You’re 100% right pointing out that the way we offer mental health care in the US hamstrings the effectiveness of psychotherapy regardless of skill and effort.!

I’m a psych NP in private practice because I just can’t do the model of mainstream psychiatric care. Basically all the issues that you cite. I don’t think I’m above doing it or that it’s not worth doing. Most of my friends work in jobs like yours and when I went into training I thought I would do community. But I just can’t do it.

The biggest downside of this is that I can only help people with top-quality insurance plans or the ability to pay hundreds of dollars OOP per appointment. I can’t say I feel guilty because just going with the flow I’ve ended up being most known for treating people with childhood abuse, neglect, and sexual molestation.

But I do hate that some patients can’t always see me as much as they’d like during rough times because they can’t afford it. I will sometimes offer a sliding scale or very occasional pro bono session(s) but I don’t bring in enough revenue to do it on any consistent basis. It’s also a dangerous precedent to set with patients who are always testing boundaries, which also sucks because they’re often people who need care the most

IMO short infrequent appointments cripple the potential of psychotherapy. 45 min is actually pretty good in relative terms - most of my friends get 15-20 - but with infrequent follow-ups it’s like you start heating the pot for boiling again right when it’s totally cooled down from the heat.

I generally only see transformative progress from therapy for patients for patients I see on a weekly or at most consistent biweekly but it’s still helpful as a complement to meds. I do 25 min for med mgmt for pts without interest in therapy and 45 as default, though if I don’t have a patient afterwards I’ll usually go to an hour. I’d go longer but again it can be a slippery slope.

Tbh I don’t really believe therapy can be studied in the way drugs are and I personally consider RCTs pretty meaningless. Every modality has useful techniques to add to your skill set but it’s too variable. Manualized therapy can be done on one’s own with books or apps now. CBT was designed to perform well on the tests that we use to measure effectiveness and we basically have studied it as if it’s a drug or a surgical procedure.

When psychodynamic is studied it’s generally just as effective, but it barely is bc it’s been tossed aside as pseudoscience. Psychodynamic therapists also don’t have much interest in trying to prove statistically that it works as well as medication and psychoanalysts believe the idea of studying therapy through RCTs is laughable.

From that perspective approaching with fixed priors obscures the clarity of your observation and affects the patients’ own view of themselves. Specific therapeutic strategies are seen as potentially manipulative and stereotyped behavior we resort to when we don’t feel like we’re reaching a patient bc of our own anxiety. Patient coping techniques are considered an evasion (albeit useful and potentially crucial in the the short-medium term) from much deeper issues that could be resolved so that the techniques are no longer necessary to use on any regular basis.

This may sound cold but my general attitude is if a patient isn’t going to familiarize themselves with basic CBT principles by going through a workbook as a companion to therapy then they’re probably not a good candidate for therapy.

Though I do assign homework, which is a CBT technique lol - I don’t believe CBT isn’t worth learning or is useless or harmful, I just dislike that it tries to stamp out other modalities. We are in desperate shortage as a profession and I refuse to spend the valuable time my patients are devoting and my own effort reading from a book. But I know some of my friends are only allowed to use CBT and would literally be fired if they started practicing from a psychodynamic perspective.

I personally see a therapist twice weekly to help me deal with the difficulty of the job. I hear a lot of dark stuff. I went through a period where literally every family I saw I was like “I wonder if the parents are sexually or brutally physically abusing the kids” because it happens way more than I thought and well-off families are not at all immune. I have to remind myself that I don’t see a representative sample of the general population - people come to see me because they’ve been traumatized.

I feel like most of us are in an unhappy tug of war between the table scraps government and lousy insurance (and most insurance is lousy these days even for people working at places like Google and Goldman Sachs) think is sufficient to treat mental illness vs. the fact that only the well-off can receive anything like what psychotherapy was and is meant to be and while they deserve treatment there are more people and more acute cases in working class populations.

It’s a tough decision. Practice therapy the way it’s meant to work but only be able to see an already privileged strata of the population, or try to help the community shortage under a system that fights you at every step and doesn’t really care what happens to your patients. I wish mental health care access was not a two-tier system but I also worry that under a universal access system therapy would slowly die and all we’d have left is med mgmt.

I do not look down at people who work in community or hospital settings in the least. It’s not wrong to work these jobs. Medication management is far better than nothing.

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