Psychotherapy training — Bare minimum vs. extensive?

[foreverbull]

Hi folks! There’s a lively thread in the psychology forum regarding psychiatry and psychotherapy training en route to completing training. I’m interested to hear how extensive or bare bones your psychotherapy training has been.

According to multiple psychiatrists I’ve spoken with, training has been very bare bones and not thorough enough, so I am trying to get a sense of how common this is in residency. One person in the other thread has argued that your psychotherapy training is extensive and prepares psychiatrists for psychotherapy well (without needing to seek additional training on your own).

So what has your experience been?

And who oversees the psychotherapy practice of psychiatrists once licensed?

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[SourceOfDenial]

*hot take* Apart from select programs in the country, psychotherapy training for residents falls short of what you would see hours wise and supervision wise in most PsyD, clinically focused PhD, MFT and therapy focused SW programs. I don’t think most psychiatrists coming out of residency are really competent in even CBT.

 

[Liquid8]

Our basic training had a few therapy requirements. The main one was a psychotherapy long case – at a minimum 40 x 1 hour sessions with a 10k word case report and passing that was required before one could progress into advanced training. As our Australian psychiatry training goes for 5 years, some people would stick with their patients beyond the 40 sessions and even after they had moved into private practice.

Psychotherapy supervision was mandated at 1 hour a week, which we usually did in groups. In some places this was provided at no cost by a staff psychiatrist during their working hours, but sometimes our training networks had links with local psychotherapists who would offer this for a discounted fee. In my last 2 years I remember doing sessions with a semi-retired psychotherapist who mainly worked with borderline and dissociative patients and had an interest in drama therapy. At the time there were 3 of us who had just cleared our exams and he only charged us $30 an hour which was far less than he could have earned otherwise.

The other requirements were relatively minimal, although enough to get a decent grasp on each modality. Had to do two CBT cases (minimum 6 sessions each, supervised by a psychologist), as well as a few other mandatory cases – interpersonal, supportive and family therapy, which I did a heap of during my child & adolescent rotation. I think there were some addiction/motivational interviewing type requirements grouped into that too.

Teaching-wise in our first year we had a block of psychotherapy lectures (3 hours/week x 9 weeks) but that was honesty pretty bad due to the first third being incomprehensible and poorly presented. However, as part of our final exit exam, we would have to interview and manage a patient under observation, so one would have to be able to discuss all aspects of management including therapies in detail to get through. That of course meant a lot of additional self-study which also helped to reinforce things.

A few of my colleagues who were more interested in therapy went on to complete Advanced training psychotherapy certificates which is another 2 years focused on a specific therapy of their choice. One of my friends who has completed this and is working towards just doing psychotherapy (and not prescribing medications) has organised monthly supervision from another psychiatrist, again at discounted rates.

 

[dl2dp2]

The variation in this area is very high.

I would say "top 10" programs (esp. on the coasts) overall do a very good job, and there are certainly psychiatrists who focus their practice on more advanced therapies (DBT/TFP, analysis, etc). Going down the list things start to deteriorate. This is for historical and other reasons (i.e. payor, etc.)

In general, I would say an average psychiatrist practicing for a while in the community at a facility typically has not done significant therapy for years. OTOH, *most* private practice psychiatrists probably do some degree of therapy in their practice.

 

[tr]

Hi folks! There’s a lively thread in the psychology forum regarding psychiatry and psychotherapy training en route to completing training. I’m interested to hear how extensive or bare bones your psychotherapy training has been.

According to multiple psychiatrists I’ve spoken with, training has been very bare bones and not thorough enough, so I am trying to get a sense of how common this is in residency. One person in the other thread has argued that your psychotherapy training is extensive and prepares psychiatrists for psychotherapy well (without needing to seek additional training on your own).

So what has your experience been?

And who oversees the psychotherapy practice of psychiatrists once licensed?

Excuse me I did not say that psychotherapy training for all MDs is extensive and prepares psychiatrists well without additional training.

I said the training *I* received was *sufficient* to prepare me for the competent exercise of a limited number of modalities, and that I could not speak for the implementation in other people's programs.

Obviously the psychotherapy training obtained in psychiatry residency does not approximate that of a PhD psychologist in any case and I said that multiple times on the other forum.

 

[dl2dp2]

Obviously the psychotherapy training obtained in psychiatry residency does not approximate that of a PhD psychologist in any case and I said that multiple times on the other forum.

I would dispute this as a universal feature. A small number of residency programs have therapy training that rival or even exceed the best PhD programs. On a therapist by therapist basis, mostly certainly--some of the best therapists I know are MDs. And in general MDs from that cohort are better therapists than top PhDs I've encountered. Maybe it's a bias, but think more likely reflects squashing of variance due to top MD residency programs being vastly more selective than a top PhD program as they are by in large much larger.

 

[clozareal]

In my residency, we are required to learn CBT (64 sessions with at least 2 patients + 64 weekly hours of CBT supervision), IPT (24 sessions with 48 hours of supervision), EFT (24 sessions with 48 hours of supervision), psychodynamic (at least one year for at least two patients + about 100 hours of weekly supervision). In addition, we have therapy electives for learning ACT (1 hour per week of therapy + 1-2 hours of supervision/seminar) and other types of therapies such as CPT, PE, CBIT, ERP, infant-parent psychotherapy, each one hour per week of therapy plus one hour per week of supervision.

I am also doing psychoanalytic training with the local institute that requires 3 hours per week of seminar and case discussions for two years, one weekly therapy case for one year (~50 sessions), one twice a week case for 6 months (~50 sessions), and two hours per week of supervision from an analyst (need to have two separate supervisors, one for each case). Case transcripts for process notes are expected for supervision.

In total, the minimum number of therapy hours expected for my residency program to graduate is probably around 400 hours. Even with the additional 350 hours of therapy training I'm doing, this falls extremely short of the 3000 hours required by the state board for psychologists in my state to become licensed (1500 hours during training and 1500 hours as a postdoc psychological assistant).

I would argue that my residency training in therapy is probably between the bare minimum and extensive (I hear from colleagues that they get much less therapy experience and supervision in other programs), but not equivalent by any means when comparing it to a psychologist's training.

 

[CalmAndCollected]

In my residency, we are required to learn CBT (64 sessions with at least 2 patients + 64 weekly hours of CBT supervision), IPT (24 sessions with 48 hours of supervision), EFT (24 sessions with 48 hours of supervision), psychodynamic (at least one year for at least two patients + about 100 hours of weekly supervision). In addition, we have therapy electives for learning ACT (1 hour per week of therapy + 1-2 hours of supervision/seminar) and other types of therapies such as CPT, PE, CBIT, ERP, infant-parent psychotherapy, each one hour per week of therapy plus one hour per week of supervision.

