talk therapy

[billypilgrim37]

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Not to be offensive, but diagnoses by DSM criteria don't seem to be that hard to make for a large proportion of psych patients and you can look up standard of practice treatments from any computer. If we are only prescribing medications and watching for side effect is that really a satisfying and rewarding professional life, especially given the immense investment in training we have undergone? Just a devil's advocate question, but in my darker moments I sometimes feel this way.

Fortunately, the truth of practice for most people is more in the middle between this extreme and the couch, and accurate diagnosis is much more of a challenge than just running through the DSM, because psychiatric diagnoses are by and large longitudinal, and learning how to ask questions to actually give you useful information is much more of an art than you might imagine. And in this processing, learning how to develop rapport and being therapeutic even when not in a formal therapy session and supporting behavior change is still a complicated art. Most therapy is not about delving the soul. Most is primarily supportive, with almost every manualized treatment being on the supportive spectrum, but even most psychodynamic treatment being more supportive than expressive. We have become a specialty of supporting function over actualization in general, but there's so much more richness to that than is obvious.

There is still nothing close to psychiatry in richness of human behavior, even if it ain't what it used to be.

 

[LM02]

A psychologist in an inpatient setting or in my practice could meet those requirements right?

No, because by law psychologists have independent licenses that do not require supervision by any other professional. If there is an administrative arrangement in a particular setting that requires supervision by an MD, then so be it. But that is a decision to make when choosing a job - the parameters of one particular job are not the parameters of the profession of psychology as a whole. We are completely equipped and licensed to "lawfully acquire, diagnose, treat, and discharge patients" on an independent basis.

Honestly, I wish psychiatry trainees were more informed about the scope of practice of psychologists and the level and type of training we receive. I remember as a psychology intern, giving a CBT case formulation to the treatment team on an inpatient setting. Later, the first year resident said to me, "wait, have you done this before?" Meanwhile, I had been providing individual CBT for 4+ years (starting in my 2nd year of grad school).

I'm by no means saying we're better or you're better. We just have a different emphasis of training and a different training model - which is largely unknown to psychiatry trainees when they enter residency (though not for all!). Luckily, most residents I work with have figured this out before they graduate and move on with their careers... which does ultimately allow for strong and productive collaboration.

 

[nitemagi]

I'm by no means saying we're better or you're better. We just have a different emphasis of training and a different training model - which is largely unknown to psychiatry trainees when they enter residency (though not for all!). Luckily, most residents I work with have figured this out before they graduate and move on with their careers... which does ultimately allow for strong and productive collaboration.

🙄

 

[Manicsleep]

Because most of us envision ourselves probing the depths of a person's soul to offer them enduring solutions, not running through SIGECAPS, ruling out past manic episodes, and then writing an SSRI. When confronted with the thought of mostly running through a simple questionnaire style interaction and then choosing an appropriate medication comes up it makes us feel that there is nothing special about psychiatry after all; that in fact it may have left behind the human element that drew us to the field in the first place. Remembering that another field had something compelling to it (and feeling like Psych has lost its allure) we just might choose that other field, not because we will get to do talk therapy there but because if we can't have that kind of interaction at all we might as well choose something else to pursue.

Not to be offensive, but diagnoses by DSM criteria don't seem to be that hard to make for a large proportion of psych patients and you can look up standard of practice treatments from any computer. If we are only prescribing medications and watching for side effect is that really a satisfying and rewarding professional life, especially given the immense investment in training we have undergone? Just a devil's advocate question, but in my darker moments I sometimes feel this way.

You can teach a monkey to do surgery too. Its knowing the tough cases to be tough cases and then knowing what to do that makes psychiatrists unique.

 

[voyeurofthemind]

Not this crap again. Psychologists are not mid-levels.

Agreed, I have completed a Master's in Clinical Psychology already and am about to embark on another 4 year period of doctoral level graduate education plus internship and post doc. I don't think I am doing all that to, in the end, be a "mid-level" practitioner.

 

[Majesty]

No, because by law psychologists have independent licenses that do not require supervision by any other professional. If there is an administrative arrangement in a particular setting that requires supervision by an MD, then so be it. But that is a decision to make when choosing a job - the parameters of one particular job are not the parameters of the profession of psychology as a whole. We are completely equipped and licensed to "lawfully acquire, diagnose, treat, and discharge patients" on an independent basis.

Honestly, I wish psychiatry trainees were more informed about the scope of practice of psychologists and the level and type of training we receive. I remember as a psychology intern, giving a CBT case formulation to the treatment team on an inpatient setting. Later, the first year resident said to me, "wait, have you done this before?" Meanwhile, I had been providing individual CBT for 4+ years (starting in my 2nd year of grad school).

I'm by no means saying we're better or you're better. We just have a different emphasis of training and a different training model - which is largely unknown to psychiatry trainees when they enter residency (though not for all!). Luckily, most residents I work with have figured this out before they graduate and move on with their careers... which does ultimately allow for strong and productive collaboration.

So your are going to pick on PGY1s huh? Get off it pal. You aren't equipped to admit to an inpatient hospital. I wouldn't send a patient within a hundred yards of a place where the admissions were being done without a physician.
Don't tell me about PGY1s and their comparison to your psychology internship. Thats the end of your mental health training and many times, near the beginning of ours. The difference is that we have a lot of other training already under our belts by that time and this allows us jion the rest of the medical field with the mental health field.

