I Want What I Want And Be Quick About It

I talked to the trainees about an article I found that describes the dismal state of psychotherapy training in psychiatric residencies [1]. But first, let’s have a look at something even more important–the look of my new/old office which I was supposed to be moving back into today-HA! Compare it to my temporary office and the old office before it was remodeled as part of accommodating the construction of the new children’s hospital.

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Did you spot the difference? That’s right; I no longer have a window. Nor do I have furniture–yet. As I wrote this I was in between offices so I had to camp in the Resident Lounge, staring at an ironically appropriate poster on the wall:

list of what world owes you

 

resident lounge easy chairs

The residents have easy chairs and a lamp; I don’t.

resident lounge water cooler with refills

The residents have a water cooler with refills; I don’t.

I also noticed that the Resident Lounge is…very nice compared to my offices. And what’s this taped to the fridge (the residents have a fridge; I don’t)?:

Matball resident win pic

2015 Residents Win First Annual Psychiatry Department Mat Ball Tournament…but when I win my 53rd annual Kalahari Olympic Special Mat Ball Super Gala Strenuous Event (Logo “We Roast the Host Who Sweats the Most from Coast to Coast”) against a host of martian opponents and my smack down lights up every galaxy in the universe, you will know what winning truly means, and then surely, Rameses, you will let the people go with their flocks and their herds and a calf, a calf of gold…

 

my officeAnd I still can’t get in my office. Anyway, getting back to the Kay and Myers article, which was published only a couple of years ago, I thought it represented one of the many mixed messages residents and medical students get about psychotherapy in general and about psychodynamic psychotherapy specifically. Very few psychiatrists are beating the drum in favor of it, but the authors here do an outstanding job. I agree with them.

On the other hand, trainees are getting far different messages from different quarters. Kay and Myers point out that, because actual psychiatrists working as psychotherapists are in short supply, we could take advanage of on line resources, like Psychotherapy
Training e-Resources (PTeR). Note the cost for an individual subscription is $389, which buys you CME credit. Also note the cost for institutional subscriptions, for which you can’t get CME. You don’t have to be a rocket scientist to figure out that the McMaster architects of this enterprise are probably much better businesssmen than the rest of us.

McMaster Online Psychotherapy resource pricing as of May 26 2016

screenshot taken May 26, 2016

 

Now go to the American Board of Psychiatry and Neurology (ABPN) website and looks for any psychotherapy Maintenance of Certification (MOC) approved products for credit. You won’t find any.

Don’t forget to read the section on the psychiatrist’s role in collaborative care (look to the right of the page to download the report Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model, by APA and APM.): “The most common reasons for psychiatric consultation in Collaborative Care are diagnostic clarification and psychopharmacologic recommendations.”

Settle down; I’m not bad-mouthing collaborative care, just pointing out that the arrangement involves curbside consultation without mention of expertise in psychotherapy–because that is not expected from us. And what are most psychiatrist headhunters (I mean recruiters) looking for? They’re trying to fill slots in very busy med-check clinics.

But Kay and Myers doggedly and eloquently cry out:

Although it is challenging to assess the impact of the ACA and parity initiatives, it will once again force educators to provide more with less: more administrative and leadership experiences and less time for broad-based learning during the residency. In light of the decreasing provision of psychotherapy by psychiatrists (Mojtabi & Olfson, 2008), it is imperative that the core clinical skills consolidated through psychotherapy not be jettisoned from residency training. After all, this is where trainees develop the capacity to tolerate ambiguity, develop humility, understand the intricacies of the doctor-patient relationship, work with strong patient and staff affect, and appreciate in a systematic fashion that the reason for maladaptive behavior is very often outside of patient awareness. If psychiatrists are to assume team leadership roles and psychotherapy will be provided increasingly by other mental health clinicians with the expected expansion of services under the ACA and parity legislation, psychiatrists must be able to teach and supervise the delivery of these treatments. One cannot teach what one does not know.

