Psychotherapy Training Requirements

[solumanculver]

Hi,
How much "talk-therapy" training does a residency program have to provide in order for it to be accredited? Does anyone think that this minimum threshold of therapy training will decrease in the future?

I've recently been accepted to some medical schools, and my intention is to become a psychiatrist, but I'm really not interested in this therapy kind of stuff. My interest is in things like schizophrenia and psychotic disorders and the more neuroscientific and psychopharmacalogical approaches to treatment.

I'm not trying to bash therapy, I just don't want to do that sort of stuff and I'd like to avoid having to spend a lot of time learning about it. If a lot of time in psychiatry residency is spent on this sort of stuff, is there any alternate route through neurology that could feasibly lead to specialization in schizophrenia? It seems like a neuropsychiatry fellowship is not designed for that type of thing, but for dementias or something...

Also, it seems like I read a statistic somewhere saying that the efficacy of therapy has no correlation with the level of training of the practitioner. If that's the case, then doesn't it seem like not a good use of time in a psychiatry residency? Because I think that success in prescribing medication is correlated with level of training, so it seems like more time should be devoted to that...

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[strangeglove]

Sounds like you might want to do your residency at a place like WashU, Pittsburgh or Iowa. They tend to look down on psychotherapy and accordingly teach very little of it to their residents. Remember that you won't lose much by learning a little psychotherapy, but you stand to gain quite a bit. Also, the psychopharm stuff is relatively easy to pick up by reading and through accumulated experience with patients (there are only so many drugs right now and so many diagnoses). However, it is therapy that really demands supervision in order to learn effectively.

 

[solumanculver]

Hey, so do you mean that there is no minimum amount of psychotherapy that's required for a program to be accredited?

You think that the psychopharm stuff is really easy but the therapy requires more training? I'm surprised at this, given the statistic that I mentioned... though I didn't cite it. Do you doubt that statistic?

 

[Chimed]

Even if you do not want to directly practice psychotherapy, there are many benefits that you’ll gain from those skills, the least of which is to help you build a therapeutic alliance with your patients. For example, your skills can be used during med checks to help figure out why a patient is not compliant with their meds and help find ways to improve this.


I personally don’t think learning psychopharmacology is easy. Sure, anybody can learn the MOA, side-effect profile, etc., from a book. However, I believe it takes years of direct experience (under supervision) with patients to really learn the subtleties and nuisance of using psych meds. Not only do you have to learn the individual medications, but also how they work differently in patients and the effects of other med’s and comorbid conditions. Personally, I need to follow patients over time and work with those medications to learn this.

I also read a study a few years ago that stated there is no correlation between years of training and outcomes in psychotherapy. Does anyone know about this??? However, even if this is true, keep in mind that as far as amount and hours of psychotherapy is concerned, psychiatrists generally get the least.
My suggestion is to not look for a program with the least amount of psychotherapy training, but rather find one that has strong pharmacology training.

With that said, one program that might be of interest to you is Hopkins. It might be what you’re looking for….

 

[billypilgrim37]

You think that the psychopharm stuff is really easy but the therapy requires more training? I'm surprised at this, given the statistic that I mentioned... though I didn't cite it. Do you doubt that statistic?

Psychopharm isn't easy, it's just much easier to learn over the course of taking care of psychiatric patients over 4 years and/or from reading books and articles. Therapy, however, requires supervision and an extensive curriculum to learn. If you're not taught it during residency, you'll never learn it. My personal biases are heavily biological, but I'd prefer a residency with extensive therapy training, because a) I love psychopharm, and trust my own ability to read, and b) if I'm going to be a psychiatrist, I want all the tools in my box to be sharp.

I've heard many people cite the "doesn't matter what level the practitioner
is" study without ever producing a reference. Even if it exists (probably does), I'd have some pretty extensive questions about its methods. Psychotherapy is notoriously hard to study in clinical trials, so at least be cautious about what you're reading (both ways--about efficacy OR lack thereof).

 

[solumanculver]

Psychotherapy is notoriously hard to study in clinical trials, so at least be cautious about what you're reading (both ways--about efficacy OR lack thereof).

Hey, this is one of the reasons that I'm not really excited about learning it. It seems a little bit unscientific, in a way.