I am also doing psychoanalytic training with the local institute that requires 3 hours per week of seminar and case discussions for two years, one weekly therapy case for one year (~50 sessions), one twice a week case for 6 months (~50 sessions), and two hours per week of supervision from an analyst (need to have two separate supervisors, one for each case). Case transcripts for process notes are expected for supervision.

In total, the minimum number of therapy hours expected for my residency program to graduate is probably around 400 hours. Even with the additional 350 hours of therapy training I'm doing, this falls extremely short of the 3000 hours required by the state board for psychologists in my state to become licensed (1500 hours during training and 1500 hours as a postdoc psychological assistant).

I would argue that my residency training in therapy is probably between the bare minimum and extensive (I hear from colleagues that they get much less therapy experience and supervision in other programs), but not equivalent by any means when comparing it to a psychologist's training.

I would love to know which specific programs these are.

 

[Attending1985]

I would dispute this as a universal feature. A small number of residency programs have therapy training that rival or even exceed the best PhD programs. On a therapist by therapist basis, mostly certainly--some of the best therapists I know are MDs. And in general MDs from that cohort are better therapists than top PhDs I've encountered. Maybe it's a bias, but think more likely reflects squashing of variance due to top MD residency programs being vastly more selective than a top PhD program as they are by in large much larger.

I agree that the MD therapists I’ve encountered are the best. I think the thing about administering therapy is so much is dependent personal elements and not your length of training. Those with emotional intelligence, good judgement and good personality functioning will do well regardless of training.
Those who are lacking will not despite extensive training. I’ve worked with many phds who despite credentials were very ineffective. I’ve worked with many masters level therapists who were excellent and much more effective than their PhD counterparts.

 

[tr]

I agree that the MD therapists I’ve encountered are the best. I think the thing about administering therapy is so much is dependent personal elements and not your length of training. Those with emotional intelligence, good judgement and good personality functioning will do well regardless of training.
Those who are lacking will not despite extensive training. I’ve worked with many phds who despite credentials were very ineffective. I’ve worked with many masters level therapists who were excellent and much more effective than their PhD counterparts.

I agree that the natural inclinations of the individual therapist may be the most relevant factor of all in determining efficacy.
BUT
I also think that there is this pervasive idea in psychiatric training programs that just being a sympathetic and present listener comprises a sufficiently effective intervention. If there is a problem with psychotherapy training in psychiatric residencies, it is this, not volume.

My first four or five experiences with supervised therapy involved repeated exchanges that went something like this:

Me: "Uh, I don't know what I"m doing."
Supervisor: "You're doing great! It's a holding environment. Just keep being there." Etc.

Being a warm body with a modicum of human empathy does not constitute a professional intervention.
You could do thousands of hours of this type of supervision and still not improve your therapeutic efficacy one iota.
Thank goodness I stumbled into a training venue where people were actually interested in identifying, measuring and improving therapeutic efficacy.

 

[tr]

I would dispute this as a universal feature. A small number of residency programs have therapy training that rival or even exceed the best PhD programs. On a therapist by therapist basis, mostly certainly--some of the best therapists I know are MDs. And in general MDs from that cohort are better therapists than top PhDs I've encountered. Maybe it's a bias, but think more likely reflects squashing of variance due to top MD residency programs being vastly more selective than a top PhD program as they are by in large much larger.

How the hell do you even know if someone you know professionally is a good therapist or not. You have asked their patients? Seen their videos? Obtained their rating forms?

 

[Attending1985]

I agree that the natural inclinations of the individual therapist may be the most relevant factor of all in determining efficacy.
BUT
I also think that there is this pervasive idea in psychiatric training programs that just being a sympathetic and present listener comprises a sufficiently effective intervention. If there is a problem with psychotherapy training in psychiatric residencies, it is this, not volume.

My first four or five experiences with supervised therapy involved repeated exchanges that went something like this:

Me: "Uh, I don't know what I"m doing."
Supervisor: "You're doing great! It's a holding environment. Just keep being there." Etc.

Being a warm body with a modicum of human empathy does not constitute a professional intervention.
You could do thousands of hours of this type of supervision and still not improve your therapeutic efficacy one iota.
Thank goodness I stumbled into a training venue where people were actually interested in identifying, measuring and improving therapeutic efficacy.

I completely agree. My biggest frustration is reflective listening purported as therapy. I see therapist me across the board with all different backgrounds doing this. I’m assuming they’re burned out.
What I meant was therapeutic knowledge cannot translate clinically without instrinsic qualities of the therapist.

 

[foreverbull]

Some of what is said here (ie bias against PhD graduates and generalization of anecdotes) makes me wonder if this sentiment is being communicated to those colleagues in some way—which would certainly flavor their interactions with you.

I’ve had colleagues talked down to by different psychiatrists and particularly in hospital settings, psychologists’ input seen as far less important than the psychiatrist’s regarding case conceptualization. That said, I’ve worked directly with a few psychiatrists who were great; who knew what I brought to the table and respected me for my unique contributions and skills and I respected theirs. I don’t overgeneralize and assume your entire field is mostly the former type, and I would hope broad assumptions weren’t being made about psychologists based purely on anecdotes.

 

[Attending1985]

Some of what is said here (ie bias against PhD graduates and generalization of anecdotes) makes me wonder if this sentiment is being communicated to those colleagues in some way—which would certainly flavor their interactions with you.

I’ve had colleagues talked down to by different psychiatrists and particularly in hospital settings, psychologists’ input seen as far less important than the psychiatrist’s regarding case conceptualization. That said, I’ve worked directly with a few psychiatrists who were great; who knew what I brought to the table and respected me for my unique contributions and skills and I respected theirs. I don’t overgeneralize and assume your entire field is mostly the former type, and I would hope broad assumptions weren’t being made about psychologists based purely on anecdotes.

I’m reading this thread and I don’t read a bias against PhDs. Can you clarify?

 

[foreverbull]

I’m reading this thread and I don’t read a bias against PhDs. Can you clarify?

I would dispute this as a universal feature. A small number of residency programs have therapy training that rival or even exceed the best PhD programs. On a therapist by therapist basis, mostly certainly--some of the best therapists I know are MDs. And in general MDs from that cohort are better therapists than top PhDs I've encountered. Maybe it's a bias, but think more likely reflects squashing of variance due to top MD residency programs being vastly more selective than a top PhD program as they are by in large much larger.

Yes, should've quoted this and the post from the other thread. The same poster in the other thread had stated that those who wanted to be doctors should have gone to medical school.

I'm curious @sluox how you compare the different training and what factors into this determination. Or is this based on interactions?

 

[Candidate2017]

How the hell do you even know if someone you know professionally is a good therapist or not. You have asked their patients? Seen their videos? Obtained their rating forms?

I know when a therapist is bad: I've had plenty of therapists call and ask why I, the mean doctor, didn't prescribe controlled substance x, y, z to a mutual patient, despite the therapist receiving my notes documenting my rationale.

