Where do psychiatrists do a fair amount of psychotherapy?

[w1116]

To preface, I'm looking at psychiatry as a possible career change. I greatly appreciate the fact that they largely take into account the bio/neuro aspect of the human being while also wielding the ability to conduct psychotherapy. Having said that, after doing some research about the current state of psychiatry, it seems to be the case (generally speaking), that psychiatrists are more or less on the medication side while MSWs, PhD Psychs, etc, do the counseling. This fact concerns me. Now, before going further, if my generalization is absolutely wrong, please correct me.

Regardless, psychiatrists still get training in psychotherapy during residency and can continue to learn more afterwards. My question is this: just where is it that psychiatrists are doing, or able to do, a fair amount of psychotherapy? The only answer I keep coming up with is in cash only, private practice settings, where insurance isn't the boss of the psychiatrist. Are there any other settings? Again, back to my first paragraph, my current view of the psychiatrist is one who is more or less strictly on the medical model side, while others are handling the in depth counseling.

Thanks

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[HarryMTieboutMD]

It seems like you have already found your answer (which is the correct one). You can find a residency training program where psychotherapy is emphasized and MDs who will refer to themselves as "therapists", but the job market for psychiatrists practicing mainly therapy is as you described (at least if you want to make any money).

In reality one's credentials or level of training does not equate to effectiveness as a therapist. But I do think that my training as a physician (and I purposely chose a program with an intensive, medicine heavy intern year) works against me being a therapist. But I personally have no interest in doing psychotherapy as a practice, but I am glad I am learning the skills of basic supportive/CBT/IPT to guide my patient interactions. For people who need formal therapy, I would much rather refer out to someone who knows how to do it effectively.

 

[sunlioness]

The place I work now has a psychotherapy practice where psychiatrists do both the therapy and med management. And it's affiliated with a multi specialty hospital based organization that accepts insurance. But that's RARE. Exceedingly rare. And they know it, which makes them very proud of it. It's really successful. Docs like it. Patients like it. They seem to make money at it. I hope it sticks around. Eventually I'll do a day or two a week there. The credentialing for it takes a bit longer. I'm still waiting on that. And I need to brush up on my skills.

I think you get out of residency psychotherapy training what you put into it. You can start the path to becoming a competent therapist if you set out with that as your goal. You can also skate through that part and get your boxes checked off if it's not your thing. I think most pursue some sort of middle ground. At least I think that's what I did. If I am going to be doing it more, I need to brush up and do some continuing Ed stuff, perhaps get some supervision at first.

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[MiddleRoad]

In New York City there is a large market, unlike most cities in the US (with maybe the exception of LA as a close second), where there are many psychiatrists who have very active psychotherapy practices, mostly in private practice but also in some of the well known academic centers. It is difficult to break into this, however, without training in the city and developing a network of referral sources.

 

[Doctor Bagel]

In reality one's credentials or level of training does not equate to effectiveness as a therapist. But I do think that my training as a physician (and I purposely chose a program with an intensive, medicine heavy intern year) works against me being a therapist.

Why would being a physician with a medicine heavy background work against being a good therapist? Sure, that might take time away for a while from honing psychotherapy skills, but those can be gained over time. I'm just curious about this statement.

 

[Doctor Bagel]

The place I work now has a psychotherapy practice where psychiatrists do both the therapy and med management. And it's affiliated with a multi specialty hospital based organization that accepts insurance. But that's RARE. Exceedingly rare. And they know it, which makes them very proud of it. It's really successful. Docs like it. Patients like it. They seem to make money at it. I hope it sticks around. Eventually I'll do a day or two a week there. The credentialing for it takes a bit longer. I'm still waiting on that. And I need to brush up on my skills.

My understanding is that people in private practice in my city doing medication management + psychotherapy do fine, so you can make money doing it. Whether it's less money than you'd make doing something else when you account for lost benefits of employment isn't clear, but they don't seem to be broke. However, I'm not aware of any employers aside from maybe an academic job where they'll pay you to do this. So that's super cool that there's actually a big system with that model.

 

[nitemagi]

Currently being able to offer therapy and medications is a niche market. Employers don't really understand how this is advantageous and thus profitable, and thus aren't selling it as a job. You can take a job and start to carve out some therapy, strategically, in certain jobs.