I want my office window back. I want a Mat Ball trophy that is totally free of strawberry jello. And I want psychotherapy training for my trainees. Is that too much to ask?

list of what world owes you

Reference:

1.Kay, J. and M. F. Myers (2014). “Current state of psychotherapy training: preparing for the future.” Psychodyn Psychiatry 42(3): 557-573.
This article provides an overview of what is currently being taught in psychiatry residency programs about psychotherapy in general, and to evolving changes in the field related to mental health parity and the Affordable Care Act (ACA) in particular. Future psychiatrists must have a firm grasp of not only the principles of psychotherapy but also the development of increasingly effective and evidence-based psychotherapies if they are to be effective health care leaders. We review what attracts medical students to psychiatry and how much their decision to train in psychiatry is rooted in a desire to learn both dynamic psychiatry and psychotherapy in its various modalities. It is no secret that the quality of teaching and learning psychotherapy is variable in our training programs. One reason for this can be attributed to trainees who ascribe more to the biological dimensions of our field and have less interest and commitment to more than basic skills in psychotherapy. In addition, in some settings there is a dearth of teachers trained in the various forms of psychotherapy who are committed to this pedagogical imperative. We conclude with several recommendations to residency training programs and to residents themselves regarding what we deem essential in both the curricular and clinical exposure to the challenges and shortcomings of the mental health parity and Affordable Care Act. Tomorrow’s psychiatrists have a fiduciary responsibility of advocating for their complex and chronically ill patients that must include providing psychotherapy.

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Comments

  1. Jim,

    I hope that you wouldn’t hesitate to bad mouth collabo-care.

    Psychotherapy training for residents is not that bad – at least if you believe this article by Weissman, et all in the old Arch Gen Psychiatry: https://www.ncbi.nlm.nih.gov/pubmed/16894069

    George

    Liked by 1 person

    • Thanks, George; posting the abstract from your reference:

      Weissman, M. M., et al. (2006). “NAtional survey of psychotherapy training in psychiatry, psychology, and social work.” Archives of General Psychiatry 63(8): 925-934.
      Context  Approximately 3% of the US population receives psychotherapy each year from psychiatrists, psychologists, or social workers. A modest number of psychotherapies are evidence-based therapy (EBT) in that they have been defined in manuals and found efficacious in at least 2 controlled clinical trials with random assignment that include a control condition of psychotherapy, placebo, pill, or other treatment and samples of sufficient power with well-characterized patients. Few practitioners use EBT.Objective  To determine the amount of EBT taught in accredited training programs in psychiatry, psychology (PhD and PsyD), and social work and to note whether the training was elective or required and presented as a didactic (coursework) or clinical supervision.Design, Setting, and Participants  A cross-sectional survey of a probability sample of all accredited training programs in psychiatry, psychology, and social work in the United States. Responders included training directors (or their designates) from 221 programs (73 in psychiatry, 63 in PhD clinical psychology, 21 in PsyD psychology, and 64 in master’s-level social work). The overall response rate was 73.7%.Main Outcome Measure  Requiring both a didactic and clinical supervision in an EBT.Results  Although programs offered electives in EBT and non-EBT, few required both a didactic and clinical supervision in EBT, and most required training was non-EBT. Psychiatry required coursework and clinical supervision in the largest percentage of EBT (28.1%). Cognitive behavioral therapy was the EBT most frequently offered and required as a didactic in all 3 disciplines. More than 90% of the psychiatry training programs were complying with the new cognitive behavior therapy requirement. The 2 disciplines with the largest number of students and emphasis on clinical training—professional clinical psychology (PsyD) and social work—had the largest percentage of programs (67.3% and 61.7%, respectively) not requiring a didactic and clinical supervision in any EBT.Conclusion  There is a considerable gap between research evidence for psychotherapy and clinical training. Until the training programs in the major disciplines providing psychotherapy increase training in EBT, the gap between research evidence and clinical practice will remain.

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  2. Donna Barker says:

    I totally agree with you! I want you to get your office back…I also agree about psychotherapy. I am one of weird psychiatrists who practice psychotherapy. Patients really, really like it and I like it as well. I worked for 16 years doing med checks and it sucked the life force out of me. No longer dislike my work. Thanks for beating the drums.

    Liked by 1 person

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