I suppose that experiences that people go through alter their neural functioning, like being a POW in 'Nam can give you PTSD. Is the idea of therapy that by going through some stereotyped interactions we can improve neural function through the same sorts of means? Is it about strengthening neuronal connections or something? Should we think of it like physical therapy in the brain?

I also don't understand the sort of proliferation of theories, or orientations, or whatever... Isn't the only theory that the brain causes behavior? Do all of the different theories postulate different means for experience to result in a change of brain function, different mechanisms of gene regulation in the brain?

It could be that the reason that I'm uncomfortable with psychotherapy is that it's efficacy seems hard to prove, and its theoretical basis, in terms of neuroscience, has never been explained to me. If any of you guys have the time to explain that stuff to me, I would really appreciate it.

 

[Chimed]

It could be that the reason that I'm uncomfortable with psychotherapy is that it's efficacy seems hard to prove,

There are many solid studies that have been done that support the use of psychotherapy, especially in CBT, DBT, and IPT. You can do a literature search and easily find them.

 

[OldPsychDoc]

Hi,
How much "talk-therapy" training does a residency program have to provide in order for it to be accredited? Does anyone think that this minimum threshold of therapy training will decrease in the future?
..

You can read the specific residency training requirements here. They're actually pretty vague.

Emphases mine:
5.
ACGME Competencies
The program must integrate the following ACGME competencies into the curriculum:
a)
Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents:
...
(3)
should develop competence in:
(a)
formulating a clinical diagnosis for patients by conducting patient interviews, eliciting a clear and accurate history; performing physical, neurological, and mental status examination, including appropriate diagnostic studies; completing a systematic recording of findings; relating history and clinical findings to the relevant biological psychological, behavioral, and sociocultural issues associated with
etiology and treatment;
(b)
developing a differential diagnosis and treatment plan for all psychiatric disorders in the current standard nomenclature, i.e., DSM, taking into consideration all relevant data;
(c)
using pharmacological regimens, including concurrent use of medications and psychotherapy;
(d)
understanding the indications and uses of electroconvulsive therapy;
(e)
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;
(f)
providing psychiatric consultation in a variety of medical and surgical settings;
(g)
providing care and treatment for the chronically-mentally ill with appropriate psychopharmacologic, psychotherapeutic, and social rehabilitative interventions;
(h)
participating in psychiatric administration, especially leadership of interdisciplinary teams, including supervised experience in utilization review, quality assurance and performance improvement;
(i)
providing psychiatric care to patients who are receiving treatment from nonmedical therapists and coordinating such treatment; and,
(j)
recognizing and appropriately responding to family violence (e.g., child, partner, and elder physical, emotional, and sexual abuse and neglect) and its effect on both victims and perpetrators.

 

[solumanculver]

There are many solid studies that have been done that support the use of psychotherapy, especially in CBT, DBT, and IPT. You can do a literature search and easily find them.

Hey. Yeah, you're right. I found a bunch of studies on the APA (psychology) website. Actually, I really didn't mean to say that I doubted the efficacy of psychotherapy in general... although that is what I wrote. I was sort of thinking of psychodynamic psychotherapy in particular.

 

[zen76]

I'd first like to start chipping away at the myth that somehow psychotherapy is "looked down upon" at Pitt. Most of us, neuroscience or biological interests or not, are interested in psychotherapy at Pittsburgh. In the past, psychotherapy has been less focused on at WPIC, but is fairly robust and vibrant, and I find people from outside WPIC saying we're all biological, and we poopoo talk therapy, but asking the residents you would not get that impression. The grand old man of Western Psych, Thomas Detre, wasn't exactly a devotee of therapy, and loved research, but things have become much more balanced over the last 10-20 years.

Also, from a neuroscience standpoint, here's how to envision therapy. Emotional regulation or inhibition of impulses in the limbic system and amygdala are greatly dimished in our patients, drugs work from the bottom up, while therapy helps provide and narrative structure, using better cognitions and affect control, to have a more satisfactory life, through the prefrontal cortex inhibiting or modulating the subcortical areas of the brain. From brain imaging studies, therapy works, and has some overlap with medications, but also unique areas are recruited. How one therapy works compared to another is still being teased apart. Therapy also lacks the multitude of side effects of psychopharm drugs as well. It gives patients more agency and control over their lives and mental states, rather than passively taking pills for years.