CBT is easy for me now. I know plenty of licensed psychologists who don't understand psychodynamic, group or family therapy. They couldn't understand DBT if it hit them in the face and they have no idea what psych testing is because they believe only the neuropsychologists do that.

I will say what you don't want to say, because you can't. Psychiatrists are top dog in the mental health game. Period. I worked for it and I deserve it.

Like it has been discussed earlier, the role of the psychologist is diminishing. You are either testers or case managers in this new world of HMO care and case management is better done by social workers.

 

[IT514]

Admit and discharge inpatients? No thanks, and no, we cant do that. I'm fine with assessing a patients cognitive capacity for discharge in an inpatient setting, but I do not have the training to make the final call. Lets not make claims we cant back up...and try to at least be accurate.

To the other post...top dog in the mental health game? How many hours did you just come off of? Calm down. Man theres a lot of amygdala in this thread.

 

[michaelrack]

If we are only prescribing medications and watching for side effect is that really a satisfying and rewarding professional life, especially given the immense investment in training we have undergone? y.

Of course not, you also need to do ECT for a rewarding prof life- and be prescribing tricky drugs like MAOI's, clozaril, lithium, antidepressant dose tricyclics, augmenting with lithium/thyroid, etc.

 

[LM02]

Admit and discharge inpatients? No thanks, and no, we cant do that. I'm fine with assessing a patients cognitive capacity for discharge in an inpatient setting, but I do not have the training to make the final call. Lets not make claims we cant back up...and try to at least be accurate.

I wasn't talking about an inpatient setting. I was talking about generally speaking, in one's practice. To be fair, it is rare for a psychologist to be working on an inpatient unit these days, anyway.

]So your are going to pick on PGY1s huh? Get off it pal.

As I stated earlier (on page 1), I'm on faculty in a psychiatry department (one that has actually been ranked quite high on several poster's ROL this year, I might add) and the environment is completely cordial and respectful. In my experience, these tensions arise much more with people who are newer to the field. My point above was that, once people actually start to work with psychologists, they often realize that we're not "wannabe psychiatrists" who are trying to claim that we have medical knowledge anywhere near as advanced as any physician (we don't) and/or that we are trying "steal" the market on psychotherapy... we're just trying to do our job and to work collaboratively with other professionals.

And ps... I'm a woman.

 

[billypilgrim37]

Seems like the answer would be to get all the psychology interns and the psychiatry interns locked in a room with a few kegs, place them all on a 16 hour hold, and see what happens.

 

[Manicsleep]

So back to the OP.
Learning psychotherapy is important and valuable. You can and will use it either directly or indirectly.

Directly, you always do therapy when you see someone (at least you should) even if it is of the supportive nature. If you want to do more intensive therapy in the HMO/managed care umbrella you will have to sacrifice some salary.

Indirectly you will be responsible for knowing what other kinds of therapy your patients are receiving. You can even direct this care if you are keep your wits about you.

Like it has been discussed earlier, the role of the psychologist is diminishing. You are either testers or case managers in this new world of HMO care and case management is better done by social workers.

There are several psychologists who would agree with this as well. Even Grohol from psychcentral writes something to the effect that psychologists are deviating from their original purpose. This is in effect putting them in a no mans land...

And ps... I'm a woman.

I mean no womans land. The nerve of Majesty to call you pal!
Although...haven't women earned the right to be derisively referred to as 'pal'?

 

[dl2dp2]

Not to be offensive, but diagnoses by DSM criteria don't seem to be that hard to make for a large proportion of psych patients and you can look up standard of practice treatments from any computer. If we are only prescribing medications and watching for side effect is that really a satisfying and rewarding professional life, especially given the immense investment in training we have undergone? Just a devil's advocate question, but in my darker moments I sometimes feel this way.

To echo some of the other sentiments (i.e. manicsleep etc.), psychopharmacology has reached a level of complexity and art that to practice it really well requires QUITE a bit of expertise. So has diagnoses of complex cases. Remember most of SSRIs are prescribed by general practitioners. Psychiatrists are providing much more specialized, high risk high reward medication management, *or* as I said previously, if you have the proper CV to back it up, high end therapy practice that only caters to the most highly functional (read: rich) patients. To a certain extent, concocting the perfect cocktail that optimize the functional status of a complex case is anything but easy and for sure requires every bit of medical training you get in medical school.

Can you do therapy as a mostly medicaid/medicare psychotherapist as a psychiatrist if you want to? Of course. You'll likely be paid less. But that's a separate issue. So now you are saying, if I find the most rewarding thing is to look into people's soul, but I only get 50k a year doing it (of course this is an exaggeration--most people in these positions are academics, and while they get paid less than a busy private doc, will still get paid substantially more than a PhD psychotherapist, on average.), I'd rather be a radiologist and look at their bone instead. I hope you see the irony in this.

The bottomline is, can you be a MD doing strict therapy and make 300k? Yes. How? Go to one of the top 3-5 residency programs, go through a nationally renowned psychoanalytic institute, and set up your shop in NYC/SF, and start marketing to the high end clients. If this is what's the most rewarding to you, psychiatry remains the ONLY specialty in medicine where you can do this. And frankly, this is really its own specialty, which I'll now call psychoanalytic psychiatry, which is likely if someone did calculations more or less as competitive as derm.