 

[Candidate2017]

Some of what is said here (ie bias against PhD graduates and generalization of anecdotes) makes me wonder if this sentiment is being communicated to those colleagues in some way—which would certainly flavor their interactions with you.

I’ve had colleagues talked down to by different psychiatrists and particularly in hospital settings, psychologists’ input seen as far less important than the psychiatrist’s regarding case conceptualization. That said, I’ve worked directly with a few psychiatrists who were great; who knew what I brought to the table and respected me for my unique contributions and skills and I respected theirs. I don’t overgeneralize and assume your entire field is mostly the former type, and I would hope broad assumptions weren’t being made about psychologists based purely on anecdotes.

In my program, we love PhD therapists and always want to know their opinion. We only look down on the few who have a rep for diagnosing ADHD in everyone who pays for a neuropsych evaluation.

My opinion is the average PhD therapist is better at therapy than the average psychiatrist. This makes sense, as they have more training at it. This is not to say there are a minority of psychiatrists who are better than the average PhD therapist. I will say that the average psychiatrist has a lot more breadth in patient exposure because we see a ton more patients and the population that sees a PhD therapist is very limited and self-selected to those who are very psychologically minded. I wish I had the patient population of my supervisors who are psychologists. PhD therapists also cannot appreciate the burden of a prescription pad and the large patient population who believes there is a pill for every ill.

 

[hebel]

Hi folks! There’s a lively thread in the psychology forum regarding psychiatry and psychotherapy training en route to completing training. I’m interested to hear how extensive or bare bones your psychotherapy training has been.

According to multiple psychiatrists I’ve spoken with, training has been very bare bones and not thorough enough, so I am trying to get a sense of how common this is in residency. One person in the other thread has argued that your psychotherapy training is extensive and prepares psychiatrists for psychotherapy well (without needing to seek additional training on your own).

So what has your experience been?

And who oversees the psychotherapy practice of psychiatrists once licensed?

Just checked out that thread...yikes.

Before answering this too concretely, what is everyone (and you sort of) arguing about in the first place?

When you say someone is adequately trained in therapy, what do you mean exactly? What benchmarks are you looking for (apart from training hours) to determine if someone meets the standard of being adequately trained or "competent" as a psychotherapist?

 

[dl2dp2]

How the hell do you even know if someone you know professionally is a good therapist or not. You have asked their patients? Seen their videos? Obtained their rating forms?

Shared patients.

 

[bashir]

I agree that the natural inclinations of the individual therapist may be the most relevant factor of all in determining efficacy.
BUT
I also think that there is this pervasive idea in psychiatric training programs that just being a sympathetic and present listener comprises a sufficiently effective intervention. If there is a problem with psychotherapy training in psychiatric residencies, it is this, not volume.

My first four or five experiences with supervised therapy involved repeated exchanges that went something like this:

Me: "Uh, I don't know what I"m doing."
Supervisor: "You're doing great! It's a holding environment. Just keep being there." Etc.

Being a warm body with a modicum of human empathy does not constitute a professional intervention.
You could do thousands of hours of this type of supervision and still not improve your therapeutic efficacy one iota.
Thank goodness I stumbled into a training venue where people were actually interested in identifying, measuring and improving therapeutic efficacy.

Would you mind sharing details about that training venue? Or if anyone else has advice on how to go about obtaining high quality supervision I'd love to hear it. I imagine that with the pandemic-induced pivot to teletherapy geographical barriers in finding supervision have been leveled to a large degree. I am a newly minted psychiatrist on the "inadequately trained in residency" side of the spectrum. Some of my patients do not have access to therapy unless I'm the one providing it, so I feel a responsibility to develop competency. Plus I enjoy it, and I imagine I'd enjoy it a lot more if I were better at it.

 

[tr]

I completely agree. My biggest frustration is reflective listening purported as therapy. I see therapist me across the board with all different backgrounds doing this. I’m assuming they’re burned out.
What I meant was therapeutic knowledge cannot translate clinically without intrinsic qualities of the therapist.

Actually I think reflective listening can be a really powerful tool. Sometimes when you just repeat someone's thoughts/emotions back to them in a neutral way, they realize what's distorted about them in a way that they couldn't before.

But that's not a normal thing that regular human beings do in conversation, it's something that you have to be explicitly taught to do.
Empathetic listening, on the other hand - just listening, nodding, and sympathizing - is something we do in everyday conversation, and while it can be helpful and can also be a good way to establish initial rapport and open the door for more effective work, it's not something that constitutes effective psychotherapy by itself. But I had multiple therapy supervisors in residency try to convince me that it really was, like, a helpful intervention that was worth spending multiple sessions on.

 

[tr]

Would you mind sharing details about that training venue? Or if anyone else has advice on how to go about obtaining high quality supervision I'd love to hear it. I imagine that with the pandemic-induced pivot to teletherapy geographical barriers in finding supervision have been leveled to a large degree. I am a newly minted psychiatrist on the "inadequately trained in residency" side of the spectrum. Some of my patients do not have access to therapy unless I'm the one providing it, so I feel a responsibility to develop competency. Plus I enjoy it, and I imagine I'd enjoy it a lot more if I were better at it.

The most useful training I had was a group supervision where we learned how to structure a CBT session and actually practiced the tools and techniques on each other. It was incredibly helpful to reverse-engineer the work. You got to experience what it was like to say certain things as a therapist, and then run the simulation again and experience what it was like to hear them as the patient. It was really powerful and helped hone my interactions. Some things that sound almost equivalent to the speaker can come out with vastly differing valences to the listener.

 

[Sushirolls]

Folks here are also forgetting that before you do therapy, you need to have a diagnosis. You need to know what is going on with the patient before you start doing anything.

I respect and value the depth and time applied in Psychology (PhD & PsyD) programs, especially when compared to masters level programs. However, I have observed that in general PsyD / PhD miss the diagnosis mark more than masters level clinicians. I attribute this in part to patient pool being less broad during their training, and not seeing the breath of severity of mental illness across the life spectrum. Psychiatrists, hands down, unequivocal, no contest see the breadth of all mental illness across the life spectrum and as such have a greater acumen at applying the DSM-5.

It gets old fast how many times I have patients report back to me "my therapist and I think I have PTSD / ADD / Bipolar" when no, no, they don't, and they truly lack criteria, and the mental health is better explained by DSM-5 diagnosis XYZ.

 

[foreverbull]

Just checked out that thread...yikes.

Before answering this too concretely, what is everyone (and you sort of) arguing about in the first place?

When you say someone is adequately trained in therapy, what do you mean exactly? What benchmarks are you looking for (apart from training hours) to determine if someone meets the standard of being adequately trained or "competent" as a psychotherapist?