Therapy, like medication or ECT, is just another tool to help our patients. They both have their place, but they need to be tailored to the patient, like everything else in medicine. Furthermore for a lot of personality D/O, medication doesn't really help the disorder, symptoms can improve, but the underlying disorder is certainly not "cured." You're missing the boat on at least half of psychiatric clinical training w/out therapy. However, if you're really into the neuroscience, you can go to any top psych program (Hopkins, Harvard, Columbia, UCLA, WashU, Michigan, Pitt, UPenn, Stanford, UCSF, NYU, Mt. Sinai, UTSW, San Diego, Yale, NIMH, etc.) and find excellent research opportunities, but try to keep an open mind, and become more comfortable with the grey rather than just black and white. And this from someone who has a strong interest in the genetics of trait versus state in depression, and gene environment interactions in a mouse model with depression and substance use.

Good luck.

 

[solumanculver]

Also, from a neuroscience standpoint, here's how to envision therapy. Emotional regulation or inhibition of impulses in the limbic system and amygdala are greatly dimished in our patients, drugs work from the bottom up, while therapy helps provide and narrative structure, using better cognitions and affect control, to have a more satisfactory life, through the prefrontal cortex inhibiting or modulating the subcortical areas of the brain. From brain imaging studies, therapy works, and has some overlap with medications, but also unique areas are recruited. How one therapy works compared to another is still being teased apart. Therapy also lacks the multitude of side effects of psychopharm drugs as well. It gives patients more agency and control over their lives and mental states, rather than passively taking pills for years.

Hey Zen, this has been a really helpful post. Let me see if I've gotten it right...

Psychiatric patients have decreased emotional regulation and impulse control. This is caused by a dysfunction of the limbic system and amygdala. Therapy stimulates the prefrontal cortex to rewire these areas of the brain to correct the problems.

If this is correct, it seems to support my image of psychotherapy as being really analogous to physical therapy for the brain. Do you agree with that analogy?

Do you think that this subcortical rewiring that occurs during therapy is of the same type that occurs to sabotage the brain in something like PTSD? If it is, then do you think that the really elaborate explanations of approaches like psychoanalysis have any relation to their efficacy, or that it's really just another method to stimulate the brain to rewire itself more or less the same as any other method?

Lastly, and without trying to bring up psychologist prescribing rights, does it seem like a natural division of labor for psychiatrists to specialize in the sort of chemical and anatomical features of mental illness while psychologists focus on this kind of therapy approach? I kind of think that the two things are different enough that they seem to require two different professions. It also seems like a feature of psychiatric practice forced on physicians by the reimursement model that they mostly stick to medication management. Why don't psychiatrists and psychologists formally stick to a model like PM&R and PT?

 

[strangeglove]

I think that, ultimately, the most effective psychotherapies will be those that work in synergy with the brain. I'm not talking just about the fact that meds and psychotherapy combined are better than either alone (we already know this). I'm talking of a future in which psychotherapies are designed by people who know a good deal about the brain (i.e. their view is more complex than cortex inhibiting subcortical structures - this is an oversimplified view of emotion). In the future, there will be psychotherapies that take advantage of the fact that certain drugs (like D-cycloserine) make specific neural systems susceptible to change. The people who administer these psychotherapies will have to know a good deal about the brain, as well as about psychotropic medications. I think that this is the future of psychiatry, not clinical psychology.

 

[solumanculver]

Hey Strangeglove,
That's a really interesting vision. So you don't see a time where a psychiatrist could prescribe a specific psychotherapy to go with their medication strategy, but not really have to provide that therapy themselves? I think that psychologists must really like to do therapies, but aren't necessarily too good at chemistry, whereas I really like to think about brains, but am not interested in talking about feelings... there must be a natural marriage in there somewhere.

Also, if therapy is simply always going to be a big part of psychiatry, is there a way to get into schizophrenia as a neurologist? Well, I mean to legitimately have patients referred to you for schizophrenia even though you're not a psychiatrist...

Thanks for the discussion, by the way.

 

[toby jones]

There have been some studies done on how psychotherapy can effect similar neurological alterations as medication effects (with less side effects than medication). With mindfulness meditation breaking the 'OCD circuit' in OCD etc. If you think about it therapy has to work by creating neurological changes. Therapy isn't divine intervention after all ;-)

> do you think that the really elaborate explanations of approaches like psychoanalysis have any relation to their efficacy, or that it's really just another method to stimulate the brain to rewire itself more or less the same as any other method?