Regarding the medical training working against being a good therapist, I agree and disagree. I agree it's a training model (and thus a system of interpreting the world) that can be our default. Doing good therapy (IMPO) involves interpreting a person, a situation, a system, etc, through multiple theoretical frameworks and lenses, and thus requires practice in switching thinking. In that way it doesn't matter where you start. Unless you're only looking to practice one type of therapy, in which case you learn that and that's it. In my experience those therapists have a more limited population they'll work with, though.

 

[Doctor Bagel]

Currently being able to offer therapy and medications is a niche market. Employers don't really understand how this is advantageous and thus profitable, and thus aren't selling it as a job. You can take a job and start to carve out some therapy, strategically, in certain jobs.

Regarding the medical training working against being a good therapist, I agree and disagree. I agree it's a training model (and thus a system of interpreting the world) that can be our default. Doing good therapy (IMPO) involves interpreting a person, a situation, a system, etc, through multiple theoretical frameworks and lenses, and thus requires practice in switching thinking. In that way it doesn't matter where you start. Unless you're only looking to practice one type of therapy, in which case you learn that and that's it. In my experience those therapists have a more limited population they'll work with, though.

Right -- so learning how to be a good physician and think about patients through a medical model doesn't preclude being a good therapist. It seems odd to me to think that learning one thing well would prevent you from learning another perspective/treatment paradigm well. Many excellent residency programs have rigorous medicine requirements and yet still provide high quality psychotherapy training -- think about the big name NYC places.

 

[w1116]

Currently being able to offer therapy and medications is a niche market. Employers don't really understand how this is advantageous and thus profitable, and thus aren't selling it as a job. You can take a job and start to carve out some therapy, strategically, in certain jobs.

Thank you for the reply (and thanks to everyone else as well). Nitemagi, the reason I am singling you out is because I have seen some posts by you come up as I've done some digging and research on these forums. Correct me if I'm wrong but you perform a large amount of psychotherapy, right? What type of setting are you in that allows you to do this? Is it the one I mentioned in my first post: cash only, private practices?

In any case, it seems a bit unfortunate that the cash only private practice setting might be the only true setting where a combination of psychotherapy and using/managing medication is allowed and permitted. I hope I'm not too off base but it seems to me that these settings are for the more affluent in our society. Would you consider that a true statement?

To go on a bit further, part of the reason that psychiatry entices me more so than the psychologist or the MSW is that a) the psychiatrist has a concrete understanding of the human qua neurological & biological entity and b) that there is potential for psychotherapy. I do not wish to make the claim that mental health professionals outside of psychiatry are reductionists (eg "it's all psychological", "it's all cultural/societal"), but from my limited readings of the various fields it seems to be the case that the psychiatrist has a larger capability to stave off reductionism, given their overall knowledge and training in the medical model and in psychotherapy. Then again, any professional could agree that a person is more than just their brain or their background, etc, and still not know how Haldol works, and that is totally fine. And I'm sure it's the case that there are countless psychiatrists out there that focus on the medical side, yet recognize there are more options available to help someone.

I guess to put things in a simpler and slightly different way, in my mind the psychiatrist could potentially be "the full package (or jack of all trades)" (with regards to their knowledge), as opposed to the other mental health professionals. Is this true?

Sorry to get a tad philosophical (though that's another reason psychiatry and mental health in general is so enticing...you folks are tackling a very large amount of philosophical problems)

 

[Doctor Bagel]

Thank you for the reply (and thanks to everyone else as well). Nitemagi, the reason I am singling you out is because I have seen some posts by you come up as I've done some digging and research on these forums. Correct me if I'm wrong but you perform a large amount of psychotherapy, right? What type of setting are you in that allows you to do this? Is it the one I mentioned in my first post: cash only, private practices?

Not nitemagi, and the answers probably vary based on your location. In my city, psychiatrists who do a lot of psychotherapy often accept insurance in a private practice setting. The insurance you accept is limited, and these providers generally don't accept public pay types of programs (medicaid, medicare). So yeah, your practice is limited to people who are able to pay cash (or out of network fees, which really aren't huge) or who have decent insurance, meaning you're seeing middle class or up folks.

Getting back to paying cash -- paying cash for analysis could cost a fortune ($200 for 3 to 5 times/week for years -- yikes!). Paying cash for a weekly session is probably affordable for lots of people who aren't wealthy. If you're doing short term treatment, it's even more affordable. I've seen irrationality on both sides with payment issues -- analysts who insist treatment is affordable provided you give up your vacations, etc, and people with means who refuse to pay relatively small amounts of their income for any medical expense.

