What's the best therapy modality for a practicing psychiatrist to get trained in?

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Dopamemes

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I graduated years ago from a decent program but one where I got mediocre to below mediocre therapy training. I'm doing outpatient psychiatry right now, 30 minute follow ups, and would like to get trained in a therapy modality that I can incorporate into my visits. I'd say I have an average level of training in CBT, supportive therapy, and motivational interviewing but that's about it.

Any suggestions from the more therapy-focused psychiatrists here on what would be a good modality for me to get trained in. I don't plan on doing weekly therapy sessions but looking for something I can incorporate into my current patient flow (modal visit is 30 minute follow up monthly).

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Good Psychiatric Management of BPD
Clinical Hypnosis
 
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I'm not as therapy oriented as most, but I think you've already got the training in the areas that are going to be most easily practiced in 30 minute follow-ups. Ie good supportive therapy and CBT. I think learning CBT-I can be quite helpful if patients are willing to buy in as almost all patients I work with have some kind of sleep issue. I also think having a good understanding of IPT to help patients understand how to build appropriate relationships and manage their emotions while interacting with others is very helpful as problems (or just perceived problems) with social interactions is a very common theme with patients.
 
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I've seen CBT, psychodynamic, and supportive therapies successfully mixed into a 30 minute visit. Really just depends on your style/affinity.
 
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It's so personal. The best modality is the kind you enjoy doing the most. Patients are going to pick up immediately if you hate it and they will too.
 
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MI is pretty underrated by most psychologists and psychiatrists from my personal experience, maybe for its surface simplicity, but is probably the most widely applicable (I say this is as someone who didn't read my assigned MI book in med school during FM and got no training in it during training).

I think 3rd wave therapy's are making as big of waves as they are for a reason, but it's pretty touch to weave into 30 min apts. If you were really enthralled with DBT or mindfulness based techniques, I do think you could find a way.

CBT is probably the easiest for people who have rational/scientific minds and I have certainly seen patient's respond to brief CBT based interventions.

As above it's what interests you the most. You have to be at least modestly fluent in it for things to go well.
 
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MI is pretty underrated by most psychologists and psychiatrists from my personal experience, maybe for its surface simplicity, but is probably the most widely applicable (I say this is as someone who didn't read my assigned MI book in med school during FM and got no training in it during training).

I think 3rd wave therapy's are making as big of waves as they are for a reason, but it's pretty touch to weave into 30 min apts. If you were really enthralled with DBT or mindfulness based techniques, I do think you could find a way.

CBT is probably the easiest for people who have rational/scientific minds and I have certainly seen patient's respond to brief CBT based interventions.

As above it's what interests you the most. You have to be at least modestly fluent in it for things to go well.

ACT is almost purpose-built to be usable in shorter appointments and that's as third wave as they come.
 
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ACT is almost purpose-built to be usable in shorter appointments and that's as third wave as they come.
Completely missed that, I really like ACT and strongly recommend it as well. Was just using that this week with one of my sickest patients.
 
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Do you really need more training? (There are better things to do with my time. You've been trained enough already for self-sufficiency). Pick a modality you have affinity towards, read about it, practice, and enjoy the process. We've all been hypnotized into thinking that we need formal training to develop a high level of skill. My vote... just get at it! If the process of training more in a formal fashion is something you would truly enjoy (and you have the time to train) then by all means go train. Either way, enjoy the ride!
 
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Do you really need more training? (There are better things to do with my time. You've been trained enough already for self-sufficiency). Pick a modality you have affinity towards, read about it, practice, and enjoy the process. We've all been hypnotized into thinking that we need formal training to develop a high level of skill. My vote... just get at it! If the process of training more in a formal fashion is something you would truly enjoy (and you have the time to train) then by all means go train. Either way, enjoy the ride!
I would agree with this so long as there was good training during residency and it also depends on how much skill and emphasis on this aspect of the treatment that the psychiatrist wants to develop. I personally believe that it is very difficult to develop high levels of therapy skills without learning from others with some mastery. Formal training in a didactic setting would be less useful in my mind than a regular consultation with another psychiatrist or psychologist if you want to improve and hone the skills. In my experiences with psychiatrists, there is a lot of variability in this and a few of them are damn good and others are operating at an amateur level as a therapist still thinking that giving advice or telling people how to live their lives is psychotherapy. Another aspect of this is ability to formulate or conceptualize cases with higher levels of sophistication which I think goes hand in hand with some of the psychological training, but this aspect is easier to acquire through reading and self-study.
 