 

[Bartelby]

So now you are saying, if I find the most rewarding thing is to look into people's soul, but I only get 50k a year doing it (of course this is an exaggeration--most people in these positions are academics, and while they get paid less than a busy private doc, will still get paid substantially more than a PhD psychotherapist, on average.), I'd rather be a radiologist and look at their bone instead. I hope you see the irony in this.

If you want a career which is interesting and pays enough for loan repayment and a good lifestyle there are many means to that end. You make a good point about the need for experience in managing psychoactive medication though, really when you think about it other practitioners would have probably already taken that over if it were so simple.

Anyhow the insights above posters mentioned are good ones. Thinking about it a lot of many doctors' practices are easy "cookbookable" things (DM and flu on ambulatory and FM, asthma and COPD on pulm, well checks and viruses on peds, etc etc) and what really defines the worth of a specialist is knowing what to do with the less usual cases that also come through. Also it really devalues the difficulty of catching odd diagnoses and coming up with individualized treatment plans to paint a picture of merely placing a label and looking up a treatment.

Articles like the above do give pause to people like me who see psychopharmacology as augmenting progress in many cases as not as the main event. It also makes me wonder how much good I would be in treatment of personality disorders, phobias, mild depression, and generally things that seem better suited to therapy than medication. Do you turn a phobia patient away, or worse yet just give them benzodiazepines for acute anxiety and hope they find someone else for therapy? Still I agree that the richness of human experience that makes up psychiatry is what really speaks to me as a medical student, and in the end I will make it work.

 

[Manicsleep]

Originally Posted by Therapist4Chnge
Not this crap again. Psychologists are not mid-levels.

If you say so...

Originally Posted by Therapist4Chnge
3. Too busy fending off mid-level providers with a fraction of the training that are pushing for a broader scope of practice without any additional training?

😱
This above post from a thread by T4C about SWorkers vs psychologists. So socials workers are midlevels to a psychologists but psychologists are not mid levels.

There was also material in there about not enough training etc etc.
Yet no one is arguing against 6 states trying to allow psychologists to prescribe. The hypocrisy is laughable.

I think in some delusional state, the doctoral degree makes them think they are very close to physicians but very removed from social workers when in fact the opposite is true.

This is another reason to do psychotherapy OP. All the psychologists will be prescribing drugs and doing no therapy. I happen to agree with Majesty's comment. Psychiatrists are the experts in the mental health field. You need to learn psychotherapy because it is your job and your duty. Other people will try and tell you not to learn it or that you arent good at it or that its a psychologists/LCSWs arena. Hogwash.

 

[nitemagi]

Agreeing wholeheartedly. While there has been a mini-generation of providers that essentially went through residency without any therapy training, there was a generation (who's still in practice) before them that had a lot of therapy training, and a generation emerging that is not only being trained in therapy, but enthusiastic about it and seeking more and more training, even beyond residency.

It's that generation in-between and those ignorant of the uniqueness of psychiatry (i.e. other specialties) that may tell us that psychiatry will just become a part of neurology, and other mental health providers (psychologists, SW'ers) who may tell us therapy is now their domain. But I don't buy any of it.

 

[Therapist4Chnge]

This above post from a thread by T4C about SWorkers vs psychologists. So socials workers are midlevels to a psychologists but psychologists are not mid levels.

I'm glad you are staying on topic and not making this personal by digging around other posts I've made on unrelated topics and trying to make them relevant here. 🙄

There was also material in there about not enough training etc etc. Yet no one is arguing against 6 states trying to allow psychologists to prescribe. The hypocrisy is laughable.

One group is seeking additional training and mentorship...and one is not. Again, not related to this discussion. Nice strawman.

I think in some delusional state, the doctoral degree makes them think they are very close to physicians but very removed from social workers when in fact the opposite is true.

This is another reason to do psychotherapy OP. All the psychologists will be prescribing drugs and doing no therapy. I happen to agree with Majesty's comment. Psychiatrists are the experts in the mental health field. You need to learn psychotherapy because it is your job and your duty. Other people will try and tell you not to learn it or that you arent good at it or that its a psychologists/LCSWs arena. Hogwash.

More strawman arguments.

 

[nitemagi]

More strawman arguments.

There are multiple parts of the argument, and your strawman rebuttal misses many of the original propositions, which have truth to them.

 

[kugel]

Really?
Psychology vs Psychiatry again?
It is NOT a competition.
In those places where there is an argument about scope of practice, there is very little worry of that there will ever be too few patients.

Can we please pursue a more useful argument?
Barber vs Beautician?
Yellow vs Green?
Wolverine vs Magneto? (adamantium isn't magnetic, is it?)

 

[OldPsychDoc]

Really?
Psychology vs Psychiatry again?
It is NOT a competition.
In those places where there is an argument about scope of practice, there is very little worry of that there will ever be too few patients.

Can we please pursue a more useful argument?
Barber vs Beautician?
Yellow vs Green?
Wolverine vs Magneto? (adamantium isn't magnetic, is it?)

Star Trek is better than Star Wars.

 

[235750]

Can we please pursue a more useful argument?

