3 I would have a course 'Psychotherapy: a lifespan approach' considering lifespan development and family systems theories and psychopathology, and issues of psychotherapy with children, adolescents, and the elderly as well as issues of mother-infant psychotherapy and psychotherapy at the end of life. At least 2 family therapy cases, a DBT group experience, and learn hypnosis and Ericksonian approaches (which are great for working with families and for C/L psychiatry)

In PGY-4 I would have a 'Clinical Psychopharmacology and Psychotherapeutics' course considering the psychological effects of psychotropic medication, effectively combining psychopharmacology and psychotherapeutics, working with resistance to medication, approaches to patients who use psychotropic medication as a way of avoiding engaging psychologically with their problems, and issues of the placebo effect, contextual healing, building positive expectancy, the 'meaning' of psychiatric intervention.
In addition to whatever therapy cases they have residents should have to choose to learn CBT, psychodynamic psychotherapy, or family systems therapy in more depth and take one at least one case that is more challenging
Further residents should opt to learn an evidence-based therapy e.g. IPT, EMDR, problem-solving therapy, mentalization-based treatment with at least one case

By the end of residency I think all residents should have worked psychotherapeutically with all the following: depression, bipolar disorder (family therapy/CBT/IPSRT), schizophrenia (family therapy/CBT), panic disorder (exposure therapy), OCD (ERP), PTSD (CBT/EMDR), substance abuse/eating disorder (MI), borderline personality disorder, and conversion disorder and everyone should have experience with working with families, couples and groups.

Neuroscience and psychiatric genetics do not spell the end of psychotherapy - if anything we are learning how the developing brain is affected by early experience, the neural basis of psychotherapeutic effects, and genetic predictors of response to psychotherapy similar to pharmacogenetics. Sadly some psychiatrists are pill pushers, but most of us don't want to be pill pushers and most of our patients don't want that either. As psychologists seek to expand the scope of their practice, why should we seek to limit ours?

👍
Excellent plan. I would add use of brief therapies and implementation of this in other contexts, including short visit clinics, emergency, even consult in appropriate situations.