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I'm not as therapy oriented as most, but I think you've already got the training in the areas that are going to be most easily practiced in 30 minute follow-ups. Ie good supportive therapy and CBT. I think learning CBT-I can be quite helpful if patients are willing to buy in as almost all patients I work with have some kind of sleep issue. I also think having a good understanding of IPT to help patients understand how to build appropriate relationships and manage their emotions while interacting with others is very helpful as problems (or just perceived problems) with social interactions is a very common theme with patients.
Agreed on this. This is a great place to start if you're CBTi-curious: CBT-Iweb.
 
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I graduated years ago from a decent program but one where I got mediocre to below mediocre therapy training. I'm doing outpatient psychiatry right now, 30 minute follow ups, and would like to get trained in a therapy modality that I can incorporate into my visits. I'd say I have an average level of training in CBT, supportive therapy, and motivational interviewing but that's about it.

Any suggestions from the more therapy-focused psychiatrists here on what would be a good modality for me to get trained in. I don't plan on doing weekly therapy sessions but looking for something I can incorporate into my current patient flow (modal visit is 30 minute follow up monthly).
I like ACT as an approach to certain patients with significant cognitive rigidity that struggle with CBT. Interpersonal therapy can be great for some patients that struggle with their feelings as they relate to relationships
 
Interpersonal therapy can be great for some patients that struggle with their feelings as they relate to relationships
I found the relationship map exercise as well as narrative analysis have been especially helpful tools to pull from IPT. Agree that it can be woven in for some patients with those IPT-oriented problems.
 
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I would agree with this so long as there was good training during residency and it also depends on how much skill and emphasis on this aspect of the treatment that the psychiatrist wants to develop. I personally believe that it is very difficult to develop high levels of therapy skills without learning from others with some mastery. Formal training in a didactic setting would be less useful in my mind than a regular consultation with another psychiatrist or psychologist if you want to improve and hone the skills. In my experiences with psychiatrists, there is a lot of variability in this and a few of them are damn good and others are operating at an amateur level as a therapist still thinking that giving advice or telling people how to live their lives is psychotherapy. Another aspect of this is ability to formulate or conceptualize cases with higher levels of sophistication which I think goes hand in hand with some of the psychological training, but this aspect is easier to acquire through reading and self-study.
All anyone needs to have done is spent time in therapy supervision with a so-so psychologist versus a psychologist who spends all day-every day treating folks with a specific modality to know there is such a wide variety of actual efficacy. I had one supervising PhD who could come up with a CBT founded answer to literally every problematic cognition or behavior presented over a year of supervision in a matter of seconds. It was very clear that she had lived/breathed the work. Being really good at psychotherapy is like being a really good doctor, it's a lifelong skill that requires serious pursuit. There are plenty of (typically older) MDs who are great at it as well, but it's not an accident, its from a ton of painstaking work to excel at it.

All that to say I completely agree with smalltownpsych as above.
 
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mastering CBT would likely give you the most benefit.

agree that CBTi is useful, but limited by the people actually motivated to buy into it is the issue.

realistically in 30 minute follow ups, i think it would be hard to do more than CBT and supportive therapy
 
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Something else, easy to learn and practically done in a 30-minute follow-up is Written Exposure Therapy (WET).
 
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Is your goal to feel more confident in justifying +90833? If so, you might find brief supportive psychotherapy to be the closest to what you're already doing with patients and a way to give you more structure on which you can build the "what did I actually do with the patient today that constitutes therapy?" part of your note.

I think anyone who works with a sufficient number of patients with OCD would be well served to at least have some theoretical foundation in ERP, even if you never provide the therapy directly.
 
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Is your goal to feel more confident in justifying +90833? If so, you might find brief supportive psychotherapy to be the closest to what you're already doing with patients and a way to give you more structure on which you can build the "what did I actually do with the patient today that constitutes therapy?" part of your note.

I think anyone who works with a sufficient number of patients with OCD would be well served to at least have some theoretical foundation in ERP, even if you never provide the therapy directly.

As someone who not infrequently cleans up the mess that can result with OCD folks are treated by someone without these foundations, yes please.
 
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Good Psychiatric Management of BPD
Clinical Hypnosis
GPM is great! How do you incorporate Clinical Hypnosis in a psychiatric practice? Are there specific patients that benefit more? (I'm thinking maybe conversion disorders, personality disorders?)
 
As a CAP, parent management training has been my most helpful therapy technique.
 