Wolverine vs Magneto? (adamantium isn't magnetic, is it?)

It most certainly is magnetic!! Adamantium is an alloy of steel and vibranum [sic?].

(Never thought I'd be able to whip out that little tidbit of knowledge ever, let alone in the psychiatry forum on SDN!)

 

[Daftrage]

Star Trek is better than Star Wars.

I used to have respect for you OPD.

 

[Manicsleep]

More strawman arguments.

I don't think you understand what strawman means. I think there is a reason you have more than 10k posts on this forum. Getting rx rights won't fix that.

Really?
Psychology vs Psychiatry again?
It is NOT a competition.
In those places where there is an argument about scope of practice, there is very little worry of that there will ever be too few patients.

It most certainly is NOT a competition. A competent and fully trained psychiatrist should be able to do everything a clincal psychologist can.
Certain psychiatrists cannot and therefore, due to inferior training, poor motivation to get that training or keep up with training, believe that the training scope for a psychiatrist is different than for a psychologist. It is not. It encompasses everything a clinical psychologist can do and much more.

This is not about too few patients. This is about poor patient care. There is a very big difference.

 

[Ibid]

Star Trek is better than Star Wars.

Ali vs Tyson

Obama and the Pope vs Nelson Mandela and Maggie Thatcher in a tag team wrestling match

These arguments just go on forever……..

 

[kugel]

This is not about too few patients. This is about poor patient care. There is a very big difference.

90% of PhD and PsyD psychologists do therapy and psych testing much better than 90% of psychiatrists do. If some psychiatrists get advanced training in these areas, fantastic.

Currently published ACGME Psychiatry requirements state residents:
IV.A.5.a).(3)
should develop competence in:
IV.A.5.a).(3).(e) applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and longterm individual practice....

That alone would take years. You'll notice that there is no mention in the regs as to how long such training should take, nor how many patients should be treated using each of these modalities, nor how the supervision and testing of that competence should occur. Thus, it is left to each residency to assure this in whatever way they choose.

Section 2914 of the Business and Professions Code and Section 1387 of the California Code of Regulations require 2 years (3,000 hours) of supervised professional experience, at least 1,500 of which must be completed post-doctorally.

I see it like this...
When my car breaks, I can
A) take it to a physicist who will explain the forces within the combustion chamber
B) take it to a mechanical engineer who can design a better or different combustion chamber, or a new propulsion mechanism
vw_rear_dr_open1_pscopy.jpg
C) take it to a mechanic who can get me out of the shop with a running automobile

When I want the automobile engine to run a sump pump, I will consult the engineer. When I want to determine if it is theoretically possible for an internal combustion engine to operate in the atmosphere of Saturn, I will consult an exoplanetary physicist.

I don't see the physicist as "encompasses everything (the others) can do and much more."

When I want psych testing on an inpatient, I consult the psychologist who can design and implement a set of tests that will do the most good in answering what questions I've got. - and then help me to interpret the results. I could go get that training myself, but why? I have plenty to do and no time in my work day to be doing that. And by consulting the psychologist, I get a fresh and unbiased look at the case - which I could not provide for myself.

 

[Manicsleep]

90% of PhD and PsyD psychologists do therapy and psych testing much better than 90% of psychiatrists do. If some psychiatrists get advanced training in these areas, fantastic.

Back that claim up...show me what you're working with! 😀
Psychiatrists don't need advanced training to be as good as anyone else in the mental health field. It is already present as part of normal training.

Currently published ACGME Psychiatry requirements state residents:
IV.A.5.a).(3)
should develop competence in:
IV.A.5.a).(3).(e) applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and longterm individual practice....
That alone would take years. You'll notice that there is no mention in the regs as to how long such training should take, nor how many patients should be treated using each of these modalities, nor how the supervision and testing of that competence should occur. Thus, it is left to each residency to assure this in whatever way they choose.

It does take years. 4 years of med school and 4 years (at least) of residency. I am not counting undergrad although that is important as well.

I think you have a misperception of how much time, especially face time with patients, psychologists actually spend. Having taught them, I learned that a huge chunk of their time is completely away from patients. If you ask them though, you will just get vague answers like "it really depends etc." Also, much of their time is very repetitive and there is very little variation in the variability of patients.

Section 2914 of the Business and Professions Code and Section 1387 of the California Code of Regulations require 2 years (3,000 hours) of supervised professional experience, at least 1,500 of which must be completed post-doctorally.

Which residency takes 2 years to work a resident 3000 hours? Even under the current rules that is only 1 year. I certainly hope you don't mean that this means psychologists are better trained because they take a lot of classes in industrial psychology and train for 3000 hours.

I see it like this...
When my car breaks, I can
A) take it to a physicist who will explain the forces within the combustion chamber
B) take it to a mechanical engineer who can design a better or different combustion chamber, or a new propulsion mechanism
vw_rear_dr_open1_pscopy.jpg
C) take it to a mechanic who can get me out of the shop with a running automobile

When I want the automobile engine to run a sump pump, I will consult the engineer. When I want to determine if it is theoretically possible for an internal combustion engine to operate in the atmosphere of Saturn, I will consult an exoplanetary physicist.

I don't see the physicist as "encompasses everything (the others) can do and much more."