 

[notdeadyet]

Paying cash for a weekly session is probably affordable for lots of people who aren't wealthy. If you're doing short term treatment, it's even more affordable. I've seen irrationality on both sides with payment issues -- analysts who insist treatment is affordable provided you give up your vacations, etc, and people with means who refuse to pay relatively small amounts of their income for any medical expense.

I've heard this argument from lots of cash-only psychiatrists, but I'm not sure I buy it.

You are going to have to be somewhat affluent to consider paying cash for medical care. I know lots of folks who wouldn't dream of coughing up cash for a medical appointment, I don't think I'd expect them to do the same for mental health care.

I have no objection to folks making their living any way they want, but I think pretending that cash payments for mental health care is scalable or should be considered a realistic plan for the sizable majority of most Americans isn't realistic.

 

[birchswing]

Why would being a physician with a medicine heavy background work against being a good therapist? Sure, that might take time away for a while from honing psychotherapy skills, but those can be gained over time. I'm just curious about this statement.

The power differential is too strong, IMO, for a psychiatrist to provide ongoing medication and therapy to a patient. I think it's combining too many things into one relationship. Therapy is about your goals and how to achieve them yourself. Medication management is a psychiatrist telling you what to do to treat a medical condition. To me, it's too different, and the latter relationship has too much of a power differential to be able to cross over into the former.

 

[splik]

The power differential is too strong, IMO, for a psychiatrist to provide ongoing medication and therapy to a patient. I think it's combining too many things into one relationship. Therapy is about your goals and how to achieve them yourself. Medication management is a psychiatrist telling you what to do to treat a medical condition. To me, it's too different, and the latter relationship has too much of a power differential to be able to cross over into the former.

This is interesting. In the UK for historical reasons, psychiatrists do either psychotherapy or they diagnose and prescribe medications, not both (at the very least not with the same patient).

That said, I think most psychiatrists would tell you the power differential is much greater in a psychotherapy relationship than in a standard psychiatric encounter. Patients who experience abuse by psychiatrists almost always are in psychotherapy with them, and psychiatrists who have sex with their patients are almost always psychotherapists (up to 10% of psychiatrists doing psychotherapy report having had sex with a patient).

There are sometimes good reasons for split treatment (for example in the treatment of PTSD, it is much better if the therapist isn't also prescribing medication as this allows the therapist to avoid doing trauma work when things start getting uncomfortable). But most patients seem to like the idea of having one person doing both. They want the person who knows them best (their therapist) prescribing their medications. There are certainly challenges of providing combined treatment and whole articles and books have been written about it. For example, therapists may be less aggressive at increasing the dose of medications where indicated, or may view prescribing medications as failure (because therapy was not enough). In your case, this discussion of the power differential would probably open up a dialog on the transference meanings of medication, and your fears of dependency and need to be in control.

When patients want split treatment it can sometimes be telling. A former patient of mine was in analysis and came to me and didn't want his analyst to know he had a psychiatrist because he thought she would disapprove, and didn't want to be a disappointment to her. He thought it would show "lack of faith" in her ability to help him. Actually, nothing could be further from the truth, but his own need to please and protect others preventing him from being fully honest with his analyst which became a stranglehold on the treatment. In my own formulation the purpose of medications was to dampen down his high level of intolerable affect, to allow him to more effectively engage in analytic treatment.

 

[Doctor Bagel]

The power differential is too strong, IMO, for a psychiatrist to provide ongoing medication and therapy to a patient. I think it's combining too many things into one relationship. Therapy is about your goals and how to achieve them yourself. Medication management is a psychiatrist telling you what to do to treat a medical condition. To me, it's too different, and the latter relationship has too much of a power differential to be able to cross over into the former.

I think this statement is really telling regarding your experience with treatments, but I don't think it's true. Medication management can also be used to help you achieve your goals, and it doesn't have to limited to treating a medical condition. As splik has mentioned, I'm not sure I would think someone who prescribes has more power than a therapist either.

 

[Doctor Bagel]

I've heard this argument from lots of cash-only psychiatrists, but I'm not sure I buy it.

