Too many cheifs in the kitchen

[EEGNeurofeedback]

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I am doing psychotherapy with all patients even those whom come to me for only medication management. This isn't working out too well. I speak with patients psychologists to make sure that we all understand each other. But, patients get confused because there are still differences in opinions between providers.

 

[vistaril]

I am doing psychotherapy with all patients even those whom come to me for only medication management.

huh? Weren't you the guy who just a week or so ago was saying you schedule 4 pts an hour? What kind of 'psychotherapy' are you doing in that time?

 

[erg923]

1. No, You're probably not. Not in a 15 minutes med check session that is.

2. Why are two providers providing psychotherapy to the same patient anyway? Seeing a substance abuse counselor/therapist and then having another therapist for general MH issues is not too uncommon, but why two therapists for the same MH issues?

3. Are you providing generic supportive stuff or are you actually running evidence-based treatment protocols (ACT, CBT-I, exposure, etc.)?

 

[shan564]

Are we talking about chefs, chiefs, or "cheifs"?

 

[SteinUmStein]

This is especially funny because the idiom is "Too many cooks in the kitchen..." No chefs involved.

 

[EEGNeurofeedback]

huh? Weren't you the guy who just a week or so ago was saying you schedule 4 pts an hour? What kind of 'psychotherapy' are you doing in that time?

I am now only seeing one patient per hour. More time for therapy, although it may not be worth it for meds management clients.

 

[EEGNeurofeedback]

This is especially funny because the idiom is "Too many cooks in the kitchen..." No chefs involved.

No wonder the statement sounded off. Thanks for correcting it.

 

[EEGNeurofeedback]

1. No, You're probably not. Not in a 15 minutes med check session that is.


2. Why are two providers providing psychotherapy to the same patient anyway? Seeing a substance abuse counselor/therapist and then having another therapist for general MH issues is not too uncommon, but why two therapists for the same MH issues?

3. Are you providing generic supportive stuff or are you actually running evidence-based treatment protocols (ACT, CBT-I, exposure, etc.)?

1) I now see one patient per hour.

2) Some patients see me for medication management only, but I now include some therapy in those sessions. So all of my patients get therapy if they are interested; some patients are not, so I only go into meds management stuff

 

[nitemagi]

If they're getting therapy from two providers, at least make sure your strategies are different (and complementary).

 

[masterofmonkeys]

I am doing psychotherapy with all patients even those whom come to me for only medication management. This isn't working out too well. I speak with patients psychologists to make sure that we all understand each other. But, patients get confused because there are still differences in opinions between providers.

I think this is always a mixed bag. We do 30-45min slots and I always end up with a little time for therapy. I think it's sort of like co-therapy in a family therapy setting. You and your co-therapist need to 'gel' even if you're not in the same room or working with the patient at the same time. I work quite well with some and not as well with others. I'm sure sometimes it's me, sometimes it's them, and sometimes it's a combination. And sometimes the patient just can't handle two different therapists.

What's worked well for us is not doing the exact same approach. One of us with a little more MI, one of us with a little more CBT. One more supportive, one more insight-oriented, sometimes swapping who does what.

 

[smalltownpsych]

I agree that if more than one therapist is involved, collaboration is essential. Otherwise, problems with splitting will occur. In a collaborative working relationship, when one of my patients tells me they are frustrated with another provider because of x, y, and z. Then we can bring everything out in the open and help the patient address whatever the source of the conflict.
Also, just to make it clear because we all can get pulled into the trap of the bad example.
Bad therapy would be to say, "You are right, Dr. X doesn't know______." Good therapy would be, "So you were frustrated with Dr. X, what did you say or do?" "Why do you get frustrated in situations like this?" "How does this connect to other relationships you have had?" 🙂

 

[Therapist4Chnge]

So….do the other therapists agree that this is the best approach? It would irk me if I were in their shoes and you didn't first consult with me about the idea, as there are quite a few pitfalls associated with two providers working in the same wheelhouse.