😕

When did I say that psychiatrists encompassed everything. If this was about psychiatrists and everything regarding the brain/mind, then perhaps I would agree with you.

So for example, while I wouldn't argue with a computational neuroscientists regarding the abilities of the silicon chip and emulation of the human mind, I can tell you that the psychiatrist is the final word with respect to clinical mental health.

When I want psych testing on an inpatient, I consult the psychologist who can design and implement a set of tests that will do the most good in answering what questions I've got. - and then help me to interpret the results. I could go get that training myself, but why? I have plenty to do and no time in my work day to be doing that. And by consulting the psychologist, I get a fresh and unbiased look at the case - which I could not provide for myself.

I think its very important for the psychiatrist to understand what those tests mean and why they are being ordered.
Anyways, if you do need it by all means, use a psychologist if it is cheaper or you don't feel up to it. Its important to know your limitations. I ask psychologists to do testing as well. I also ask psychiatrists for consults. Just don't think that psychiatrists cannot do it as a profression. When psych testing is a combination of interview and data, it is best to have the person who is best at performing the clinical interview...aka The Psychiatrist.

If you are doing it for fresh and unbiased looks, have any colleague look at it or if cost is a concern, get a social worker.

It is important, to the OPs point, that it is made clear that psychiatrists truly are able to do labs, medicine, therapy, testing, imaging, procedures etc. Of course the less you use of something, it will become dull. However, those tools are given to us in training and that is why we have such rigorous training.

 

[kugel]

It encompasses everything a clinical psychologist can do and much more.

.

 

[DrBosse]

Very interesting thread . . . I can see both sides here. Today I met with a medical student thinking about quitting and I was wondering to myself, what if I had become a psychologist? My debt would be lower. My periodic misery over the past 4 years would have been much less, or at least of a different nature; medical school has not been fun. At this point, I have to believe that the 180k of debt and the stress and criticism and long hours of the past four years lead to an outcome that is significantly different that the outcome would have been if I'd gone to a PhD program. Maybe I'm projecting here but I think that is the main reason why psychiatrists are so defensive on this forum. If there isn't something substantial and worthwhile that we gain, careerwise, from going to medical school, then we all would (very uncomfortably) have to wonder why on earth we did it.

 

[kugel]

Back that claim up...show me what you're working with! 😀

Of the 100 or so psychiatrists that I know reasonably well, not a one got enough training in residency to be good at all the general medicine required plus the diagnosis and treatment planning of psychiatric patients, plus the psychopharmacology AND was also taught sufficiently to be really good at all the modes of psychotherapy delineated in the ACGME requirements. So, out of 101 (me included), 0% got enough training in residency to master all of that. I know a few who think they are good at all of it - but none of them are.

So, I have some data in a sample of about 100.
What does your survey of 100 psychiatrists trained in the last 20 years show?
How many feel they got good training (while in residency) in all those modes of psychotherapy in residency to be able to do it well now?

 

[nitemagi]

Very interesting thread . . . I can see both sides here. Today I met with a medical student thinking about quitting and I was wondering to myself, what if I had become a psychologist? My debt would be lower. My periodic misery over the past 4 years would have been much less, or at least of a different nature; medical school has not been fun. At this point, I have to believe that the 180k of debt and the stress and criticism and long hours of the past four years lead to an outcome that is significantly different that the outcome would have been if I'd gone to a PhD program. Maybe I'm projecting here but I think that is the main reason why psychiatrists are so defensive on this forum. If there isn't something substantial and worthwhile that we gain, careerwise, from going to medical school, then we all would (very uncomfortably) have to wonder why on earth we did it.

Interesting theory. Sure everyone is defensive about their professional identity. In every camp. But I'm not seeing your point as to why we're defensive. Because we need to recognize we've gained something, or need to be unique?

And while PhD's may have less debt, they also have on average substantially lower salaries.

 

[loveoforganic]

Interesting theory. Sure everyone is defensive about their professional identity. In every camp. But I'm not seeing your point as to why we're defensive. Because we need to recognize we've gained something, or need to be unique?

And while PhD's may have less debt, they also have on average substantially lower salaries.

And lower job security as far as I can tell. If the argument works at all, I think it works in the reverse direction.

That said, psychiatrists do have a niche clearly distinguishing them from the vast, vast majority of psychologists in psychopharmacology, and the rx movement isn't going to change that anytime soon. What's being argued by some is that psychologists don't have that unique niche.

 

[Manicsleep]

Of the 100 or so psychiatrists that I know reasonably well, not a one got enough training in residency to be good at all the general medicine required plus the diagnosis and treatment planning of psychiatric patients, plus the psychopharmacology AND was also taught sufficiently to be really good at all the modes of psychotherapy delineated in the ACGME requirements. So, out of 101 (me included), 0% got enough training in residency to master all of that. I know a few who think they are good at all of it - but none of them are.

So, I have some data in a sample of about 100.
What does your survey of 100 psychiatrists trained in the last 20 years show?
How many feel they got good training (while in residency) in all those modes of psychotherapy in residency to be able to do it well now?

Before I go into selection bias and tell you about my anecdotal evidence...where does that prove that psychologists are any better?

Also, you may be right about your own incompetence. How are you measuring others?

 

[nitemagi]

Before I go into selection bias and tell you about my anecdotal evidence...where does that prove that psychologists are any better?