People are still trying to work out the mechanisms of change (as they are with medications).

Why are there different kinds of SSRI's? Because different people respond differently to them. What is effective for one may be ineffective for another. Why are there different kinds of therapy? Similar reasons. It would be cool to know which clients are likely to respond to which kinds of therapy (whether talk therapy or medication) but we don't know a great deal.

There might have been one study to show that the experience of therapists isn't correlated with their effectiveness, but I'm sure I've encountered other studies to show that the experience of therapists is correlated with their effectiveness - though theoretical orientation is more problematic (with most therapies coming up fairly comperable to one another - yet with some clients helped by one and not by another). Kind of like... SSRI's...

One idea is that the fit between the client and the therapist might be the most theraputic factor. Not just in therapy, but in medication as well. Positive transference is correlated with the client doing the therapy as prescribed (attending sessions / taking the medication) etc. Positive transference / fit is hard to measure...

It is also hard to compare therapies because it is hard to conceal from the client what kind of therapy they are having - whereas it is easier to disguise a medication. There are epistemic problems with running randomised double blind control trials for therapy (the client will surely know if they are having therapy or not!) Ignoring something... Doesn't make it's effects go away... In a way... Social and psychological causal mechanisms are harder to figure out than neurological causal mechanisms because of epistemic barriers to finding out what we need to know...

I hear that you are interested in schizophrenia. I'm interested in schizophrenia too, but I'm particularly interested in psychological and social causal mechanisms (and potential psychological and social interventions). While particular symptoms (delusion, hallucination etc) have been recorded in Ancient Greece and there have been many case studies describing clients all the way back... There is no description of a case study who would meet present day criteria for schizophrenia prior to the industrial revolution. What to make of this? One take was that there might have been some pathogen present during that time (hence the virus theory). Another take is that... Schizophrenia is a product of our social environment similarly to how eating disorders are (see studies on second generation Pakistan immigrants to England).

The WHO did a study... Then replicated it twice because they couldn't quite believe the results... While one third of people with a diagnosis of schizophrenia recover in developed Western Nations, two thirds of people with a diagnosis of schizophrenia recover in developing Western Nations. (Yes they were matched for severity). What to make of this? People tend to have better social supports and seem to be accepted by their societies in developing nations. People face more stigma and less social support (and also better access to psychiatrists and medications) in developed Western Nations.

There aren't many studies that have been done on the long term effects of psychiatric medications. In particular: Neurodegeneration that might potentially be CAUSED by psychiatric medications. FDA approval doesn't require investigating the long term side effects of medications. FDA doesn't devote much in the way of resources to study this. Nazi scientists dissected many a schizophrenic brain. Did they report enlarged ventricles (they had the technology to see that!) The search for the 'Schizophrenia gene/s' isn't going so well. One study finds something statistically significant. Others fail to replicate the finding. If my identical twin has schizophrenia I'm less likely to have schizophrenia than to have schizophrenia.

There have been studies done on the relationship between schizophrenia and creativity. There is also the idea that what may be revered in one society (prophets, seers, holy men) may be shunned in another. Evolutionary fitness is always relative to a society...

I think it would be a shame indeed if psychiatry missed out on all of that...

 

[strangeglove]

Hey Strangeglove,
I really like to think about brains, but am not interested in talking about feelings... there must be a natural marriage in there somewhere.

It's too bad that you aren't interested in talking about feelings, since feelings are one of the many things that brains do. You'll find that some of the most interesting neuroscience, which also happens to be the neuroscience that is most relevant to psychiatry, is related to emotions and how they are felt. To be a good neuroscientist these days, you have to talk about feelings. Of course, you don't have to do psychotherapy to have insight into emotions, but it can only be helpful.

 

[solumanculver]

It's too bad that you aren't interested in talking about feelings, since feelings are one of the many things that brains do. You'll find that some of the most interesting neuroscience, which also happens to be the neuroscience that is most relevant to psychiatry, is related to emotions and how they are felt. To be a good neuroscientist these days, you have to talk about feelings. Of course, you don't have to do psychotherapy to have insight into emotions, but it can only be helpful.