 

[watto]

The two most frequent source of "therapy conflict," for me are:
1) I am trying to teach exposure therapy and negative role of avoidance in anxiety disorder patients and their other therapist is emphasizing avoidance as a "coping strategy" which only buttresses the patient's belief that anxiety is dangerous. Results in an awkward phone call to therapist.
2) Differing viewpoints on what defenses are helpful for pt and which are not so much and need to be illuminated and challenged - tend to defer to primary therapist on this one depending on strength of that relationship; again, need to call therapist to discuss

 

[michaelrack]

I am now only seeing one patient per hour. .

So you switched from 4 patients an hour to one patient an hour in one week?????

 

[vistaril]

So you switched from 4 patients an hour to one patient an hour in one week?????

agreed....story does not add up.

 

[Doctor Bagel]

So you switched from 4 patients an hour to one patient an hour in one week?????

I'm scratching my head about this one as well. Either we're being played, or EEG might be a little too reactive in switching practice models based on SDN feedback.

 

[smalltownpsych]

My biggest concern regarding this relates to competency to practice psychotherapy. It has been my understanding and also my experience that psychiatrists are generally not getting the level of training and experience sufficient to develop effective psychotherapy skills. I hesitate to post this on a psychiatry forum, but after having many years of intensively supervised clinical experience in all of the complexities of psychotherapy, I worry when it is taken too lightly. I imagine that psychiatrists feel the same way when they think about a psychologist prescribing without sufficient medical background and knowledge.

 

[Doctor Bagel]

My biggest concern regarding this relates to competency to practice psychotherapy. It has been my understanding and also my experience that psychiatrists are generally not getting the level of training and experience sufficient to develop effective psychotherapy skills. I hesitate to post this on a psychiatry forum, but after having many years of intensively supervised clinical experience in all of the complexities of psychotherapy, I worry when it is taken too lightly. I imagine that psychiatrists feel the same way when they think about a psychologist prescribing without sufficient medical background and knowledge.

I'm just going to say I disagree with this 100%. We are trained in psychotherapy, and we don't take it lightly. Sure, there might be some programs out there that don't do a good job at this, but overall, psychiatrists are trained to be therapists. Psychiatrists who take the effort to make psychotherapy a part of their work also often seek out their own ongoing training because we all understand that becoming a therapist is a long term endeavor.

 

[vistaril]

My biggest concern regarding this relates to competency to practice psychotherapy. It has been my understanding and also my experience that psychiatrists are generally not getting the level of training and experience sufficient to develop effective psychotherapy skills. I hesitate to post this on a psychiatry forum, but after having many years of intensively supervised clinical experience in all of the complexities of psychotherapy, I worry when it is taken too lightly. I imagine that psychiatrists feel the same way when they think about a psychologist prescribing without sufficient medical background and knowledge.

agree with all this.

 

[smalltownpsych]

I'm just going to say I disagree with this 100%. We are trained in psychotherapy, and we don't take it lightly. Sure, there might be some programs out there that don't do a good job at this, but overall, psychiatrists are trained to be therapists. Psychiatrists who take the effort to make psychotherapy a part of their work also often seek out their own ongoing training because we all understand that becoming a therapist is a long term endeavor.

I really wished that I ran into more psychiatrists that had this type of understanding, maybe my experience has been different since I have primarily worked in rural settings. However, I have seen several articles in the NY Times making this same point and as I recall, they were written by psychiatrists.

I do agree with the importance of understanding that psychotherapy is a long-term endeavor. I have been at it for about 12 years now, including practicums, internship, and residency and still feel that I have so much to learn. Just for an example, yesterday I was reviewing the relevant literature on treating trichotillomania and strategies for implementing CBT for anxiety with younger children. The truth is, every day, I have something new to learn which is one reason I love this field so much.

 

[notdeadyet]

I really wished that I ran into more psychiatrists that had this type of understanding, maybe my experience has been different since I have primarily worked in rural settings. However, I have seen several articles in the NY Times making this same point and as I recall, they were written by psychiatrists.