You are going to have to be somewhat affluent to consider paying cash for medical care. I know lots of folks who wouldn't dream of coughing up cash for a medical appointment, I don't think I'd expect them to do the same for mental health care.

I have no objection to folks making their living any way they want, but I think pretending that cash payments for mental health care is scalable or should be considered a realistic plan for the sizable majority of most Americans isn't realistic.

Eh, I've paid cash for psychotherapy as a resident making $60k/year. I don't think I counted as affluent in that bargain although admittedly I wasn't impoverished either. Not bitter or anything but I'm totally jealous of residency programs where they help you find low cost psychodynamic treatment. You're right, though, that people have this strange block on the notion that you can actually sometimes pay some out of pocket money that's not a deductible for healthcare. I remember in child clinic seeing a pretty affluent family where they were giving their child some wonky stimulant dosage just because their insurance didn't cover an easier/possibly better formulation. This family would think nothing of paying a soccer coach/SAT coach/personal trainer, etc. the money that that more expensive stimulant could cost. Honestly I don't think this family even understood that it was an option to pay a little more money for health care to get a potentially better/easier treatment or outcome. We've created this world where people don't even consider the option of actually paying cash for treatment. So maybe we change the paradigm and let people consider that they actually sometimes pay money for treatment that's of value even if it's out of network or whatever.

 

[Ceke2002]

The power differential is too strong, IMO, for a psychiatrist to provide ongoing medication and therapy to a patient. I think it's combining too many things into one relationship. Therapy is about your goals and how to achieve them yourself. Medication management is a psychiatrist telling you what to do to treat a medical condition. To me, it's too different, and the latter relationship has too much of a power differential to be able to cross over into the former.

If you really think the two things are such polar opposites that they cannot be combined, you just haven't met the right Psychiatrist. Medication management can be a collaborative effort where you work together with your Psychiatrist to achieve better health/stability (meaning it does not have to be a Psychiatrist just sitting there dictating things to you in complete contrast to the goals of therapy. My Psychiatrist doesn't completely shift gears and have a complete change of attitude/approach with therapy versus medication management (when I'm on medication that is), he applies the same principals of therapeutic alliance to both situations.

To be honest I find there's far more of a noticeable power differential in the Psychotherapeutic relationship than in any sort of medication management. And acknowledging that power differential is not necessarily a bad thing. Sometimes power differentials are in place because they need to be, because they contain the field of therapy and help maintain boundaries (and keep both Psychiatrist and patient safe).

 

[Ceke2002]

Not nitemagi, and the answers probably vary based on your location. In my city, psychiatrists who do a lot of psychotherapy often accept insurance in a private practice setting. The insurance you accept is limited, and these providers generally don't accept public pay types of programs (medicaid, medicare). So yeah, your practice is limited to people who are able to pay cash (or out of network fees, which really aren't huge) or who have decent insurance, meaning you're seeing middle class or up folks.

Why is that though? I mean what is it about US culture/society that Psychotherapy isn't widely covered across a range of options (insurance providers, medicare/medicaid, whatever other coverage is available). Is it because Psychotherapy is seen as the more expensive option as opposed to just prescribing a pill?

 

[Doctor Bagel]

Why is that though? I mean what is it about US culture/society that Psychotherapy isn't widely covered across a range of options (insurance providers, medicare/medicaid, whatever other coverage is available). Is it because Psychotherapy is seen as the more expensive option as opposed to just prescribing a pill?

You know, I don't know the details as well as I should, but in systems where they accept medicare/medicaid, there's definitely a push for psychotherapy to be done by the cheapest provider, which is not an MD or DO. Even within these systems where psychotherapy is done by these less expensive providers, there's a push for group psychotherapy (not knocking it, but it's cheaper) and for short term psychotherapy, which yeah probably comes from a desire to pay less.

I would say, culturally, yes, there's a notion that psychotherapy is frivolous and expensive in the US. We also have this push to "work at the top of our licenses" or whatever, which sometimes means there's a push for us not to talk to patients because that's not the "top of our license."

 

[F0nzie]

I typically recommend therapy when I start treatment with medications. I may offer to provide psychodynamic, CBT, supportive, or a combination of these therapies. Whether I do or I don't I always give outside therapy referrals. I essentially leave it up to the patient to choose between combined or split treatment.