I was actually asking to see what residency training entailed for comparison. I discussed my training to some extent on the other thread ... but am wondering about type of training & length, number of clients seen specifically for psychotherapy purposes, supervision specific to psychotherapy, etc. Hours are helpful if the unrelated didactics and non-psychotherapy sessions are removed, but so far that seems to be a tough question given the wider focus of psychiatry training.

The original question was whether psychiatrists provided psychotherapy and it morphed into a discussion comparing training. I personally wanted to understand how well or ill prepared the average psychiatrist is to provide psychotherapy upon licensure without seeking additional training outside of the program—but that’s hard to do when you don’t know much about PhD training to compare.

 

[AbnormalPsych]

Psychiatrists, hands down, unequivocal, no contest see the breadth of all mental illness across the life spectrum and as such have a greater acumen at applying the DSM-5.

Do you have a citation for this?

 

[hebel]

I was actually asking to see what residency training entailed for comparison. I discussed my training to some extent on the other thread ... but am wondering about type of training & length, number of clients seen specifically for psychotherapy purposes, supervision specific to psychotherapy, etc. Hours are helpful if the unrelated didactics and non-psychotherapy sessions are removed, but so far that seems to be a tough question given the wider focus of psychiatry training.

The original question was whether psychiatrists provided psychotherapy and it morphed into a discussion comparing training. I personally wanted to understand how well or ill prepared the average psychiatrist is to provide psychotherapy upon licensure without seeking additional training outside of the program—but that’s hard to do when you don’t know much about PhD training to compare.

I still think there needs to be a clear understanding of what everyone is talking about, especially with something so nebulous as engaging in talk therapy with another human being. Competency to me could range from enough training to be effective (some people would even debate how to define effective) for xx% of patients, to just getting to the point that you can match a placebo response and are not going to harm the patient in the process. I think every psychiatry residency graduate (barring personality issues) receives sufficient therapy exposure to ensure the latter.

To answer your question, there is definitely variability between programs (and even within programs). In the majority of programs (including mine), it's easy to graduate without extensive psychotherapy training. However, I've never seen these psychiatrists clamoring to do psychotherapy as attendings. And why would they? There's definitely no external incentives to do so.

I think if you surveyed the few psychiatrists (usually in private practice) who actually do end up doing psychotherapy regularly, their experiences are different from the average residency graduate.

As for my personal training (current end of year PGY-4), I've averaged 4 hours of psychotherapy supervision per week. Some of this used to be CBT, but in my last year it's transitioned to all being psychodynamic. The supervision involves discussing readings (articles and books) from time to time, but generally focuses on review of my video-recorded therapy sessions. I currently see 8 weekly therapy patients (although it's been higher before), and by therapy I mean that I am operating within a specific modality. I am not including the additional patients seen periodically for "supportive therapy." Paradoxically, I think more weekly patients during training aren't necessarily better and found that my ability to learn was more difficult when my patient load was higher. Of course, during this period I was still seeing a much larger number of patients than your average psychologist in various settings, just not solely for therapy.

In addition to the above, throughout training I go to regular didactics, case conferences, have participated in and facilitated therapy groups, and have been in group supervision (where I get to see other residents' recorded sessions).

After graduation I plan to pay out of pocket for continual supervision and other forms of continuing education (workshops, etc).

I think I've gotten to the point where I "know what I don't know," and can appropriately screen-out patients that wouldn't be a good fit. I chose to narrow my training to two specific therapy modalities to allow for more depth, and have identified specific populations that are appropriate for this form of therapy. I consider myself competent and better than my community's standard for what passes as therapy.

As an aside, I'm surprised your cohort is throwing out comparisons of us doing psychotherapy to NP's diagnosing and prescribing medications independently.

I think a good psychologist is worth their weight in gold and wish there were more of you around.

 

[Attending1985]

Actually I think reflective listening can be a really powerful tool. Sometimes when you just repeat someone's thoughts/emotions back to them in a neutral way, they realize what's distorted about them in a way that they couldn't before.

But that's not a normal thing that regular human beings do in conversation, it's something that you have to be explicitly taught to do.
Empathetic listening, on the other hand - just listening, nodding, and sympathizing - is something we do in everyday conversation, and while it can be helpful and can also be a good way to establish initial rapport and open the door for more effective work, it's not something that constitutes effective psychotherapy by itself. But I had multiple therapy supervisors in residency try to convince me that it really was, like, a helpful intervention that was worth spending multiple sessions on.

For the psychologically sophisticated patient yes reflective listening can be a good tool. I maintain if it’s the only tool used even in the sophisticated patient it falls short. At worst I’ve seen it help unsophisticated patients become more entrenched.
I see empathetic listening as another good tool to increase feelings of safety and being understood in the patient before any real work can be done. I can see certain cases where it might warrant a couple of sessions.

 

[Attending1985]

Folks here are also forgetting that before you do therapy, you need to have a diagnosis. You need to know what is going on with the patient before you start doing anything.

I respect and value the depth and time applied in Psychology (PhD & PsyD) programs, especially when compared to masters level programs. However, I have observed that in general PsyD / PhD miss the diagnosis mark more than masters level clinicians. I attribute this in part to patient pool being less broad during their training, and not seeing the breath of severity of mental illness across the life spectrum. Psychiatrists, hands down, unequivocal, no contest see the breadth of all mental illness across the life spectrum and as such have a greater acumen at applying the DSM-5.

It gets old fast how many times I have patients report back to me "my therapist and I think I have PTSD / ADD / Bipolar" when no, no, they don't, and they truly lack criteria, and the mental health is better explained by DSM-5 diagnosis XYZ.

This is a huge problem with masters levels therapists in my experience. I’m not sure how much inpatient/ed experience people get in other training settings but experiencing psychosis and mania is invaluable. I think this lack of experience leads to a lot of problems.

 

[AbnormalPsych]

@hebel thank you for the thoughtful response, that was insightful.

One thought:

As an aside, I'm surprised your cohort is throwing out comparisons of us doing psychotherapy to NP's diagnosing and prescribing medications independently.

I would also disagree with this comparison. NPs diagnosing and prescribing would be comparable to the midlevels MFTs, LCSWs, and LPPCs for us.

I think a closer comparison would be what if psychologists prescribed as a field. Say we add on additional years of training on top of our already current required study of psychopharmacology, neuroanatomy, biological basis of behavior, etc... How would psychiatry view us integrating that intervention into our psychotherapy practices?

Personally, I am opposed to this and would never do it, even if I could in a limited capacity with things like SSRIs. There are experts like you all who know way more about this than I ever would, because you went to medical school and the following gold standard training channels. But I am curious what you think.

 

[foreverbull]

I still think there needs to be a clear understanding of what everyone is talking about, especially with something so nebulous as engaging in talk therapy with another human being. Competency to me could range from enough training to be effective (some people would even debate how to define effective) for xx% of patients, to just getting to the point that you can match a placebo response and are not going to harm the patient in the process. I think every psychiatry residency graduate (barring personality issues) receives sufficient therapy exposure to ensure the latter.