Also, you may be right about your own incompetence. How are you measuring others?

Play nice boys. 😉

Though I do agree about the evidence about psychologist superiority. I have yet to see data supporting this.

 

[Manicsleep]

Play nice boys. 😉

Though I do agree about the evidence about psychologist superiority. I have yet to see data supporting this.

I am not being derogatory in this. If it comes across that way, I apologize.
Earlier Dr. Kugel had mentioned that 90% of psychologists do therapy better than 90% of psychiatrists.
I asked him to back that up. His claim was that he did not know how to do therapy and his colleagues are just as unable to do therapy. Also, he claims, those colleagues of his that claim to be able to do therapy are in fact deluded.

I can understand that his own competence is up to him. How is he judging others and particularly, how is he judging psychologists is what I want to know. After this I will consider possible errors made in his decision. The fact remains that about 60% of psychiatrists do therapy. They may not do psychodynamic or analytic therapy but they do some kind of therapy. There is data to support that.

If he can refute that, I would welcome that because then that is an issue that the ACGME, ABPN, AADPRT etc could address. With respect to anecdotal data I can tell you I was in the business of teaching residents for a few years and I had plenty of residents pass through. I also work with some excellent psychiatrists. They all have excellent training in various types of therapy. Of course the ones that continued with the psychoanalytic schools and such were much better but you don't need that to do therapy.

I have also seen a lot of psychologists, a few excellent ones but a lot of marginal ones. I think those who live and breathe ivory tower air have the sense that the psychologists that work their are a fair representation of the psychologists in the country when nothing could be further from the truth. However, the psychiatrists that work there are a fair representation of the psychiatrists in the country.

We end up comparing apples with oranges and believing that we cant or shouldn't do therapy and should leave to 'better therapists' like psychologists. This just isn't the case and psychiatrists who believe this unjustified myth just need a good kick in the pants. Not for turf battles or to ensure income or for ego but simply because its what needs to be done to ensure optimal patient care.

 

[loveoforganic]

Where does your belief that psychiatrists but not psychologists maintain competency comparable to academics stem from? Differences in board certifications alone?

 

[235750]

Currently published ACGME Psychiatry requirements state residents:
IV.A.5.a).(3)
should develop competence in:
IV.A.5.a).(3).(e) applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and longterm individual practice....

That alone would take years.

It does take years. 4 years of med school and 4 years (at least) of residency.

Manicsleep: perhaps your medical school integrated 4-years of therapy classes into your curriculum, but most of us are not so lucky. We get a fairly brief overview of the subject, to put it mildly, to the point where claiming any sort of knowledge beyond basic familiarity is bordering on fraudulent. Are you really claiming your 4 years in medical school as counting towards your education in 'talk therapy'?

I also saw that you criticized psychologists for doing some of their training without patient contact. Maybe you went to medical school in, say, the early 80s when students did LPs and colonoscopies in their first year, but things are different now. Our first two years of school are almost completely didactic. Sure, I have pt contact, but it's superficial at best.

And I don't know about everyone else, but our core psychiatry rotations are at acute care centers. You know, people trying to kill themselves (or others). No talk therapy done there as far as I know. Where psychiatry is concerned, our step exams test on medications for different conditions, or coming up with the correct dx given a short story. No talk about CBT, psychoanalysis, etc, except only to know, roughly, what they are. At our school you can do an elective in therapy during your MS4, but I hardly think a month makes a difference.

I think you have some great points Maniac, but I think you go over the top with some of your claims.

 

[Ibid]

Physician, heal thyself

 

[Manicsleep]

I think you have some great points Maniac, but I think you go over the top with some of your claims.

Cute.

Manicsleep: perhaps your medical school integrated 4-years of therapy classes into your curriculum, but most of us are not so lucky. We get a fairly brief overview of the subject, to put it mildly, to the point where claiming any sort of knowledge beyond basic familiarity is bordering on fraudulent. Are you really claiming your 4 years in medical school as counting towards your education in 'talk therapy'?

Yes, medical school education, even didactic education about gastroenterology is important for talk therapy. If I am treating someone with stomach cancer, it is important to have an understanding of that disease. How do you not understand that?

Also, I don't know how you operate but basic familiarity is important before intimacy. Thats important in knowledge as well as life...its scary that you don't understand that...in so many many ways.

I also saw that you criticized psychologists for doing some of their training without patient contact. Maybe you went to medical school in, say, the early 80s when students did LPs and colonoscopies in their first year, but things are different now. Our first two years of school are almost completely didactic. Sure, I have pt contact, but it's superficial at best.

The point of that statement was to compare face time with patients of psychologists and psychiatrists. Even assuming no face time in the first 2 years, how does that change anything?

And I don't know about everyone else, but our core psychiatry rotations are at acute care centers. You know, people trying to kill themselves (or others). No talk therapy done there as far as I know. Where psychiatry is concerned, our step exams test on medications for different conditions, or coming up with the correct dx given a short story. No talk about CBT, psychoanalysis, etc, except only to know, roughly, what they are. At our school you can do an elective in therapy during your MS4, but I hardly think a month makes a difference.

