Psychiatrist thoughts on therapists?

[SmallBird]

Pretty complex question isn't it? Still trying to wrap my head around it all.

I faintly recall a thread posted many years back where a psychologist argued that masters therapists tend to be more skilled at therapy simply because they tend to focus on it specifically. I definitely see the importance of having the ability to evaluate research though. And as others have said supervision seems key and would no doubt be better on the psychology side. But I wonder if a LCSW who was proactive about paying for good supervision even after they were fully licensed would make up for that lack of research experience?

Would it be totally ridiculous to get certified as a LCSW then do a research based masters in psychology on the side afterwards? So one would have that exposure to academia? I've seen folks who were licensed as both LCSWs and PsyDs for some reason. Always wondered what the logic behind that was

I hesitate to accuse any of your statements as 'ridiculous' when this thread includes detailed rants about fax machines, but I would say that it is hugely excessive to obtain a masters degree in order to be a consumer of behavioral health research. If as a masters level therapist you commit to reading several papers a year that provide high level, integrated presentations of the most salient new findings that are relevant to practice you will be stellar and shouldn't need much in the way of statistics/research exposure to do that.

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[allantois]

I hesitate to accuse any of your statements as 'ridiculous' when this thread includes detailed rants about fax machines, but I would say that it is hugely excessive to obtain a masters degree in order to be a consumer of behavioral health research. If as a masters level therapist you commit to reading several papers a year that provide high level, integrated presentations of the most salient new findings that are relevant to practice you will be stellar and shouldn't need much in the way of statistics/research exposure to do that.

You know I think one can be a good consumer of research just with a Bachelors degree as I think most of us learned research basics in undergrad. You have to remember, however, than most masters level therapists do not enter their programs with science backgrounds and in my understanding are not taught research skills so I highly question how effectively they could disseminate research especially given the lack of need to do so to conduct therapy. I would imagine the main advantages of pursing a psychology PhD would be to gain expertise on diagnosis as well as neuro behavioral side more so than the therapy side.

 

[allantois]

Most therapists I've seen don't have a fax. This really pisses me off. Why? Cause I can't send the person records nor will the therapist provide me with records when asked. Some therapists asked me to e-mail records despite that this is a HIPAA violation. I tell the therapist, "hey man get with the 1970s. Faxes aren't new, e-mailing patient records is illegal unless its a HIPAA secure e-mail, and you can get an online office fax program for cheap."

Unfortunately from my experience about 90% of the therapists in my city don't have a fax. (Off on a tangent over 80% of the time my patient or I request records from another medical institution we're told on the phone they'll send it to us and they don't send it to us).

Most don't listen to me.

The few therapists that do have a fax have been great. We send each other our records and we're better on top of understanding each other. IMHO and I don't think this is being selfish, the need for continuity of care should make having a fax just like being available by phone the standard of care. Faxes should be part of a minimum just like having to write a frakking note is part of a minimum requirement.

Aside from this therapists run the gamut. There's so many different types of psychotherapy. So the first thing is the patient should have the right therapist for their pathology. Like a good psychiatrist, IMHO a good therapist will within 3 visits identify the core and priority problems and state upfront if they can handle it. I've seen some patients see a therapist for literally months even years and not get better. Same with psychiatrists. When the patient asks why they're not better they're told some Freudian/Confucian mumbo jumbo "what is better? How do you really know you really exist" bull$hit, or the patient doesn't know the provider is full of it cause they don't know what is good care vs bad care.

I tell my patients upfront if 1-the other therapist isn't communicating with me. Several don't call me back or provide records. EFF them. I'm not going to defend this lack of continuity of care or defend these people. I'm not going to histrionically exaggerate it either. I just tell the patient upfront in a matter-of-fact manner I tried to communicate with them, show my attempts (e.g. faxes, phone calls) and that they didn't respond and I will give up after 3 attempts, and it's up to the patient to either accept this, demand better from their therapist, or get a new one. I'm not the therapist's boss. 2-Tell my patients they deserve to know what the therapist thinks about the patient's case and that the therapist should have at least 3 visits. 3-In the therapist's defense I tell the patient that psychotherapy can be subjective and it's possible for a therapist to objectively do what is considered a good professional job but for whatever reason the patient themselves might not be fair or doing their end. E.g. I've seen some patients not like a therapist because "he looks like my Dad. I hate my Dad," or "I don't want a therapist that's younger than me."


Now all this this said there's some great therapists out there. Just like psychiatrists there's bad ones out there too. Refer to the good ones and refer to the ones that specialize in what your patient needs.

You know unless therapists work as part of a larger behavioral health group/network, I find that they never send their records. Sometimes they will be nice enough to send a clinical summary. Sometimes I’ve seen them write some really unprofessional/questionable stuff about the medication side of things (patient doesn’t feel heard by their psychiatrist or reports that medication isn’t working) yet no attempt was made to notify the prescriber of this issue. Imagine I was writing in my notes about all the patients who complain to me about their psychotherapists? I have to remind myself that therapists did not go through medical training and I am lead to believe that they may be unaware of their duty to even release the records that are requested as that is standard medical communication which they may be completely oblivious to from their training.

Btw you can get an online fax number completely free

 

[TexasPhysician]

You know unless therapists work as part of a larger behavioral health group/network, I find that they never send their records. Sometimes they will be nice enough to send a clinical summary. Sometimes I’ve seen them write some really unprofessional/questionable stuff about the medication side of things (patient doesn’t feel heard by their psychiatrist or reports that medication isn’t working) yet no attempt was made to notify the prescriber of this issue. Imagine I was writing in my notes about all the patients who complain to me about their psychotherapists? I have to remind myself that therapists did not go through medical training and I am lead to believe that they may be unaware of their duty to even release the records that are requested as that is standard medical communication which they may be completely oblivious to from their training.

