Saturday, December 26, 2009

Alex and Me

Last night I finished reading Dr. Irene Pepperberg's book, Alex and Me. If you are curious about her work, check out The Alex Foundation. I was recently given the book by someone who knows I share my home with Toby, and African Grey parrot.

Pepperberg weaves her own life story with the research discoveries made during over 30 years of study with African Grey parrots. Through exhaustive and rigorous research Pepperberg demonstrated the amazing cognitive abilities of the African Grey. Among other things, she demonstrated that he possessed  more than 100 vocal labels for objects, actions, and colors; could identify some objects by what material they were made of; could count sets of objects up to six; developed his own "zero-like" concept; could infer connections between written numbers, object sets, and the vocalization of the number; and had the concept of phonemes which are the sounds that make up words.

A pretty impressive bird!

However, I was more struck by Pepperberg herself. Her personal story, as revealed by her book, is not an easy one. Her research has not always been popular or well received by peers. Funding for her work has not come easily. Despite the difficulties, she stuck with her passion and her science, opening up a window into the unseen world of nature.

I finished the book thinking of how often the unconventional, unorthodox, or different viewpoint is squashed by a society that values sameness. While we often give lip-service to diversity, we very rarely celebrate it or encourage it. I was left thinking about how much we lose when the chorus of the masses drown out a new voice asking us to see something in a different way.

I'm glad Dr. Pepperberg used her voice and opened up a new world of discovery for all of us. I hope we all find a way to learn by her example and find the courage to pursue our individual voices in a disciplined, organized, and thoughtful way.

Friday, December 25, 2009

Friday News Roundup

Grocery Chain's Decision to Drop Mental Health Coverage Raises Concerns

As I feared, the loopholes in the coming requirement for health insurance plans to offer parity for mental health treatment are starting to cause problems. One Wisconsin supermarket chain has cut the mental health portion of its health care benefit "because it will be too costly due to the passage of the federal mental health parity law." Shame on them!

Could Acetaminophen Ease Psychological Pain?

A team of researchers at the University of Kentucky uncovered evidence indicating that acetaminophen, the active ingredient in Tylenol, may blunt social pain. On a self-report measure of hurt feelings, participants taking the medicine reported lower levels of social pain than those who were not taking the medication. Watch out for side effects: too much acetaminophen can be toxic!

How Psychotherapy Works

Bruce Wampold, Ph.D. is the author of the recent book, "The Great Psychotherapy Debates." In that book he puts together empirical research on psychotherapy using rather sophisticated methods. He even places that research in an historical and anthropological context. In this article, he answers questions about how psychotherapy helps people. He notes the differences between different treatments in terms of benefit to patients are small if not negligible as long as the treatments are intended to be therapeutic, are delivered by competent therapists, have a cogent psychological rational, and contain therapeutic actions that lead to health and helpful changes in a patient's life.

Wednesday, December 23, 2009

What's in a Name?

There are so many different kinds of psychotherapists in the world practicing so many different kinds of psychotherapy. At one point in my post-doctoral fellowship the training director gave us a hand out with a non-exhaustive list of over 300 different kinds of therapy! We spent some time sorting through that list--what had we heard of? What have we tried? What do we think works? What do we think is little more than a modern snake oil?

Different kinds of psychotherapy would be an interesting discussion. I'll save that for a future blog post.

Today I thought it would be helpful to define the alphabet-soup bowl of terms one encounters when looking for a therapist. Ph.D.? MSW? LMHC? Psy.D.? M.D.? What are all these letters and what do they mean to you?

The importance of these letters depends a lot of what kind of question you are asking. If you are looking for someone with a specific kind of training, skill set, or viewpoint, these letters mean something. If you are looking for someone compassionate and can listen, the individual letters mean somewhat less.

Most terms (psychologist, psychiatrist, social worker, counselor) are terms that are set aside by the Commonwealth of Massachusetts to legally define a profession. To call oneself a psychiatrist, for example, one must have a medical degree. Likewise to call oneself a psychologist, one must have a doctoral degree in psychology. The Commonwealth (and every other state) does this to ensure public safety: these professions are regulated by law so that the public can be assured that they are going to a professional with a specific kind of training.

Here is a quick run down of the different kinds of professions that are licensed and regulated by the Commonwealth. Today's blog post is going to be on a basic level: in the coming weeks I'll write more detailed blog entries about the differences between how the different professions view people and their problems.