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All anyone needs to have done is spent time in therapy supervision with a so-so psychologist versus a psychologist who spends all day-every day treating folks with a specific modality to know there is such a wide variety of actual efficacy. I had one supervising PhD who could come up with a CBT founded answer to literally every problematic cognition or behavior presented over a year of supervision in a matter of seconds.

Agree on the top part, but is it really that useful for the therapist to be coming up with the reframes? I feel like it's usually more effective for the patients to come up with them.

Sometimes I'll use Socratic questioning to guide them, or provide some sample reframes for people who are really blanking but generally I think the benefit is greater when they do it themselves.

It's... not that hard to come up with reframes for other people's issues. Trickier when they're your own!
 
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GPM is great! How do you incorporate Clinical Hypnosis in a psychiatric practice? Are there specific patients that benefit more? (I'm thinking maybe conversion disorders, personality disorders?)
I occasionally use a light induction script to improve the efficacy of guided relaxation or visualization exercises. I do often find that people with personality issues find this particularly helpful.
 
Agree on the top part, but is it really that useful for the therapist to be coming up with the reframes? I feel like it's usually more effective for the patients to come up with them.

Sometimes I'll use Socratic questioning to guide them, or provide some sample reframes for people who are really blanking but generally I think the benefit is greater when they do it themselves.

It's... not that hard to come up with reframes for other people's issues. Trickier when they're your own!
This is a CBT focused PhD doing supervision for 3 MDs carrying CBT cases in residency. I am sure in session it's a different experience working with her. I absolutely think its tricky to reframe any issue presented across a panel of patients, I am a decent cognitive therapist and couldn't come close to the level of skill this individual demonstrated on a daily basis in supervision.
 
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This is a CBT focused PhD doing supervision for 3 MDs carrying CBT cases in residency. I am sure in session it's a different experience working with her. I absolutely think its tricky to reframe any issue presented across a panel of patients, I am a decent cognitive therapist and couldn't come close to the level of skill this individual demonstrated on a daily basis in supervision.
OK sure, I'll take you at your word since you were there and I wasn't.

I guess I never thought of coming up with reframes as particularly difficult, or a skill, really.
Most of my patients' negative thoughts seem pretty nonsensical to me - because I'm not depressed or anxious, or suffering from whatever their particular problem is - and so the reframes from my perspective are usually fairly trivial.

That doesn't mean the patient is going to see it the same way I do though. From their depressed, anxious perspective, my optimistic reframe sounds empty. It's only through coming up with a reframe on their own that they develop and reinforce the circuits that support that alternative way of thinking. A lot of their reframes, especially the early ones, still sound excessively pessimistic to me; but they're the patients' own, and they do get better with time.
 
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Most of my patients' negative thoughts seem pretty nonsensical to me - because I'm not depressed or anxious, or suffering from whatever their particular problem is - and so the reframes from my perspective are usually fairly trivial.

Depends a bit on how deeply the patient holds the beliefs. Automatic thoughts? Easy. A core belief of worthlessness for which they fill three journals of evidence? A bit harder.
 
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This is a CBT focused PhD doing supervision for 3 MDs carrying CBT cases in residency. I am sure in session it's a different experience working with her. I absolutely think its tricky to reframe any issue presented across a panel of patients, I am a decent cognitive therapist and couldn't come close to the level of skill this individual demonstrated on a daily basis in supervision.

Most of my patients' negative thoughts seem pretty nonsensical to me - because I'm not depressed or anxious, or suffering from whatever their particular problem is - and so the reframes from my perspective are usually fairly trivial.

I think this is a good illustration of an under-emphasized concept in learning psychotherapy - each psychotherapy approach is a lens, and whether the vision that particular lens gives you is a clear and useful way of seeing the patient's problem determines whether that approach is a good one for you (and your patients). For @Merovinge 's supervisor, the cognitive behavioral lens was clear and useful, but for @tr not so much.
 
Depends a bit on how deeply the patient holds the beliefs. Automatic thoughts? Easy. A core belief of worthlessness for which they fill three journals of evidence? A bit harder.

I mean, I don't believe anyone is intrinsically worthless, so those three journals of evidence are convincing to the patient, not to me personally.

For the same reason, my reframe of "everyone has intrinsic worth" sounds right on to me, but may not be convincing to the patient, at least unless they are able to arrive there on their own.
 
I mean, I don't believe anyone is intrinsically worthless, so those three journals of evidence are convincing to the patient, not to me personally.