As far as you know is probably about right. Either you are at a really bad medical school or more likely, you just don't see therapy done right in front of you. I really hope its the latter because that just means you are an inexperienced medical student, which is fine and there is nothing wrong with that. The problem is that some med students think they can do surgery when they get the acceptance letter to med school. It just isn't so.

Learning, for most students and physicians, is continuous. Every patient makes a difference. A month certainly makes a difference.

 

[Manicsleep]

Where does your belief that psychiatrists but not psychologists maintain competency comparable to academics stem from? Differences in board certifications alone?

There is a big difference in psychologists who train at academic university centers and work at academic university centers vs those who get there degrees elsewhere and work in the community, prison systems, rehab centers etc.

 

[nitemagi]

Most modern medical curriculums have some level of patient contact and clinical training in the first 2 years, though not at the intensity of 3rd year clerkships.

I'd agree with some of ManicSleep's points that clinical exposure is an important aspect of therapy. Psychiatrists have as much face time with patients in their first year and a half of residency as psychologists get in all their clinical hours (3000 at most). The difference is that psychologists label all that time as psychotherapy time, whereas psychiatrists don't label ALL of that time as such. In fact most programs don't formally call it psychotherapy training until at least the 2nd year.

I'm gearing up to do some lit searches to actually look at outcomes between different providers with psychotherapy. I did a search on psycinfo with terms "psychologist," "psychotherapy," and "outcome." 40-something hits. One compared psychologist vs. psychiatrist, with the raters being 1 psychiatrist and 1 psychologist. Outcomes showed now difference, but that older clinicians were rated as better than younger ones.

 

[Majesty]

Yes, medical school education, even didactic education about gastroenterology is important for talk therapy.
-----------------
Also, I don't know how you operate but basic familiarity is important before intimacy.
----------------------
The problem is that some med students think they can do surgery when they get the acceptance letter to med school. It just isn't so.
Learning, for most students and physicians, is continuous. Every patient makes a difference. A month certainly makes a difference.

1) Agree
2) Agree
3) Amen.

Arrogant/all knowing med students are perhaps the most annoying thing every created.

 

[Majesty]

I don't do any sit down, face to face, therapy only sessions on the inpatietn unit.
That doesn't mean I don't do talk therapy. For me its all a hodgepodge. I do work with the patients and then the therapists can help out further.

Look I learned to do therapy and it wasn't in the early 80s. Maybe there are some psychiatrists that don't feel comfortable. Thats too bad becasue its not that hard given all our training. If I wanted to do it full time, it may take me a little bit and I may want to ease into it but I am confident I could do it. The problem is that I can't see enough people and there is a shortage of psychiatrists in my area. So I let the other therapists do the therapy.

 

[Ibid]

Arrogant/all knowing med students are perhaps the most annoying thing every created.

Nothing worse than angry know all dinosaurs either. Things get better because young people challenge the status quo, not because grisly old reactionaries seek to protect it.

 

[Majesty]

Nothing worse than angry know all dinosaurs either. Things get better because young people challenge the status quo, not because grisly old reactionaries seek to protect it.

I would agree but I am barely out of residency...in my early 30s and very willing to challenge the status quo.
Especially the status quo held by certain old dinosaurs that psychotherapy isn't done by psychaitrists anymore. Maybe woolly mammoths..the dinosaurs are actually excellent therapists.

 

[Ibid]

I understand. While I was making a point as much as having a direct dig, making assumptions about people based on postings is a bit daft. For instance I might come across as an rsole whereas in real life…..no thats not working, bad example….

Anyway, tangentially Thoughtbroadcast has a nice take on this…..

http://thoughtbroadcast.com/2011/02/23/to-treat-depression-just-give-em-what-they-want/

 

[dl2dp2]

Of the 100 or so psychiatrists that I know reasonably well, not a one got enough training in residency to be good at all the general medicine required plus the diagnosis and treatment planning of psychiatric patients, plus the psychopharmacology AND was also taught sufficiently to be really good at all the modes of psychotherapy delineated in the ACGME requirements. So, out of 101 (me included), 0% got enough training in residency to master all of that. I know a few who think they are good at all of it - but none of them are.

I'm not sure what the point of this is. Are you arguing, thus, that psychologists provide most, if not all of the therapy, since they can do it better and cheaper? But then it sounds like you also lament the fact that psychiatrists can no longer do therapy. I find this position self-contradictory.

 

[Chimed]

Wow. I've been away at a conference for a several days and can't believe this thread is still going!

 

[Majesty]

It may seem like beating a dead horse however, I think there are some really important discussions going on here. Some of them are listed below.

1) Should someone who wants to do therapy go into Psychiatry?

2) Do Psychiatrists still do psychotherapy?

3) Are Psychiatrists good at psychotherapy?

4) Are Psychiatrists competent at psychotherapy?

5) What is the role of a Psychiatrist on the mental health team?

Psychiatrists are leaders of the mental health team and are trained in every aspect of the mental health treatment. The are at the forefront of this treatment. There is a concerted effort on the part of certain trade groups to undermine this and unfortunately some Psychiatrists as well as other physicians buy into this myth.

The psychologists association will try to tell you that the vast most psychiatrists only prescribe drugs and that they overwhelmingly don't do any therapy. This is simply not true. They also want prescribing privileges and believe that prescribing psychologists will be better equipped than MDs/DOs.

