tag:blogger.com,1999:blog-7772182113499451603.post5393117397059651281..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: Whatever Happened to IPT?George Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-7772182113499451603.post-29470329633181440372017-09-28T22:37:12.651-05:002017-09-28T22:37:12.651-05:00Very glad to hear about your training program as w...Very glad to hear about your training program as well.<br /><br />Psychiatric practices vary considerably from practice to practice. In Minnesota for example we have had decades of maximum market control by 3 large MCOs. We are also seeing an increase in private practices and small groups who are practicing in a very eclectic manner. If you check out their web sites they are very explicit that they offer a lot more than medications including psychotherapy.<br /><br />I know a lot of these psychiatrists and they also have total control over patient selection and payer source in their practices. They are not bound bound to a productivity model that is based on maximizing prescribing over the entire population. <br /><br />In those same MCOs, if you explicitly request psychotherapy - you will see a therapist on the average for 2 or 3 sessions. In other words, psychotherapy access is as controlled as "medication management" by business managers. Nobody in an MCO setting gets the recommended course of IPT or CBT based on clinical trials. They get the business modified version.<br /><br />I can tell you that patients prefer seeing a psychiatrist who talks to them rather than being poised over a prescription pad or EHR. I base that on people coming up to me who I saw 10-20 years ago and asking me: "Do you remember that conversation where you said.....?" Far fewer people say the same thing about medications - even when you clearly have come up with (by all measures) a brilliant psychopharmacology treatment plan. Understandable human communication has more meaning to the average person.<br /><br />An overlooked aspect is being able to organize your thinking about the formulation. Have you covered all possible etiologies of the patients problems? Do they agree with what you are saying? The atheoretical DSM based approach generally falls flat on the formulation side, especially when it is clear that medication effects are weak.<br /><br />The actual time delivering the therapy is not a limiting factor. I have lost count of the number of times people have told me about their usual "sounding board" therapy. They end up going to a weekly session and reciting what happened the previous week. The therapist provided minimal feedback or rote homework assignments. <br /><br />If you know what you are doing - you can do more in 10-15 minutes that years of sounding board therapy. <br /><br />My final observation is the people who can't take any medications. There are many of them and even more who have varying levels of partial response. If they are seeing you as a psychiatrist - they are fairly ill - possible disabled. Do you think that you are going to find a therapist to refer them to?<br /><br />I worked with a psychiatrist who in my estimation is legendary. He ran a very busy clozapine clinic when it first came out. He had outstanding communication skills and would typically see people in 20 minutes or if things got complicated 30 minutes. He eventually moved on to a different state. 15 years after that clinic shut down people approached me to ask if I had heard about him and how he was doing. That is not how people describe their psychiatrists to me who only prescribe medications and get through the appointment in 5 or 10 minutes.<br /><br />I would not be frustrated by people dictating how you are supposed to practice. Learn how to treat people with all of the available tools and the future of psychiatry for you is bright. George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-90103198613010248112017-09-28T21:10:03.050-05:002017-09-28T21:10:03.050-05:00In my residency program IPT and many other modalit...In my residency program IPT and many other modalities are taught as well. There are lots of opportunities in academic settings as a trainee. It is just that when you go into practice, it doesn't seem like most psychiatrists are doing psychotherapy. I suppose that that they may be doing it in a subtle, unspoken way, or it may be permeating from their approach subconsciously, I don't know. But then that begs the question, what is the effectiveness of these therapies when they are given in a sparse, diluted version? As opposed to the manualized forms where the evidence base comes from? Having a psychotherapy informed practice is one thing, but what about the actual practice of psychotherapy proper? I still haven't figured out the future of that is in the psychiatric profession..victormtanghttps://www.blogger.com/profile/07733973610708973273noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-41474149673258538792017-09-27T21:55:52.801-05:002017-09-27T21:55:52.801-05:00It is great to hear that it is being taught in som...It is great to hear that it is being taught in some residency programs. I think that all psychiatrists need to work on different paradigms of talking to patients in a therapeutic way in residency and throughout their careers. Picking this up on your own possible after getting the basic interviewing skills and psychotherapy skills down.<br /><br />To cite a couple of brief examples:<br /><br />1. One of the first books I read in internship was Yalom's Existential Psychotherapy. Those concepts stayed with me through my career and I could pull them up as a framework whenever existential conflicts seemed to be the most significant problem. That included crisis situations consulting in the hospital and in the ED.<br /><br />2. I was interested very early in the psychotherapy of schizophrenia and other severe problems and read books by Arieti, Grinker, and Kernberg in addition to books on basic supportive psychotherapy. I started doing that on an inpatient basis with a cross section of inpatients in acute care settings. I found it to be extremely useful even in patients where most people thought that pharmacotherapy was the only approach. As time went on I found books being published on same type of psychotherapy that I had been doing for 20 years. Now the psychotherapy of severe disorders is an accepted form of therapy.<br /><br />This is what I mean by an intellectual approach to psychotherapy. It takes a lot of reading and a lot of study but it allows you to communicate in a relevant manner with people who have a much wider range of problems. It also enhances your thinking on mental models of these disorders - your diagnostic formulations improve tremendously. George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-77557650460196197012017-09-27T21:41:11.892-05:002017-09-27T21:41:11.892-05:00Another good example of the government and managed...Another good example of the government and managed care companies putting psychotherapy out of business.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-59891155883937782602017-09-27T20:02:33.994-05:002017-09-27T20:02:33.994-05:00We are still taught it during our third year, but ...We are still taught it during our third year, but that may be location specific. Do you think this is something that 1st and 2nd year residents ought to try and pick up on their own for inpatient use? (If picking it up on your own is even possible?)Simonhttps://www.blogger.com/profile/00479654709456729629noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-27853983177865520672017-09-27T16:31:23.977-05:002017-09-27T16:31:23.977-05:00The short answer is there was not enough money in ...The short answer is there was not enough money in it.James O'Brien, M.D.https://www.blogger.com/profile/14994350319492582321noreply@blogger.com