Saturday, March 28, 2015

Weekly Whine: Psychiatrists

I'm writing this from the perspective of somebody who has a close family member who is a psychiatrist, and is great at his job. However, I have to say, pretty much every psychiatrist that I have worked with has been terrible at psychotherapy.

I am not ashamed to admit that I have seen therapists intermittently in the past. I believe the talk therapy can be really helpful during stressful periods, or when making important life decisions. My understanding is that therapists can be either psychiatrists, psychologists, or social workers.

The worst therapist I have ever seen by far was a psychiatrist. This woman had the worst interpersonal skills I have ever experienced, and had no business being a therapist, in my opinion. Maybe she was good at medication management, I don't know. But every time I spoke with her, I felt awkward and uncomfortable.

Since then, I've talked with some patients who saw psychiatrists for talk therapy, and they all had similar experiences. Sometimes they just went for a medication adjustment, and they were frustrated that they felt the psychiatrist didn't understand them.

It makes me think that psychiatrists don't get enough training in how to do psychotherapy, and most of their training is just focused on medications. Which means that they're about as qualified to give talk therapy as I am.


  1. I know one person who went into PM&R and they weren't very bright, had poor interpersonal skills and barely finished medical school. A friend's friend did PM&R and my friend thinks that person was mediocre also. Makes me wonder about the whole field and if they're all incompetent. The above is factually true but an absurd conclusion. No?

    Psychiatry residency has a standardized curriculum containing CBT and psychodynamic therapy. You start therapy training as a PGY2 and all of 3rd year is outpatient, a mix of therapy and med management with a lot of supervision. 4th year is mostly elective and those interested in therapy get more training. Many do therapy right after residency and some do additional therapy training and supervision.

    The reality is that insurance would rather reimburse an MSW or psychologist (for less $$) than a psychiatrist so psychiatrists who do a lot of therapy are often cash only and others don't keep up their therapy skills. Around here, therapy psychiatrists charge $200/session and have wait lists of months. If you prefer to see psychologists or social workers that's fine but it's ridiculous to conclude that you have as much training in therapy as a psychiatrist bc you saw one bad one.

    Do you know for sure that the patients you surveyed (after you made up your mind that shrinks suck at therapy--how unbiased…) had therapy visits versus 30 min med checks? Because clearly patients are never confused about which treatment they're getting…

    There are a lot of mediocre docs across all specialties and it's unprofessional for you to imply that one entire specialty is weak in a whole modality of treatment when your evidence is one bad experience.

    In case you're interested (you don't seem to be interested in actual evidence):

    -Psych resident

    1. Maybe the problem is that, as you said, the amount of training you get in psychotherapy is very variable, based on your amount of interest. It sounds like somebody who wants to be good therapist could probably take a lot of time and get good at it. But my concern is that there are probably plenty of psychiatrists who don't take that time.  I was lazy, and oversimplified my bad experiences in that post, which have been pretty universal.

      You probably don't need that training if you're just doing psychosis or treatment of dementia, but if you're just treating standard things like depression, even if it's just for a 30 minute medication check, I think somebody with real empathy and understanding is needed to treat it properly. Because you can't just look at numbers.

      Maybe the problem is that 30 minutes isn't long enough for what you have to do.

    2. I laughed at the first paragraph of Anonymous' response. Looks like Fizzy hit a nerve. Granted, the Anonymous Psych Resident gave a good reply. I admit that I fall into a similar line of thinking as Fizzy's post, but it's likely that the problem has less to do with training and more to do with the fact that psychiatrists aren't engaging in it as often due to the insurance companies. Which is really a shame... when I did my psychiatry rotation, at least, the attendings I worked with had the general view that for most people (those without major psychiatric illnesses), psychiatric medication should be a temporary band-aid of sorts while the person addresses their greater issues with various forms of therapy. Yet it often seems as if many people are chronically on psychiatric medications, foregoing therapy altogether. Granted, I don't have any data to support that statement; I'd hope that data would prove me wrong.

    3. I didn't realize before reading that comment that insurance didn't reimburse psychiatric psychotherapy. If that's the case, a better question then why are psychiatrists bad at psychotherapy is, why should they be good at it? Why waste training on something you won't be paid to do? And how could you get good at it if you never do it because insurance won't pay for it?

    4. Many plans reimburse psychotherapy but would rather pay for 45 min of SW or psychologist time versus a psychiatrist. Psychologists typically have significant therapy training but SWs often do not. As a psychiatrist you get paid a lot more for doing 3-4 med management visits in 1 hour than one psychotherapy or psychotherapy + med management.