Realistically, not every patient will be comfortable with the dynamic. And while there may be something to be gained by addressing transferential issues, there may be greater losses by delaying treatment. The best patients for this are highly motivated, well off financially and socially. They are also ready and or able to overcome their fears and accept their biases.

The ability to offer therapy is highly rewarding. I feel very fortunate to be be in a position where I can offer both. And while it has been frustrating not being able to offer therapy in other settings, I have learned to appreciate that med encounters and brief therapy session can still significantly help the patient.

 

[Ceke2002]

You know, I don't know the details as well as I should, but in systems where they accept medicare/medicaid, there's definitely a push for psychotherapy to be done by the cheapest provider, which is not an MD or DO. Even within these systems where psychotherapy is done by these less expensive providers, there's a push for group psychotherapy (not knocking it, but it's cheaper) and for short term psychotherapy, which yeah probably comes from a desire to pay less.

I would say, culturally, yes, there's a notion that psychotherapy is frivolous and expensive in the US. We also have this push to "work at the top of our licenses" or whatever, which sometimes means there's a push for us not to talk to patients because that's not the "top of our license."

Rhetorical question, but how is not talking to patients working at the top of a Psychiatrist's license? I mean look at the sheer depth of work you can do with different psychotherapeutic modalities, how does that compare with spending 15 minutes doing a medication check and then just writing out another prescription. I know there can be more to med management than that, but when you compare that model to the idea of facilitating a patient's journey into their own psyche to affect lasting change it boggles the mind how there could be this attitude of not working at the top of your profession if you're not sticking to a strictly medical and medication driven model of treatment.

 

[sunlioness]

My understanding is that people in private practice in my city doing medication management + psychotherapy do fine, so you can make money doing it. Whether it's less money than you'd make doing something else when you account for lost benefits of employment isn't clear, but they don't seem to be broke. However, I'm not aware of any employers aside from maybe an academic job where they'll pay you to do this. So that's super cool that there's actually a big system with that model.

They're still recruiting if anyone is looking to live in the greater Philly area.

 

[nitemagi]

Thank you for the reply (and thanks to everyone else as well). Nitemagi, the reason I am singling you out is because I have seen some posts by you come up as I've done some digging and research on these forums. Correct me if I'm wrong but you perform a large amount of psychotherapy, right? What type of setting are you in that allows you to do this? Is it the one I mentioned in my first post: cash only, private practices?

In any case, it seems a bit unfortunate that the cash only private practice setting might be the only true setting where a combination of psychotherapy and using/managing medication is allowed and permitted. I hope I'm not too off base but it seems to me that these settings are for the more affluent in our society. Would you consider that a true statement?
...
I guess to put things in a simpler and slightly different way, in my mind the psychiatrist could potentially be "the full package (or jack of all trades)" (with regards to their knowledge), as opposed to the other mental health professionals. Is this true?

Sorry to get a tad philosophical (though that's another reason psychiatry and mental health in general is so enticing...you folks are tackling a very large amount of philosophical problems)

Yes, I'd say my practice is about 70% therapy, by choice. It's cash pay, private practice. I've purposely pursued building a practice like this, because IMHO I consider it a higher level of practice to be able to offer both meds and multiple forms of therapy. It gives patients more choices, and allows to be able to address many issues and not deal with the many problems of split care. But I'll also consult on patients for other therapists, offering options of meds, hypnosis, etc., almost like an intervention, in collaboration with a therapist. Back in the day (prior to my time) insurance paid for psychiatrists to do therapy. That was the standard of practice. Others don't do it now not because insurance doesn't pay, but it doesn't pay equivalent to using the time for multiple med visits. Cash pay allows the full freedom of a small business.

I used to work with the homeless doing street medicine work, and would incorporate therapy with them as well as meds. That was possible because the severity of the population meant "standard" med mgmt might not cut it, and the program was designed with some time flexibility.

I'll use anything -- meds, psychodynamic, brief strategic, gestalt, CBT, DBT, family therapy, mentalization, hypnosis, whatever -- if it'll help someone.

I don't think the power dynamics are any different with meds vs therapy vs both. People will project onto you regardless. The difference is what you do with it. There's plenty of articles out there on psychodynamic psychopharmacology that are good reads.

Again, I wouldn't say cash pay is the only place to do therapy as a psychiatrist, but it offers the most freedom and flexibility in practice. The more autonomy you're given, the more you can practice the way you want to practice. Taking insurance means others dictate some parameters to your practice, which is fine, too. I've had some nightmare experiences with insurance so have chosen to not do that anymore.