Hey Dr. Strangeglove,
Well, I certainly didn't mean to say that I don't like to talk about feelings as part of the essential data that neuroscience is meant to explain... that's incredibly important. What I meant to say is that I don't like to listen to people's problems and then ask them how they feel, and then give some kind of sage advice... that kind of thing. Of course I'm not saying that that's what psychotherapy is, but I think that it requires the same sort of... whatever.

I know that Dr. Phil doesn't do any kind of therapy on his show, but every time I see him I want to be sick. What he does is talking about feelings...

 

[toby jones]

Dr Phil makes me want to be sick too I think he was trained as a motivational sports psychologist and now entertains the masses...

Maybe... Learning about psychotherapy could help you get in touch with your feelings?

Sometimes it isn't about offering advice at all. Sometimes people just like to feel heard. To be able to tell someone how they are feeling and for that person to feel like they are being heard and understood.

Has been correlated with people being compliant with their medication reigime ;-) Doesn't matter how much of a whizz you are with prescribing helpful medications people won't benefit if you aren't able to build good rapport with them such that they follow what it is that you have prescribed...

 

[manwhoisthursdy]

Hey Dr. Strangeglove,
Well, I certainly didn't mean to say that I don't like to talk about feelings as part of the essential data that neuroscience is meant to explain... that's incredibly important. What I meant to say is that I don't like to listen to people's problems and then ask them how they feel, and then give some kind of sage advice... that kind of thing. Of course I'm not saying that that's what psychotherapy is, but I think that it requires the same sort of... whatever.

I know that Dr. Phil doesn't do any kind of therapy on his show, but every time I see him I want to be sick. What he does is talking about feelings...

If you really don't want to talk about "feelings", don't like to listen to people's problems and then ask them about how they feel (!) and don't want to give advice (reassurance, comfort, etc.), well, that's fine. But I would emphasize that all of the above touchy-feely stuff -- it's part of the doctor-patient relationship that all medical specialties (maybe except rads/path) form with their patients.

All good physicians will talk about feelings when a patient is angry, or anxious, or pleased with an outcome, or depressed about an outcome.

BTW, if I've misinterpreted you, please correct me.

 

[solumanculver]

If you really don't want to talk about "feelings", don't like to listen to people's problems and then ask them about how they feel (!) and don't want to give advice (reassurance, comfort, etc.), well, that's fine. But I would emphasize that all of the above touchy-feely stuff -- it's part of the doctor-patient relationship that all medical specialties (maybe except rads/path) form with their patients.

All good physicians will talk about feelings when a patient is angry, or anxious, or pleased with an outcome, or depressed about an outcome.

BTW, if I've misinterpreted you, please correct me.

Hey, I think you are misinterpreting me. Well, I haven't really been too careful about how I phrase things.

I've had this experience many times in my life where some friend of mine, usually a girl, but not always, goes through a break-up or something and they come to talk to me to be comforted... or maybe somebody they knew died, or some other sad thing happened. It sort of involves listening for a long time, saying "uh-huh" once in a while, and after they've sort of said everything they can I'm supposed to come in with reassuring talk that makes them feel better. It's sort of a ritualized thing, in a way, because it's more or less constant across a pretty broad spectrum of people I've had to do this with.

Well I hate that kind of thing. It's really awkward and painful and I'm essentially worried that psychotherapy will have some of those characteristics... It certainly seems to entail the "listening for a long time" part. I definitely don't mind reassuring people about their health, or asking how they're feeling, I think that's more related to concerned small talk than this other thing I'm thinking about. I'm not sure if that clarifies my aversion to "talking about feelings"... it probably makes me sound like a bastard. Well, I know my limitations, I guess.

 

[Therapist4Chnge]

Dr Phil makes me want to be sick too I think he was trained as a motivational sports psychologist and now entertains the masses...

He was a forensic expert, and he use to have a very successful forensic practice that would help pick juries, etc. He did NOT do therapy or anything related to that. Scary, huh? Also, psychotherapy isn't about giving advice, that is on of the worst things to do. You are suppose to work with the pathology and through that work the patient can improve.

-t

 

[solumanculver]

Maybe... Learning about psychotherapy could help you get in touch with your feelings?