Btw you can get an online fax number completely free

I don’t want their records. I tell them if there is anything I should know, call me on my cell.

1. I don’t want to read documents designed for insurance reimbursement or chicken scratch for state guideline requirements.

2. Calls build rapport between clinicians.

3. I rarely get these calls, but when I do, the problem is legit.

4. Counselors will brag to others that they can reach their preferred psych by phone. I gain more referrals.

 

[whopper]

Btw you can get an online fax number completely free

Which is what makes this even more unacceptable and frustrating. As I said. "Get with the 1970s." Especially if the therapist is part of an organization with several therapists, there's a physical office, even a receptionist and STILL NO FAX?!?!

As TexasPhysician wrote, phone calls are even better but many also don't call me back. Even after I attempted to contact that person several times.

Again, I call it spade-for-spade, but not in a manner to escalate it, but to point out I'm doing my part in the continuity-of-care, and they aren't. E.g. "As of this writing I made 3 phone calls to the therapist at phone number xxx-xxx-xxxx and so far no answer back yet. I notified the patient I made attempts and that I usually give up after 3 tries."

IT's rare but on few occasions the patient got mad at me cause I didn't get the records. I got a rule. I diplomatically tell the patient it's not my fault they didn't send it to me if I made the attempts to contact the other entity. If the patient keeps it up (again it's rare and it's happened), and they really do something inappropriate I terminate the patient. (Rare but it's happened. E.g. Screamed at my assistant calling her and my office "incompetent." Start scream at me. Tell me "that's unacceptable" with a very angry tone of voice and blaming me for all of this but not taking any of this anger at the other provider. (In that case an angry mother called my office over 15x in a day and not once called the lab. It was cause the patient, her son, was on Clozapine and demanded I prescribe it, and the kid never got the labs done, was repeatedly warned of the need to have the labs done, was referred to case management cause I knew the patient would be noncompliant, but they kept saying they got the labs done which they didn't. In reality the mother was trying to bully me not knowing the regulations despite that I already told them this was over my head. I also told them if they didn't get the labs done they needed to go to an ER ASAP. That was the day I said to myself if this ever happens again I'm drawing the line at 3 attempts). This type of thing is rare but it's not 1 in a million. It's more like 1%. So it does happen every few weeks to every few months.

This is IMHO not a legitimate defense but could be used in court. Remember standard of care is usually geographic based. If pretty much almost every therapist isn't using a fax, and there's a bad outcome in the lines of communication the therapist could argue that they were still within the standard of care.

Lame? Yes but legally can be used. I'm sure there's some localities where the frequency of therapists using fax is higher than mine but in St. Louis, from my experience it's about 90% that don't have a fax.

I used to tell students and residents, "I'm the guy that wants to teach you what's not in the textbooks or lectures." This phenomenon of almost no one sending records when requested (not just therapists) is very common in the areas I worked-NJ, OH, KY, MO, PA.

Therapists aren't alone in this phenomenon. I get inpatient records from the patient's hospitalization less than 5% of the time and every patient I've seen who was recently discharged told me they specifically told the hospital to send me the records and all alleged the hospital told them it would be sent out. Again this has been a phenomenon in every place I've worked.

 

[tr]

You know I think one can be a good consumer of research just with a Bachelors degree as I think most of us learned research basics in undergrad. You have to remember, however, than most masters level therapists do not enter their programs with science backgrounds and in my understanding are not taught research skills so I highly question how effectively they could disseminate research especially given the lack of need to do so to conduct therapy. I would imagine the main advantages of pursing a psychology PhD would be to gain expertise on diagnosis as well as neuro behavioral side more so than the therapy side.

I work with trainees at a variety of levels (med students, psychology PhD students, residents, fellows, and psychology postdocs) and honestly my impression is that the clever ones are good at interpreting research papers and the slower ones are bad at it, regardless of training level.

I have a pair of papers (a poorly designed one and a well designed one that ask the same question and reach opposite conclusions) that I routinely assign for the purposes of illustrating how the analytical approach affects the results obtained.

Clever students, even very early in training, will identify the good paper and draw the correct conclusion quickly. Duller ones, even if highly trained, will struggle. They either take the authors' claims at face value and have no idea how to distinguish between the two papers, or get totally bogged down in unrelated details.

Even after I go through the whole thing with them, I'm not sure the ones who didn't get it on their own would ever be able to generalize that critical thinking to a different set of papers.

 

[FlowRate]

I don’t want their records. I tell them if there is anything I should know, call me on my cell.

1. I don’t want to read documents designed for insurance reimbursement or chicken scratch for state guideline requirements.

2. Calls build rapport between clinicians.

3. I rarely get these calls, but when I do, the problem is legit.

4. Counselors will brag to others that they can reach their preferred psych by phone. I gain more referrals.

This. I've never once asked for a therapist's records when I could just have a 5-10 minute phone call that will more effectively summarize the therapist's clinical impression and allow us to build some rapport.

 

[clausewitz2]

This. I've never once asked for a therapist's records when I could just have a 5-10 minute phone call that will more effectively summarize the therapist's clinical impression and allow us to build some rapport.

Hell, or a secure email with a 1-2 paragraph answer of the question 'so what do you think is going on?'