So you can think we are beating a dead horse or you can go and see that on the psychologists site there is an ongoing thread for this that has been going for years. Its just a matter of perspective.

 

[Manicsleep]

They also want prescribing privileges and believe that prescribing psychologists will be better equipped than MDs/DOs.

Read the statement by ApA spokesperson nordal huh? That Washington post article and the misinformation/partial information that it provides is why we need to make sure that psychiatrists are aware that psychiatrists are great therapists. The data they mention in the study was done at Columbia and their are serious flaws in that data. The definition of psychotherapy is any verbal techniques etc etc which is fine however at the same time they have a minimum 30 minute time limit.

This time limit may not be met, especially under HMO/Medicare guidelines even though therapy is performed. So it falsely appears as if psychiatrists are not doing therapy even though we are. You can easily do CBT using homework etc in 20 minutes, especially in a follow up appointment. Supportive therapy can be done in a much shorter period. If you just want to expand on and tweak the therapy done by mid levels, this is easily possible in a 15 minute visit for a well established patient who is there for a medication refill.

 

[PETRAN]

No, nooo, not this stuff again...


I think people are completely missing the point. A PhD in Clinical psychology is not some kind of a "cheap-mid-level-psychotherapy-producing-machine". It is a doctorate level degree aiming at producing academic scholars who are also applied practicioners of psychology in clinical settings. There is a vast scope of research and specializations. Clinical neuropsychologists are the brain-behaviour experts and are the ones responsible for the measurement of neurocognitive deficits and the planning of rehabilitation. They can make a big difference in managing (and possibly improving) the deficits of some neurological patients (stroke, TBI) and also in supporting dementia/parkinsons/MS/Huntington/other neurodegenrative disorder (by psychometrically measuring strengths and weaknesses of language/executive functions/visuospatial processing/memory etc. and trying to minimize the weaknesses by expanding strengths. Also by the means of psychotherapy in the patients themeselves and their families) Clinical health psychologists apply psychology on medical settings and i believe that they make a substantial difference on the lives of cardiovascular, pulmonary or cancer (terminal) patients. Clinical child psychologists are valuable for the treatment and management of developmental disorders. Applying stuff like ABA/CBA they can change the lives of autistic children and make a positive impact on ADHD, Conduct etc (and ofcourse they can go more far than that by counselling the family, liaising with social work etc.). And yes adult clinical psychologists can make vast contributions by applying psychological interventions on various mental health problems. I haven't seen one psychiatrist making lengthy behavioural experiments/exposures on an agoraphobic or a PD patient, yet this method is essential for the treatment of many anxiety and mood disorders.


A clinical psychologist is essential for detailed assessement (psychometric) and lengthy psychological interventions that a psychiatrist-or other medical doctor for that matter- wouldn't have the time and the appropriate training to do. Simple as that. There is also a tendency for clinical (mental health) psychologists to be more appropriate on treating "neuroses" (anxiety/OCD/somatoform etc.) and for psychiatrists for the more serious bipolar/psychotic cases but still both are needed for every single mental health case. A patient with panic disorder and social anxiety may need some SSRI to be more able to receive lenghty and painful (for hi/her) exposure therapy/ cognitive-behavioural treatment/social training. A patient with psychosis may get some help from cognitive therapy for psychosis and it is a pity that many psychotic patients are just sent home with a cocktail and nothing else.


Plus, many clinical psychologists are experts on academic research and on the development of various models and theories of the human mind or brain. Some psychiatrists do some research but they are few and far behind in comparison to psychologists. This is not some innate weakness of psychiatrists. It is just that their model is much more "medical/applied" whereas PhD-level psychologists is much more "research" oriented. And it is just fine the way it is. There are many people with severe psychosis who are in desperate need for a psychiatrist (who in the US are not many as it seems) in contrast, the more numerous PhD-level psychologists can divide their time between assessment/interventions in applied settings and research. There are many, many good clinical psychologists who have made great contributions on theories of affection, emotion, personality, cognition (and now neuroscience stuff) and their disorders and this is because their training and the psychologist's life-style allowed them to do so. Most psychiatrists simple don't have the time (or the training) for that.


Every professional can make a difference and some of you people reach the point of disturbing (or disturbed) by making yourself look like you are the best salesman in town rather than an applied scientist. "HEREE MENTAL HEALTH PATIENTSS im a psychiatristt (or a psychologistt) i have the besst treatmentsss all heree for the besst treatmentsss". Narcissistic dumb people 😛

 

[dl2dp2]

There are some consensus answers to these questions.

1) Should someone who wants to do therapy go into Psychiatry?

Depends. If you only want to do therapy, no. If you also want to do meds and also are interested in medicine in general, yes.

2) Do Psychiatrists still do psychotherapy?

Most do some. 10% don't do any.

3) Are Psychiatrists good at psychotherapy?

All existing evidence shows that psychiatrists do therapy as well as any other provider. However, in general, they charge more for therapy, and the market is able and willing to pay.

4) Are Psychiatrists competent at psychotherapy?

There's no difference in efficacy. However, do psychiatrists follow manuals or are more artful at doing psychodynamics? This question is kind of not coherent.

5) What is the role of a Psychiatrist on the mental health team?

As previously discussed, a psychiatrist is generally the presumed leader on the mental health team.