I'm curious which articles you've been reading. The takeaway I had from the ones I saw recently in the New York Times didn't indicate that psychiatrists weren't being trained in psychotherapy so much as many weren't practicing it.

All psychiatrists receive a certain amount of psychotherapy training, but it's a matter of degree. Many programs are not very psychotherapy oriented, but many are. Interestingly, the more respected programs tend to be the more psychotherapy oriented (the ones that do not do much psychotherapy are few and far between at that level). And I think most psychiatrists who practice psychotherapy do it much in the way you are describing. I'm currently trying to tweak a 16 week protocol for social skills development for a psychotic patient as we speak. The learning is always going to be ongoing. That's part of the appeal to some and why others aren't interested. Viva la difference!

 

[masterofmonkeys]

I agree with both DB and smalltownpsych lol. Many psychiatrists don't take therapy seriously, and the training requirements are such that it is possible to not be very good nor know very much when you finish. Many on the other hand do take it seriously and go above and beyond the generalized requirements for training. There are a few psychiatrists that think they 'like therapy' but really just like 'teh feels' and end up doing things like encouraging destructive defense mechanisms (like avoidance) or validating without redirecting. These have been the minority in my experience, with the largest proportions either not giving a damn about therapy or on the other hand loving it but struggling to find a way to make it work.

We're a lot more variable than psychologists, and few of us graduate with the same depth of knowledge and experience of various modalities as most psychologists do, but there are those of us that do care about it.

Also smalltownpsych, please stick around in the psychiatry forum and never hesitate to share your opinion. The regular psychologist posters on this forum make it a richer place.

 

[EEGNeurofeedback]

So you switched from 4 patients an hour to one patient an hour in one week?????

I had been planning to do this for awhile. I now have weekends open for them to come. Many are happy about this. This can be done since I am not overwhelmed with patients.

 

[EEGNeurofeedback]

All psychiatrists receive training in psychotherapy. I am sure that everyone takes this seriously as it is part of the training one must get through. But, there are some that are certainly more interested and will put more effort into it than others. Some are just not good at it, whether they like doing it or not.

 

[erg923]

We have had this discussion before, just recently, but I would be curious to learn more specifics/details about the typical (if there is such a thing) psychotherapy training and supervision in residencey programs?

I am especially curious, because it is quite obvious that psychiatry has held closer to psychodynamic concepts,compared to modern clinical psychology, and generally views therapy as almost invariably existing through this lens. This makes little sense to me because, out of all the psychotherapy providers, psychiatrists typically have the least amount of time in the room with a patient.

 

[masterofmonkeys]

I would say that the most therapy-focused programs tend to be more psychodynamically oriented, but that's more due to the peculiarities of history. Training as an analyst used to require you to be a physician and/or psychiatrist until relatively recently. The analytic community was therefore largely composed of psychiatrists with strongly scholarly (if not scientific) orientations. Scholarly psychiatrists tend to be involved in academics. Ergo, many therapy-focused programs were run by or highly influenced by analysts.

Therapy supervision and teaching runs a pretty large variation. In terms of the minimum, what you will likely see is one afternoon a week as a third year dedicated to therapy patients, which you will self-refer from your intakes/ongoing patients. Supervision will take place off-campus with a community mental health professional one hour/week. Didactic time will likely be 1hr/week or less as part of your third year curriculum.

The more intense/thorough programs offer a lot more, including didactics starting in 1st year including introductions to supportive psychotherapy, behavioral activation, and overviews of different therapy types. They might offer some experience in your first two years (only a handful). And in third year you might have a full day of protected time or be able to take on as many therapy patients as you like in the course of your regular clinic time (I've seen both). Your therapy supervisors might also be onsite. Some of these will also offer longitudinal class/seminar in CBT, psycohdynamics, and family therapy. My current program has pretty robust psychotherapy time, as did the program I started training at.