To answer your question, there is definitely variability between programs (and even within programs). In the majority of programs (including mine), it's easy to graduate without extensive psychotherapy training. However, I've never seen these psychiatrists clamoring to do psychotherapy as attendings. And why would they? There's definitely no external incentives to do so.

I think if you surveyed the few psychiatrists (usually in private practice) who actually do end up doing psychotherapy regularly, their experiences are different from the average residency graduate.

As for my personal training (current end of year PGY-4), I've averaged 4 hours of psychotherapy supervision per week. Some of this used to be CBT, but in my last year it's transitioned to all being psychodynamic. The supervision involves discussing readings (articles and books) from time to time, but generally focuses on review of my video-recorded therapy sessions. I currently see 8 weekly therapy patients (although it's been higher before), and by therapy I mean that I am operating within a specific modality. I am not including the additional patients seen periodically for "supportive therapy." Paradoxically, I think more weekly patients during training aren't necessarily better and found that my ability to learn was more difficult when my patient load was higher. Of course, during this period I was still seeing a much larger number of patients than your average psychologist in various settings, just not solely for therapy.

In addition to the above, throughout training I go to regular didactics, case conferences, have participated in and facilitated therapy groups, and have been in group supervision (where I get to see other residents' recorded sessions).

After graduation I plan to pay out of pocket for continual supervision and other forms of continuing education (workshops, etc).

I think I've gotten to the point where I "know what I don't know," and can appropriately screen-out patients that wouldn't be a good fit. I chose to narrow my training to two specific therapy modalities to allow for more depth, and have identified specific populations that are appropriate for this form of therapy. I consider myself competent and better than my community's standard for what passes as therapy.

As an aside, I'm surprised your cohort is throwing out comparisons of us doing psychotherapy to NP's diagnosing and prescribing medications independently.

I think a good psychologist is worth their weight in gold and wish there were more of you around.

To you and the others who have discussed their training in this thread, this is helpful information. I know very little about what residency is like, so this is all new.

And yes, I think one person used that comparison, but we also had some hubris from a psychiatrist or two in there on the other side. I think the concern from some is that regardless of how well- or ill- trained psychiatrists are, they are ALL able to practice psychotherapy under the law and are seen as experts in it by default and given heightened respect because of the MD. I think some of us in particular have experienced some psychiatrists taking what little training they had and running with it and/or claiming expertise in a field that doesn’t discourage this hubris because it is perfectly legal to practice with little training in psychotherapy if the training standards allow for such wide variability (prior to this, I’d spoken with psychiatrists who noted that they had very minimal training in psychotherapy). It’s a different experience in the PhD training route, where training is fairly standard and rigorous under our APA accrediting body in comparison, staying within your competence is drilled into us from day 1, and our psychotherapy practice is regulated closely by state boards after licensure (my state errs on the side of being quite punitive towards psychologists). That last point may be more of an aside, though, because I’m not sure how punitive medical boards are In terms of psychotherapy practice by psychiatrists.

Of course, if those receiving subpar training don’t practice psychotherapy or claim expertise/believe they know everything they need to know in psychotherapy, this is all just a moot point. I have worked with some great psychiatrists in which there was mutual respect for what each contributed, but historically there has been some patronizing/lack of respect toward PhDs by some psychiatrists, sometimes encouraged by the unspoken hierarchies in hospital settings in particular (and even our broader culture). Not saying this is across the board, though.

 

[Peace of Mind]

Weren't studies showing psychotherapies to be of equivalent efficacy regardless of the modality or theoretical construct?
With the therapeutic relationship being the main predictive factor of efficacy? (Some scientists even arguing a placebo effect)

Other studies showing that therapist do not become more effective with time or experience and outcomes actually worsened with experience.

Does current research actually supports the idea of having a vast arsenal of modalities as an important aspect of training?
Seems to me that psychiatry is doing the smart thing, as opposed to psychology, 4 years of residency (5 in Canada) is seen as overkill by many.

I suppose the illusion of expertise does give us comfort.

 

[Peace of Mind]

So I just received a notification, apparently someone quoted me in the psychology forum looking for back up to to justify the non evidence based curriculum people currently have to follow to become psychotherapists.

I decided to read some of the stuff in that thread.... bad idea.

At least the animosity towards medicine is constant over time:

It's year 2100. Where is clinical psychology?

If that's too far, go with 2050 or whatever. Regardless, where do you see the field headed? I see a greater influence of Eastern philosophies and religions as is already evidenced by the proliferation of mindfulness research and its incorporation into new forms of therapy. I see psychologists...

forums.studentdoctor.net

So 10 years ago psychologists predicted that by 2050 (or 2100) not only will psychiatry cease to exist but psychologists will be practicing medicine.

I really don't think this post was started in good faith.

 

[Sushirolls]

LOL. If Psychiatry disappears, so too will Psychology. ARNPs will have inherited the earth.

 

[foreverbull]

So I just received a notification, apparently someone quoted me in the psychology forum looking for back up to to justify the non evidence based curriculum people currently have to follow to become psychotherapists.

I decided to read some of the stuff in that thread.... bad idea.

At least the animosity towards medicine is constant over time:

It's year 2100. Where is clinical psychology?

If that's too far, go with 2050 or whatever. Regardless, where do you see the field headed? I see a greater influence of Eastern philosophies and religions as is already evidenced by the proliferation of mindfulness research and its incorporation into new forms of therapy. I see psychologists...

forums.studentdoctor.net

So 10 years ago psychologists predicted that by 2050 (or 2100) not only will psychiatry cease to exist but psychologists will be practicing medicine.

I really don't think this post was started in good faith.

I quoted you. There's a close dialogue going on in the psychology forum and I found it to be relevant--in fact, someone in there directly addressed the methodological issues of the training equivalency studies. I started this thread because of the dialogue in the other forum, actually, because I wanted to hear about more detail of the training experiences.

You dug up a decade-old thread from someone else (who is not me) as evidence that I didn't start this post in "good faith?" Quite a stretch, don't you think?

 

[Peace of Mind]

I was comparing the psychology forum's opinion 10 years go to what I'm seeing today.
I wasn't singling you out in particular.

 

[AbnormalPsych]

Seems irrelevant

 

[Peace of Mind]

Seems irrelevant

We will have to disagree then.
I think that exploring certain biases in your profession helps to put in context certain replies to the question ''Do psychiatrists provide psychotherapy?''

For example one of the popular ones in that thread: ''They think they do. ''

 

[AbnormalPsych]

We will have to disagree then.
I think that exploring certain biases in your profession helps to put in context certain replies to the question ''Do psychiatrists provide psychotherapy?''

For example one of the popular ones in that thread: ''They think they do. ''

You know I was thinking the very same thing.