      You can get good at it by doing therapy as an attending but capping the % of your visits that are psychotherapy versus meds and/or doing cash for therapy on a part time basis which is common. It's still important to be good at psychotherapy because it's a way of understanding what's going on with your patient since peoples' social situations and relationships play a role in perpetuating or protecting them from psychiatric illness. Also, if a patient needs/desires therapy as well as meds, having one provider do both can lead to less fragmented care.

  2. I'm a retired psychiatric and mental health nurse practitioner. I learned psychotherapy from psychiatrists, psychologists and NPs; some were good and others were abysmal. Each profession has a slightly different orientation to the patient and to treatment and each also tends to attract people with different personalities and character traits. All these differences are, of course, reflected in patient care.

    While I have the impression that in the US (I'm no longer in that country) there is increasing emphasis on short-term therapies and use of medications without talk therapy, I am not aware of any research showing that psychiatrists are worse at it then other psych/mh clinicians. There is literature, however, that shows that when patients think the therapy is not going well, the clinicians tend to agree. That leads me to believe that in the situations that you describe, Fizzy, the psychiatrist is probably as dissatisfied as the patient. There are a number of fixes for this, but in the present health care climate in the US, I'm not sure how practical they are.

    1. I wrote this post today very quickly, but I've been thinking about it a little more just now. I think what psychiatrists have to do is very very hard. When you see an internist, they take your blood pressure and they treat it.  Psychiatrists have to take more time to figure out what they're treating before they can even start think about how to treat it. That's a really difficult skill to master, maybe impossible for some people. I'm not sure I could do it with any amount of training.  And sadly, I think there are a lot of people who go into psychiatry for lifestyle (That was 100% true among my classmates) and not because of a passion for the field.  the same could be said for my field and many other fields, but I think it's easier to master knee pain than it is to master empathy.

      I think that's been my major frustration with the psychiatrists that I've worked with. They quickly assessed a situation and then treated it improperly because they didn't take the time to really understand it.  Or maybe they were incapable of understanding it.

      For that reason, it's probably really hard to be a good psychiatrist.  

  3. In the past I have used a psychologist to help me with the "talking it out" therapy. I've found that having a goody psychologist really helps me to understand the "why" of my anxieties and have really helped me with coping. When I am in a particularly difficult situation where the "talking" isn't enough to cut it, I'll supplement with a psychiatrist to help me with medications (how to wean/change doses, change medications). I found that a psychiatrist was very thorough with his medical management but very lacking in "talking" therapy. Going to him was very much like going to a PCP - evaluation of symptoms, and then appropriate medications to treat, and you're sent on your way home.

    That being said, not all psychologists are amazing, and not all psychiatrists are terrible. I think it's like with anything in life - if you're not happy with what you're paying for, try to go elsewhere. I've recently moved and am looking for a new therapist and so far I've had some terrible experiences and some mediocre ones.. still looking for my unicorn therapist. It's not my fault or their fault, we just don't mesh - what they are offering and what I'm looking for don't equate to therapeutic levels for me. The search continues!

    1. I am still searching (off and on) as well...for that "Unicorn"......My problem is, it's hard once I have had the "Gold Standard"...twice!

  4. Not sure why you expected therapy from your psychiatrist when it sounds you you saw them for Med management and had a separate therapist. I don't complain that my FP doesn't do my Pap smears Bc he knows I see a gyn

    1. For me, it was an hour-long session and I did not have a separate therapist at the time. It was supposed to be talk therapy. As it turns out, that's very rare.

  5. I have no doubt that there are bad therapists, bad fits etc. I find it absurd that you took your personal experience plus a few anecdotes to mean that psychiatrists don't learn therapy and decided to write a post about it. In fact they do for several years during residency and often after.

    I've seen two therapists a psychiatrist and psychologist. I liked the psychiatrist better but know not to extrapolate to all psychologists or all patients. I also think the psychologist would have been fine for someone else but a poor fit for me.

    I don't dispute your personal experience but find your conclusion and this post irresponsible and unprofessional. I normally really like this blog.
    Psych resident

    1. I have to respectfully disagree with a few of your assertions.

      First, I didn't make any sweeping conclusions about psychiatry. What I said was "pretty much every psychiatrist that I have worked with has been terrible at psychotherapy."  I think that talks very specifically to my own experience. And I was hypothesizing why that might be.  I think that it was pretty clear that I was talking from experience, and just hypothesizing. I don't see where I concluded that every psychiatrist was bad at therapy.