 

[Ceke2002]

I don't think the power dynamics are any different with meds vs therapy vs both. People will project onto you regardless. The difference is what you do with it. There's plenty of articles out there on psychodynamic psychopharmacology that are good reads.

I think the trouble is sometimes it can be easy for patients to confuse 'power dynamics' and necessary 'power differentials', within the necessary construct of the therapeutic relationship, with the Psychiatrist 'lording' power over them.

 

[slappy]

I must be seeing a pretty biased population. I know of many psychiatrists who do mainly weekly psychotherapy and accept insurance. It becomes cash/insurance when the number of sessions need to be increased to >1 per week. I shall find out more details about how they manage their reimbursements with such a model. I also know a lot of cash-only psychiatrists who make a killing.

 

[birchswing]

I must be seeing a pretty biased population. I know of many psychiatrists who do mainly weekly psychotherapy and accept insurance. It becomes cash/insurance when the number of sessions need to be increased to >1 per week. I shall find out more details about how they manage their reimbursements with such a model. I also know a lot of cash-only psychiatrists who make a killing.

If they're getting paid by insurance for strictly psychotherapy, I see no reason why they would be paid differently from psychologist for the same services, which makes me think they would be making less than other psychiatrists. I've never heard of such an arrangement before. The market is flooded with people legally allowed to provide therapy, but is very limited with people trained to and allowed to provide psychiatric medicine. It seems like an odd allocution of resources for a psychiatrist to primarily do therapy. Although, I've always thought a judicious psychiatrist would be one just as likely to make an informed opinion against using medicine as to medicate. And I guess that could result in therapy rather than referral for therapy. It doesn't sound bad except for the current lack of accessibility to psychiatrists for medication related issues. On the other hand, maybe the less prescribing and the more therapy there is, the less medication related issues there are that a person needs to be seen for.

 

[smalltownpsych]

Rhetorical question, but how is not talking to patients working at the top of a Psychiatrist's license? I mean look at the sheer depth of work you can do with different psychotherapeutic modalities, how does that compare with spending 15 minutes doing a medication check and then just writing out another prescription. I know there can be more to med management than that, but when you compare that model to the idea of facilitating a patient's journey into their own psyche to affect lasting change it boggles the mind how there could be this attitude of not working at the top of your profession if you're not sticking to a strictly medical and medication driven model of treatment.

At our hospital administration does not want the psychiatric NP doing therapy and didn't want the psychiatrists who was here doing it either. It comes down to a numbers game for them. It is more profitable to have the 15 minute med checks than the 8 psychotherapy sessions a day. They mainly keep us psychologists around becuase they can't find psychiatrists to work out here and the medical docs don't want to deal with our patients. Most of them actually wish we could prescribe medications too. It creates some interesting dynamics when you don't have good pharmacological mental health treatment options.

 

[HarryMTieboutMD]

To preface, I'm looking at psychiatry as a possible career change. I greatly appreciate the fact that they largely take into account the bio/neuro aspect of the human being while also wielding the ability to conduct psychotherapy. Having said that, after doing some research about the current state of psychiatry, it seems to be the case (generally speaking), that psychiatrists are more or less on the medication side while MSWs, PhD Psychs, etc, do the counseling. This fact concerns me. Now, before going further, if my generalization is absolutely wrong, please correct me.

Regardless, psychiatrists still get training in psychotherapy during residency and can continue to learn more afterwards. My question is this: just where is it that psychiatrists are doing, or able to do, a fair amount of psychotherapy? The only answer I keep coming up with is in cash only, private practice settings, where insurance isn't the boss of the psychiatrist. Are there any other settings? Again, back to my first paragraph, my current view of the psychiatrist is one who is more or less strictly on the medical model side, while others are handling the in depth counseling.

Thanks

Why would being a physician with a medicine heavy background work against being a good therapist? Sure, that might take time away for a while from honing psychotherapy skills, but those can be gained over time. I'm just curious about this statement.