I decided to read some of the stuff in that thread.... bad idea.

There is some extremely good insight from top notch professionals over there. If it doesn't align with your preixisting beliefs...well I am also sorry about the bias or willful disregard of information conflicting with beliefs on your end.

 

[AbnormalPsych]

Also, there was further description to clarify that comment (which was originally made in jest - until folks got defensive):

I think there are different conceptualizations of what psychotherapy is.

Do psychiatrists use psychotherapy techniques. Sure. Do they do it over a course of time. Sure. When put together, might this technically be considered a course of psychotherapy. Sure. Is the depth of their training and quality of the work equal to that of masters or doctoral level providers? Could be. Is this probable? No. Some of us have spent almost a decade learning psychotherapy and still feel some imposter syndrome. Even masters level providers often spend 3 years full time learning this. It does come off a bit in insulting to think someone in another field can just pick it up as a side part of their training and act so hubristic about it.

I have a range of formal coursework and didactic training in psychopharmacology, biology, chemistry, biological bases of behavior, neuroanatomy, and years of experience working with psychiatrists. Does this inform my work? Sure. Do I provide intervention in this area? No. There are others who are licensed in specifically this who know 1000% more than I ever would.

 

[beginner2011]

In my residency, we are required to learn CBT (64 sessions with at least 2 patients + 64 weekly hours of CBT supervision), IPT (24 sessions with 48 hours of supervision), EFT (24 sessions with 48 hours of supervision), psychodynamic (at least one year for at least two patients + about 100 hours of weekly supervision). In addition, we have therapy electives for learning ACT (1 hour per week of therapy + 1-2 hours of supervision/seminar) and other types of therapies such as CPT, PE, CBIT, ERP, infant-parent psychotherapy, each one hour per week of therapy plus one hour per week of supervision.

I am also doing psychoanalytic training with the local institute that requires 3 hours per week of seminar and case discussions for two years, one weekly therapy case for one year (~50 sessions), one twice a week case for 6 months (~50 sessions), and two hours per week of supervision from an analyst (need to have two separate supervisors, one for each case). Case transcripts for process notes are expected for supervision.

In total, the minimum number of therapy hours expected for my residency program to graduate is probably around 400 hours. Even with the additional 350 hours of therapy training I'm doing, this falls extremely short of the 3000 hours required by the state board for psychologists in my state to become licensed (1500 hours during training and 1500 hours as a postdoc psychological assistant).

I would argue that my residency training in therapy is probably between the bare minimum and extensive (I hear from colleagues that they get much less therapy experience and supervision in other programs), but not equivalent by any means when comparing it to a psychologist's training.

I'm a PhD student in clinical psychology, and this is really helpful info for me as I continue to try to build my understanding of other disciplines in mental health. Thanks for detailing this out.

If I'm doing the math correctly, you could complete your residency with a total of about 250 hours of F2F therapy experience spread across 4 different therapy modalities, and only 64 hours of CBT experience with 2 patients. Given that CBT is considered to be the bread-and-butter approach to psychotherapy for the vast majority of mood and anxiety disorders, I'm surprised.

For example, if I had a friend or colleague suffering from an anxiety disorder I would be extremely concerned if I learned that they were working with a therapist who had less than 75 hours of supervised experience delivering one of the most evidence-based treatments for that category of disorders.

 

[CalmAndCollected]

It's year 2100. Where is clinical psychology?

If that's too far, go with 2050 or whatever. Regardless, where do you see the field headed? I see a greater influence of Eastern philosophies and religions as is already evidenced by the proliferation of mindfulness research and its incorporation into new forms of therapy. I see psychologists...

forums.studentdoctor.net

So 10 years ago psychologists predicted that by 2050 (or 2100) not only will psychiatry cease to exist but psychologists will be practicing medicine.

I really don't think this post was started in good faith.

Maybe this is just me, but most of these posts don't read as very serious. You might want to chill at what is essentially a group of psychologist poking fun at psychiatrists and the entirety of the mental health field.

I'm a PhD student in clinical psychology, and this is really helpful info for me as I continue to try to build my understanding of other disciplines in mental health. Thanks for detailing this out.

If I'm doing the math correctly, you could complete your residency with a total of about 250 hours of F2F therapy experience spread across 4 different therapy modalities, and only 64 hours of CBT experience with 2 patients. Given that CBT is considered to be the bread-and-butter approach to psychotherapy for the vast majority of mood and anxiety disorders, I'm surprised.

For example, if I had a friend or colleague suffering from an anxiety disorder I would be extremely concerned if I learned that they were working with a therapist who had less than 75 hours of supervised experience delivering one of the most evidence-based treatments for that category of disorders.

Psychiatry residency doesn't really prioritize therapy. The minimum exposure is mostly to help psychiatrists understand the different modalities so they can refer effectively or integrate a few therapy skills as necessary during their appointments. Most residents who want to do effective psychotherapy often make extra efforts outside of what is required to do so, such as joining a psychoanalytical institute or doing specific psychotherapy tracks that are available in certain programs.

I do agree that psychiatrist should get more exposure to therapy, but it seems like the infrastructure to allow that isn't available in many programs, particularly at smaller community programs.

 

[clozareal]

I'm a PhD student in clinical psychology, and this is really helpful info for me as I continue to try to build my understanding of other disciplines in mental health. Thanks for detailing this out.

If I'm doing the math correctly, you could complete your residency with a total of about 250 hours of F2F therapy experience spread across 4 different therapy modalities, and only 64 hours of CBT experience with 2 patients. Given that CBT is considered to be the bread-and-butter approach to psychotherapy for the vast majority of mood and anxiety disorders, I'm surprised.

For example, if I had a friend or colleague suffering from an anxiety disorder I would be extremely concerned if I learned that they were working with a therapist who had less than 75 hours of supervised experience delivering one of the most evidence-based treatments for that category of disorders.

This is one example from the experience at my residency program, which is in line with the ACGME requirements. Psychotherapy training is a small part of psychiatry training in general, for me about 5-10% of my entire training. The example I gave above are also the minimum requirements and most residents are somewhere between that amount and at most double those number of hours.

The other 15,000 clinical hours of residency training are focused on more of how medicine is practiced traditionally (getting an HPI, doing an examination both mental status and neurological, ordering and interpreting laboratory and imaging tests for both etiology but also to monitor for side effects, recommending treatment, learning 2nd, 3rd, 4th and beyond line measures if initial treatments don't work, managing that treatment plan long term, on an inpatient, outpatient, consult, and emergency setting).

Once out of the restrictions of training where a trainee is required to be on certain rotations that limits the number of psychotherapy hours they can do, psychiatrists who want to do psychotherapy as part of their practice often increase the number of cases they see and get additional supervision for this. I would argue that after residency is where psychotherapy training can truly grow at an exponential rate for psychiatrists. Some residents who recently graduated from my program are seeing more than 50-75% of their practice (about 20-30 hours a week) dedicated to psychotherapy along with supervision.