For the same reason, my reframe of "everyone has intrinsic worth" sounds right on to me, but may not be convincing to the patient, at least unless they are able to arrive there on their own.

Neither do I. My point is that helping a patient restructure their own beliefs can be get pretty complex when issues such as quality and extent of the patient's evidence arise. And just to be sure we're on the same page, a core belief is different than automatic thoughts according to the theoretical model. Core beliefs are supported by assumptions and rules which are in turn supported by automatic thoughts. You can plot a continuous metric of 'perceived veracity' that starts low at automatic thoughts and works it way up to core beliefs. Hence why they are difficult for patients to restructure.
 
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Neither do I. My point is that helping a patient restructure their own beliefs can be get pretty complex when issues such as quality and extent of the patient's evidence arise. And just to be sure we're on the same page, a core belief is different than automatic thoughts according to the theoretical model. Core beliefs are supported by assumptions and rules which are in turn supported by automatic thoughts. You can plot a continuous metric of 'perceived veracity' that starts low at automatic thoughts and works it way up to core beliefs. Hence why they are difficult for patients to restructure.

Agreed. But they're difficult *for the patient* to restructure. Not for me, because I'm not depressed or suffering from whatever distorted belief system is troubling the patient.

I'm just saying that in my experience, presenting a completed positive reframe to the patient is not as useful as having them do the work to come up with one on their own.
 
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Agreed. But they're difficult *for the patient* to restructure. Not for me, because I'm not depressed or suffering from whatever distorted belief system is troubling the patient.

Fair enough. Personally, I do think teaching people to carefully weigh evidence while avoiding the implication that their experience is invalid does take a bit of skill.
 
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Like this discussion about reframes. I throw them out all day long because people have automatic irrational thoughts all the time and I have like a radar for them. With patients I will teach them the process and sometimes initially give them examples to demonstrate. With supervisees, I will be a bit more direct. Supervises are funny because one irrational belief they commonly hold is that only patients have irrational beliefs. Healthier people are just better at recognizing and challenging cognitive distortions. Also, to further tr’s point, mood states such as anxiety and depression can both be a cause and a result of more distorted thinking patterns,
 
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Like this discussion about reframes. I throw them out all day long because people have automatic irrational thoughts all the time and I have like a radar for them.

This is a good point. I think I do this more during med management sessions, where we only have 30 min and are not addressing the patient's thoughts in a structured way. In that case sometimes if I hear a distorted automatic thought I'll reflect it back with a reframe.

In a session where we are explicitly doing psychotherapy, and often writing down the negative thoughts and the reframes, I try harder to let the patient do the work rather than jump in with my own suggestion.
 
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GPM is great! How do you incorporate Clinical Hypnosis in a psychiatric practice? Are there specific patients that benefit more? (I'm thinking maybe conversion disorders, personality disorders?)
I would check out Spiegels' model of clinical hypnosis. It utilizes the assessment of hypnotizability for differential diagnosis and treatment planning. It's helped me a lot to differentiate between reactive psychosis due to personality v. dissociative disorders v. primary schizophrenia spectrum. I'm also a fan of non-traditional forms of hypnosis, like Ericksonian therapy, for people with lower hypnotizability. However, this type of intervention is often criticized by hypnosis purists as not being true "hypnosis" and rather a form of supportive psychotherapy.
 
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It’s a component of CBT, but stand alone Behavioral Activation can be pretty effective and benefits from being parsimonious. Patients “get it” at a fundamental level, and it relies on principles not far removed from exposure for anxiety, so it can be useful for mixed presentations of depression and anxiety. Sona Dimidjian and Chris Martell’s manual for clinicians is an easy, accessible read - and the patient workbook has been well liked by my patients over the years.

ETA: BA also helps avoid getting caught in a tug of war with the patient over cognitive restructuring, because it is behavior-focused. Once you get some movement from the BA, it is often easier to shift to the cognitive part of Tx.
 
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Agree on the top part, but is it really that useful for the therapist to be coming up with the reframes? I feel like it's usually more effective for the patients to come up with them.

Sometimes I'll use Socratic questioning to guide them, or provide some sample reframes for people who are really blanking but generally I think the benefit is greater when they do it themselves.

It's... not that hard to come up with reframes for other people's issues. Trickier when they're your own!
Christine Padesky has a great book on the use of “Socratic dialogues” in CBT. Highly recommend - she also has a great series of YouTube clips on how to apply the skills.

 
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