Hey Toby Jones. I actually think I'm pretty well in touch with my feelings. I just don't like talking about them. Is that a contradiction?

Sometimes it isn't about offering advice at all. Sometimes people just like to feel heard. To be able to tell someone how they are feeling and for that person to feel like they are being heard and understood.

Hey, yeah I think that this is part of the therapeutic realtionship. I just think that somebody else might be better suited to fulfill that role than me. Probably somebody who went to psychology school. After all, that's the kind of thing that they had envisioned the entire time. I'm trying to do an MD/PhD in neuroscience... well I'm interested in schizophrenia... It seems like two very different things to me.

Has been correlated with people being compliant with their medication reigime ;-) Doesn't matter how much of a whizz you are with prescribing helpful medications people won't benefit if you aren't able to build good rapport with them such that they follow what it is that you have prescribed...

Hey Toby, I think that's a really good point, but it's probably true across all of medicine and not necessarily about psychotherapy per se. I think that a lot of physicians are just bastards, which makes their patients not want to do what they tell them. Nice doctors that patients love probably get better compliance. Of course I want to be a nice doctor, but I don't think that in order to earn that title I have to do any special kind of ritualized therapy type...

 

[zen76]

Here are a few books that you might like to give a more comfortable view for you on affect, feeling, and emotions:

The Emotional Brain by Joseph Ledoux

Descartes' Baby by Paul Bloom

Anything by Antonio Damasio (he's a neurologist by training but research is related to feelings and emotions)

And if you think of psychotherapy as learning, as envisioned by Eric Kandel; like any other skill or knowledge, one can learn to modulate one's emotions, recover from addictions, and change their perceptions on their lives like learning how to ride a bike, through practice and proper guidance. Some people just pick up riding a bike, others need a lot of practice and help. It's not vodoo, just another set of skills.

 

[Nepatsdynasty]

Toby as a fourth year going into psychiatry I read your post with great interest. All the studies you said and arguments you used are definitely a part of my "Schpiel." To me there is no question that our psychological environment has profound affects on our intra and extra cellular physiology in our entire bodies, including our brains. The psychomeds we use are primitive, toxic and really much more about clever marketing than clever science. WHO studies and other critical evidence considered, I think it is fair to say there are serious questions about their long term safety, effectiveness and it is also fair to question if they don't seriously harm people in the long term.

 

[Nepatsdynasty]

I also think it is important to distinguish between a persons conscious and subconscious feelings. All doctors, even psychiatrists, struggle with this distinction. Yet I think it is important for all doctors to be aware of it. A person may consciously state one thing but subconsciously strongly need another. I.e they may swear they want to quit drinking but subconsciously drinking is a fully useful behavior for them based on their fears, intentions, belief, self image etc. Of course it is a two way street, so always remember that everything you as a doctor say and do resonates in the patients subconscious mind and influences it profoundly.

 

[Anasazi23]

The psychomeds we use are primitive, toxic and really much more about clever marketing than clever science. WHO studies and other critical evidence considered, I think it is fair to say there are serious questions about their long term safety, effectiveness and it is also fair to question if they don't seriously harm people in the long term.

There's a lot I could say, but I won't.

Primitive and toxic? You base this on?........

Please review suicide rate studies and SSRI treatment as a very beginning if you think there's so little place for medicine in psychiatry.

 

[tr]

I've heard many people cite the "doesn't matter what level the practitioner is" study without ever producing a reference. Even if it exists (probably does), I'd have some pretty extensive questions about its methods.

Luborsky et al, Archives of General Psychiatry, 1975. Review of multiple studies. All therapies are effective but the modality is irrelevant.

Smith and Glass, American Psychologist, 1977. Meta-analysis of 375 studies of psychotherapy found all therapies produced equivalent outcomes.
No effect of time spent in therapy, nor of educational level of practitioner.

Shear et al, Archives of General Psychiatry, May 1994. CBT vs "reflective listening," no difference.

There's apparently also a 1994 book on this by Robin Dawes called "House of Cards."


That said, non-pharmacological treatment is obviously effective (whether the effect is 'placebo' or not), and I think it's worth becoming comfortable with at least a few different modalities. I can't tell you how many patients I've heard say "I'm sick of psychiatrists - all they ever do is push medication, nobody ever *listens* to me." I don't really want to be that psychiatrist they're complaining about.