 

[beginner2011]

Weren't studies showing psychotherapies to be of equivalent efficacy regardless of the modality or theoretical construct?
With the therapeutic relationship being the main predictive factor of efficacy? (Some scientists even arguing a placebo effect)

Other studies showing that therapist do not become more effective with time or experience and outcomes actually worsened with experience.

Does current research actually supports the idea of having a vast arsenal of modalities as an important aspect of training?
Seems to me that psychiatry is doing the smart thing, as opposed to psychology, 4 years of residency (5 in Canada) is seen as overkill by many.

I suppose the illusion of expertise does give us comfort.

There are tons of methodological problems with the very few studies that have so far investigated these questions.

As to modality irrelevancy:
If you're referring to Wampold's "The Great Pyschotherapy Debate" (which is fantastic) that's not a fair summary of the conclusions. To begin with, depending on diagnosis, there is evidence that there are substantial differences in treatment outcome based on modality. E.g., applying supportive therapy for PTSD is vastly inferior to exposure therapy. Additionally, there is a difference between equivalency of outcome comparing findings from (1) a highly structured and rigorous randomized controlled trial where all therapists are adhering to high standards of practice in their modality and (2) independent practitioners deciding they're going to do whatever they want with patients because they can bill for it and think they're "good at that psychotherapy business."

As to experience/expertise irrelevancy:
There is a really well-written review of the literature in this area that essentially comes to the conclusion that there isn't evidence to support this claim, and in fact there is growing evidence to the contrary.

https://www.apa.org/education/ce/therapist-expertise.pdf

 

[hebel]

@hebel thank you for the thoughtful response, that was insightful.

One thought:



I would also disagree with this comparison. NPs diagnosing and prescribing would be comparable to the midlevels MFTs, LCSWs, and LPPCs for us.

I think a closer comparison would be what if psychologists prescribed as a field. Say we add on additional years of training on top of our already current required study of psychopharmacology, neuroanatomy, biological basis of behavior, etc... How would psychiatry view us integrating that intervention into our psychotherapy practices?

Personally, I am opposed to this and would never do it, even if I could in a limited capacity with things like SSRIs. There are experts like you all who know way more about this than I ever would, because you went to medical school and the following gold standard training channels. But I am curious what you think.

I think the concern from some is that regardless of how well- or ill- trained psychiatrists are, they are ALL able to practice psychotherapy under the law and are seen as experts in it by default and given heightened respect because of the MD.

No problem! It's a reasonable question, but I would not see this as an ok idea. I would MUCH prefer having this conversation in person with people, because there's a lot that can be said about this that I just don't enjoy taking the time to write!

To put it as briefly as I can, legal regulations applied to medical professions are supposed to be in place to ensure that the interventions applied by the particular profession can be performed with a reasonable assurance of safety, not necessarily efficacy or mastery. They are determining a reasonable level of entry, not the ceiling. Psychiatric interventions have the very real possibility of causing harm, especially if mismanaged. Psychotherapy, while difficult to master, has a relatively excellent safety profile.

This is why I agree with primary care physicians prescribing medications like SSRI's, but not psychologists (even though psychologists have an obviously superior expertise in certain areas of MH). Let's look at something as seemingly innocuous as the SSRI Prozac. Prozac can lead to hyponatremia with or without SIADH, serotonin syndrome (think of all the patients on 10+ daily medications to look through), upper GI bleeds, etc. You could have a guy on warfarin for AFIB who starts Prozac and a couple of months later has a hemorrhagic stroke (this is a P450 interaction scenario).

A PCP may not be psychologically sophisticated, or even a great listener! But he knows how to screen for and recognize these adverse effects (even manage some). Despite the jokes about psychiatrists not being real doctors, we often take for granted just how ingrained the medical model of interviewing, examining, ruling out medical causes, diagnosing, and treating our patients is within us from medical school and residency. I don't think these things can be picked up in a few extra supplemental training years. If the supplemental training was med school and residency, then sure...you're a doctor now.

The above example was just Prozac! Consider meds like antipsychotics, lithium, SNRI's, TCA's, MAOI's, stimulants, beta-blockers, benzodiazepines, methadone, etc...I know you only said SSRI's, but it's not that simple. This is why I am also against NP's practicing independently. It's not only about their efficacy, it's a matter of patient safety. In this scenario, I care more about mastery in the sense that they have strong knowledge about what can go wrong. This was the gist of one of my points in my first post. I think at a minimum psychiatrists are trained enough in residency to ensure to a reasonable degree that they will not cause serious harm to patients from their implementation of the intervention we call "therapy."

I also would personally be against psychologists transitioning to prescribers, because your role is so important to the mental health system. It'd be a shame to lose you guys as psychotherapists.

 

[tr]

This is why I agree with primary care physicians prescribing medications like SSRI's, but not psychologists (even though psychologists have an obviously superior expertise in certain areas of MH).

I guess I can see this point, but also sort of want to play devil's advocate a bit.

PCPs suck at prescribing antidepressants. They don't have enough time to listen to anyone's sob story so they are constantly throwing antidepressants at people who are having totally normal reactions to bad life stressors. Also they have no concept of titrating to clinical effect, they all have some dose in their heads that they are wedded to and will just start people immediately on that dose, producing loads of GI upset usually. They then won't change the dose regardless of observed efficacy. And I am pretty sure they are not screening for bipolar disorder. Psychologists would be better at all those things just by virtue of having the time to listen.

Let's look at something as seemingly innocuous as the SSRI Prozac. Prozac can lead to hyponatremia with or without SIADH,

In old people, who presumably would be out of scope of practice for psychologists due to their high risk/comorbidity status. Are you routinely checking sodium for young healthy people on Prozac? I don't and I don't know anyone else who does either.

serotonin syndrome (think of all the patients on 10+ daily medications to look through),

That's what Micromedex is for. I don't carry all those interactions around in my head. I punch them into the tool. Done.

upper GI bleeds, etc. You could have a guy on warfarin for AFIB who starts Prozac and a couple of months later has a hemorrhagic stroke (this is a P450 interaction scenario).

That guy is going to be seen weekly in Coumadin clinic and if his INR goes out of range they are going to adjust his dose pronto. But again, I would guess anyone on Coumadin would be considered overly complex to be managed by a psychologist with prescribing privileges.

And all of those scenarios are pretty rare and involve patients with other medical complexities, while crappy management of antidepressants by PCPs in otherwise healthy people is common.

(This is not a knock on PCPs. They have 1000x our knowledge base to deal with and I don't at all fault them for not having a handle on the finer details of psych meds, considering the incredibly broad range of stuff they have to deal with.)

 

[AbnormalPsych]

@hebel. Agreed.

I care more about mastery in the sense that they have strong knowledge about what can go wrong.