They are not by any means mutually exclusive, but as someone mentioned, the thinking paradigm is different. As a physician, I want to maintain the skillset of being a diagnostician through observation, inference, and deduction grounded in years of basic science education and to be able to apply that to psychiatry and similarly use the best available evidence and understanding of neuroscience to guide treatment strategies. People like to dismiss the medical model of psychiatry for a lot of reasons, but its [American] creators (Guze/Robbins/Winkour+Robert Spitzer and the RDC) were incredibly well read in other fields of mainstream medicine and tried to cast their model in the direction medicine was going. In an ideal world, we would have a mechanistic idea of why each psychotherapy works in the way it does and to what clinical problem it should be applied. Then I would be able to refer the patient to a particular therapist rather than doing the therapy itself. (Akin to a stroke neurologist referring an aphasic to a speech/language pathologist or ortho/sports med/PM&R referring a patient to PT).

 

[Ceke2002]

At our hospital administration does not want the psychiatric NP doing therapy and didn't want the psychiatrists who was here doing it either. It comes down to a numbers game for them. It is more profitable to have the 15 minute med checks than the 8 psychotherapy sessions a day. They mainly keep us psychologists around becuase they can't find psychiatrists to work out here and the medical docs don't want to deal with our patients. Most of them actually wish we could prescribe medications too. It creates some interesting dynamics when you don't have good pharmacological mental health treatment options.

Sounds like the system is set up to benefit profits and not patients. We do have a similar problem here in the CMH system, which unfortunately looks set to get worse since our current Government has seen fit to slash funding to healthcare and mental health programs have suffered in the process. Obviously the community mental health systems here are Government run and funded, and it seems they've managed to get round the issue of needing to keep the Government coffers all nice and filled by restricting funding to CMHCs (which tends to raise the ire of sections of the voting public) by now making it all about 'patient outcomes'. So sure within the CMH system a Psychiatrist can be doing a mix of emergency assessments, medication management, and Psychotherapy, whilst working in conjunction with a team of other providers such as Psych NPs, Social Workers, Psychologists, etc - but unless a patient has a severe enough pathology to almost be considered non functional without continued care, then bugger the rest of us how dare we not have gotten better within 6 months, oh the nerve of us still receiving ongoing treatment, don't we know we're making their statistical patient outcomes look bad. I think I've mentioned before that's how I ended up moving to another clinic my Psychiatrist works at, one where I can be treated for as long as need be without the purse string holders breathing down his neck about 'proven' outcomes and numbers that look good on paper.

 

[nitemagi]

Let me add that those interested in therapy but with short time available with patients might consider looking into a variety of brief therapies. CBT is considered brief therapy, but there are a host of others.

 

[smalltownpsych]

Let me add that those interested in therapy but with short time available with patients might consider looking into a variety of brief therapies. CBT is considered brief therapy, but there are a host of others.

Although when we typically think of brief therapies, aren't we usually thinking about reduced number of sessions as opposed to reduced session length? Nevertheless, I do ascribe to the belief that psychotherapy begins from the moment that they walk in the door and that a well-trained psychiatrist needs to have the understanding that all of the interactions are meaningful and have potential to either help or hinder the therapeutic process.

 

[kaige333]

For those who are able to practice a good amount of psychotherapy while also being the psychiatrist yourself, would you mind sharing a bit on how you were able to land yourself in today's position? Or what you think has been the most instrumental or helpful in your development?

I would also be very interested in hearing from Sunlioness and learn more about the kind of organization quoted below. You mentioned a practice like this is very rare now, would you have any specific recommendations on what can a med student (2nd year in my case) or a resident do to best prepare or make himself qualified for/appealing to a position like this? For example, if this were an academic or affiliated institution, would being a md/phd help? Thanks a lot!

The place I work now has a psychotherapy practice where psychiatrists do both the therapy and med management. And it's affiliated with a multi specialty hospital based organization that accepts insurance. But that's RARE. Exceedingly rare. And they know it, which makes them very proud of it. It's really successful. Docs like it. Patients like it. They seem to make money at it. I hope it sticks around. Eventually I'll do a day or two a week there. The credentialing for it takes a bit longer. I'm still waiting on that. And I need to brush up on my skills.

I think you get out of residency psychotherapy training what you put into it. You can start the path to becoming a competent therapist if you set out with that as your goal. You can also skate through that part and get your boxes checked off if it's not your thing. I think most pursue some sort of middle ground. At least I think that's what I did. If I am going to be doing it more, I need to brush up and do some continuing Ed stuff, perhaps get some supervision at first.

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