      I don't think it's "professionally irresponsible" to talk about my own experiences, partially as a patient. I'm not professionally calling out specific doctors, or shunning the entire field under my professional name in a major publication. I'm anonymous blogger and I'm talking about an experience I had on my own personal journal.  I think it's my right to do so.

      Finally, I think your post made it clear why many of the psychiatrists may not be as good at psychotherapy. If insurance doesn't pay for it, why should you waste your precious training time learning a skill you're never going to use?  I wouldn't blame you.

  6. My respect for you went up. You talked over things with someone who could give you a different perspective so you could go on helping people. Medicine is an extremely tough life, job. I totally despise the ruining of people in medicine because of the culture to not seek help before it goes to drugs and alcohol. One of the reasons I lose respect for medicine as a profession is that it does not have a culture of support amongst its own. If you aren't going to help your own talk over problems, mistakes, etc. how do you learn and support others, grow? If this is supposed to be a "caring" profession, what does it say when people have to hide talking over things? I'm proud of you for saying you talked to people because it shows you care about you, your family/friends, and your patients to get help.

    PS You are not the only person on this planet, with all due respect to the psych residents and the like, who basically understands psychologists are talkers and psychiatrists are for meds a bit more complex. I also wish that more doctors had to actually spend some time in the shoes of their patients, so they understand something other than medicine. When it is your whole life, you won't be able to relate to people.

    And I believe in mandatory time off spent with family/friends doing other medicine things, that I think if you work for/have privs at a hospital, this is required.

  7. I think I may have an interesting take on this. I am a social worker and suffer from a mental illness. While well, I have worked as a mental health counselor. I received my MSW from a school that has a rep for being very "clinically" focused, I think most of the training is fieldwork, experience, supervision, supervision supervision....
    I only worked as a counselor for a short period of time because of I recognize I am not well enough to be a clinician. I have worked in peer operated programs.
    Between my own illness and my work, I know most of the psychiatrists in the area. By being a patient of them, working with them, and/or by reputation. I would say that the shortage of psychiatrists have truly allowed some doctors crazier than me to practice. However, when considering everything...
    It is still a crap shoot. I think each profession: social work, psychology, psychiatry, mental health nursing, occupational therapy... Every profession has a different take on mental health interventions.
    I think if one has the basics of talk therapy any professional can be effective. The single most helpful factor is being able to connect with people. Being a nice person. The other important factor is using evidence based practice. And the willingness to continue to educate yourself on it. And the intelligence to know what talk therapy is effective for which situation.
    Psychiatrists are really important in acute psychiatric emergencies. Severe psychotic symptoms are not going to be talked away.


    Despite my own issues, and the fact that I felt like a fraud, I was told I was a good counselor.

    1. A mental health professional who is honest with herself, and doesn't hide behind an air of invincibility says it all. I commend you. As for feeling inadequate, "like a fraud", I think folks who are striving to be better tend to see their weaknesses rather than their strengths. That's a good thing. I'd bet dollars to donuts that you're not a good counselor, but in fact a great counselor! We need more people like you.
      - Paul

  8. The best therapist I ever saw was a Psychiatrist. It has been over ten years since we moved away and I still miss him desperately. The second best therapist I saw was a fourth year Psychiatric Resident who had been an MSW before going to Med school...he was also amazing and I miss Him sooo much too.

    The v e r y worst therapist I ever saw was a female Psychologist. After Her, I swore I would never go to a female again. Not fair, I know, but still, that's how much she hurt me.

    Tracy, sans any therapist now

  9. Here is an article, written by a psychiatrist, discussing the modern-day trent toward medicalizing all manner of things from bad behaviour, bad decisions, poor coping skills and general bad life situations. Calling it a "disease" doesn't absolve responsibility, nor does it solve the problem. Maybe the reason some psychiatrists are "bad" at therapy is that the person doesn't actually have a mental/psychiatric "illness", but rather a bad life situation, poor coping skills, absent social network, etc. I'm a PCP, and I have had a lot of patients labelled as "depressed" who were just having a normal human reaction to pretty awful life circumstances.

  10. I don't think that is universally true.

    Maybe it just has something to do with the training program in your area.

  11. Fizzy, you should check this out-

    What’s the difference between a psychiatrist and a psychologist?

    Oh, about $80,000 per year.

  12. I have been seeing a psychiatrist for my medications for years now, but I see a "therapist" when I need to talk out my issues. I am very grateful for the distinction. For years prior, I saw a variety of unhelpful therapists that tried to help my brain chemistry issue with talking. It was not very helpful