I would argue this perspective of having great depth of knowledge applies to doing psychotherapy as well. Safety risk (lethality and harm) are quite different, yes, but the efficacy issue remains. I think myself and those in the psychology forum are reacting because they want the patient to get the best care they can. Question is, what type of training and how much training is needed to get to a point to be able to think with the depth of that model with prozac above, but for psychotherapy. Some just don't know what they don't know.

 

[hebel]

@hebel. Agreed.



I would argue this perspective of having great depth of knowledge applies to doing psychotherapy as well. Safety risk (lethality and harm) are quite different, yes, but the efficacy issue remains. I think myself and those in the psychology forum are reacting because they want the patient to get the best care they can. Question is, what type of training and how much training is needed to get to a point to be able to think with the depth of that model with prozac above, but for psychotherapy. Some just don't know what they don't know.

Totally fair. My biggest issue with the discussion was the side tracking to issues with psychiatrists having the legal right to do therapy and the NP comparisons. I agree that the efficacy question is still important to examine.

Would you agree that your field (as honestly wonderful as it is), currently doesn't have a great way to uniformly define or answer the efficacy question?

Edit: also, if this is even answerable, what things come to mind when you picture a prozac-depth knowledge equivalent in psychotherapy?

 

[hebel]

I guess I can see this point, but also sort of want to play devil's advocate a bit.

PCPs suck at prescribing antidepressants. They don't have enough time to listen to anyone's sob story so they are constantly throwing antidepressants at people who are having totally normal reactions to bad life stressors. Also they have no concept of titrating to clinical effect, they all have some dose in their heads that they are wedded to and will just start people immediately on that dose, producing loads of GI upset usually. They then won't change the dose regardless of observed efficacy. And I am pretty sure they are not screening for bipolar disorder. Psychologists would be better at all those things just by virtue of having the time to listen.

In old people, who presumably would be out of scope of practice for psychologists due to their high risk/comorbidity status. Are you routinely checking sodium for young healthy people on Prozac? I don't and I don't know anyone else who does either.

That's what Micromedex is for. I don't carry all those interactions around in my head. I punch them into the tool. Done.

That guy is going to be seen weekly in Coumadin clinic and if his INR goes out of range they are going to adjust his dose pronto. But again, I would guess anyone on Coumadin would be considered overly complex to be managed by a psychologist with prescribing privileges.

And all of those scenarios are pretty rare and involve patients with other medical complexities, while crappy management of antidepressants by PCPs in otherwise healthy people is common.

(This is not a knock on PCPs. They have 1000x our knowledge base to deal with and I don't at all fault them for not having a handle on the finer details of psych meds, considering the incredibly broad range of stuff they have to deal with.)

tr, you're giving these psychologists quite the narrow patient population and treatment arsenal! Almost uselessly narrow. I'd be down for psychologists integrated into primary care providing diagnostic interviews. PCP management may not be effective enough in your eyes, but I wouldn't classify it as inappropriately unsafe.

I don't routinely draw BMP's in that scenario, but would draw it even in a young person if they were describing symptoms of hyponatremia (especially if it isn't one of our usual med side effects...like the person suddenly getting muscle cramps).

Micromedex and Lexicomp do not catch everything. Even if they do, the warnings need to be interpreted and understood correctly. Reading the Lexicomp letter-system warnings could lead to excessive caution, or worse...to warning fatigue until something bad really does happen. And would access to Micromedex be another necessary variable to these psychologists prescribing? 🙂

Chronic INR monitoring can be as infrequent as every 4-12 weeks. I've had multiple VA patients closer to the 12-week frequency.


Although it looks like we've all now established that this isn't the main issue. So I guess we carry on with the question of efficacy!

 

[tr]

haha tr, this is quite the hair-splitting devil! You're giving these psychologists quite the narrow patient population and treatment arsenal. Almost uselessly narrow. I'd be down for psychologists integrated into primary care providing diagnostic interviews. PCP management may not be effective enough in your eyes, but I wouldn't classify it as inappropriately unsafe.

I agree PCP is better in terms of safety, but I just think the safety risks of SSRIs are really low. The scenarios you describe are either rare or apply to populations that I have to be assume would be excluded from treatment by a prescribing psychologist.

I don't routinely draw BMP's in that scenario, but would draw it even in a young person if they were describing symptoms of hyponatremia (especially if it isn't one of our usual med side effects...like the person suddenly getting muscle cramps).

I mean, I'll grant this, but I've never seen hyponatremia from SSRI in anyone under about 65. And it could be dealt with by redirection to primary care, who would draw a BMP right off almost regardless of history really.

Micromedex and Lexicomp do not catch everything. Even if they do, the warnings need to be interpreted and understood correctly. Reading the Lexicomp letter-system warnings could lead to excessive caution, or worse...to warning fatigue until something bad really does happen. And would access to Micromedex be another necessary variable to these psychologists prescribing? 🙂

I dunno but it's necessary for *me* to be prescribing. Hell if I am going to try and keep an exponentially large network of potential interactions all in my own brain. I have better uses for those neurons.

Chronic INR monitoring can be as infrequent as every 4-12 weeks. I've had multiple VA patients closer to the 12-week frequency.

Not if you tell the clinic you just started Prozac! Then it's every week. Q 12 weeks is for people who have had stable INRs for a long time and are not making changes to their medications.

 

[CalmAndCollected]

I agree PCP is better in terms of safety, but I just think the safety risks of SSRIs are really low. The scenarios you describe are either rare or apply to populations that I have to be assume would be excluded from treatment by a prescribing psychologist.



I mean, I'll grant this, but I've never seen hyponatremia from SSRI in anyone under about 65. And it could be dealt with by redirection to primary care, who would draw a BMP right off almost regardless of history really.



I dunno but it's necessary for *me* to be prescribing. Hell if I am going to try and keep an exponentially large network of potential interactions all in my own brain. I have better uses for those neurons.



Not if you tell the clinic you just started Prozac! Then it's every week. Q 12 weeks is for people who have had stable INRs for a long time and are not making changes to their medications.

I’m confused, are you suggesting therapist should only be able to prescribe SSRIs?

Once the discussion turns to other antidepressants like TCAs or mood modulators like lithium or VPA your argument for safety falls apart. And that is not even talking about antipsychotics, controlled substances, or difficult meds like MAOIs or clozapine.

Arguing therapist should only be able to prescribe “safe drugs” would be so limiting as to be pointless. Why would a patient even go to a therapist for prescriptions if they “can’t get the real drugs”. Wouldn’t there also be problems of therapist overprescribing SSRIs when other drugs would work better because “when your only tool is a hammer, everything looks like a nail”. Maybe they have an anxiety patient who could use a small dose of PRN benzos to rescue themselves from severe anxiety attacks, but the therapist refuses to refer to a psychiatrist out of fear of losing a patient.