Psychologists are licensed in Massachusetts by the Board of Registration of Psychologists. According to statue, a psychologist is defined as the following:
Psychologists observe, describe, evaluate, interpret, and modify human behavior by the application of psychological principles, methods and procedures, in order to assess or change symptomatic, maladaptive or undesired behavior. Psychologists' work may focus on issues such as interpersonal relationships, work and life adjustment, personal effectiveness, and mental health. The practice of psychology includes, but is not limited to, psychological testing, assessment and evaluation of intelligence, personality, abilities, attitudes, motivation, interests and aptitudes; counseling, psychotherapy, hypnosis, biofeedback training and behavior therapy; diagnosis and treatment of mental and emotional disorder or disability, alcoholism and substance abuse, and the psychological aspects of physical illness or disability; psychoeducational evaluation, therapy, remediation, consultation, and supervision. Psychological services may be rendered to individuals, families, groups, and the public. Certification as Health Service Provider (HSP) is required in order to independently offer health services to the public or to supervise such services. Psychologists may also teach and do research (license not required), and consult to organizations. The title "psychologist" is protected by law and cannot be used unless the individual is licensed by the Board   
A psychologist must have a doctoral degree (Ph.D., Psy.D., Ed.D.) which normally involves 5 to 7 years of study beyond an undergraduate degree. During school, psychologists-in-training normally complete between 1,500 and 2,000+ clock hours of supervised psychotherapy experience. Prior to graduation psychologists-in-training are required to complete a minimum of a 1 years 2,000 clock hour internship. Prior to licensure, the Commonwealth requires an applicant to receive a passing score on two different examinations and have had a minimum of one full-time year of supervised experience.

Social Work

Social Workers are licensed in Massachusetts by the Board of Registration of Social Workers. According to statue, a social worker is defined as the following:
Social workers provide services to consumers as defined by the statutes and described in the regulations. Generally, social work professionals provide services to individuals, couples, families, groups, and communities directed towards specific goals. They may also assist or refer individuals or groups with difficult day-to-day problems, such as finding employment or locating sources of assistance. Social workers at an advanced level (LCSW, LICSW) may diagnose and treat emotional and mental disorders. Some social workers organize community groups to work on specific problems and help to create social policy and planning.
A social worker must have a masters degree (MSW, MSSA, etc.) which normally involves 18 months to two years of education beyond an undergraduate degree. During the course of training social work programs require a minimum of 900 hours of supervised clinical experience. A social worker may, but is not required, to have a doctoral degree (Ph.D., DSW, etc.). To be an Licensed Independent Clinical Social Worker (LICSW) the commonwealth requires an social-worker-in-training to have at least 3,500 hours of post-masters social work experience under the supervision of a social worker and pass an exam. In order to be a Licensed Clinical Social Worker (LCSW) one is not required to have any documented post-masters experience and pass an exam. 

Licensed Mental Health Counselors (LMHC)

LMHCs are licensed in Massachusetts by the Board of Registration of Allied Mental Health and Human Services Professionals. According to statue, a psychologist is defined as the following:
Mental Health Counselors render professional services to individuals, families or groups. They apply principles, methods and theories of counseling and psychotherapeutic techniques to define goals and develop a treatment plan of action aimed towards the prevention, treatment and resolution of mental and emotional dysfunction and intra or interpersonal disorders.
A LMHC must have a masters degree (MA, MS, etc) which normally involves 2 years of study beyond an undergraduate degree. They can, but are not required, to have a doctoral degree (Ph.D., Ed.D., etc.). During school, LMHCs-in-training normally complete a practicum of 100+ clock hours of supervised psychotherapy experience. Prior to graduation LMHCs-in-training are required to complete a minimum of a 600 clock hour internship. Prior to licensure, the Commonwealth requires an applicant to receive a passing score on an and have had a minimum of two full-time years of supervised experience.

Licensed Marriage and Family Therapists (LMFT)

LMFTs are licensed in Massachusetts by the Board of Registration of Allied Mental Health and Human Services Professionals According to statue, a psychologist is defined as the following:
Licensed marriage and family therapists apply principles, methods and therapeutic techniques to individuals, family groups, couples or organizations for the purpose of resolving emotional conflicts, modifying perceptions and behavior, enhancing communication and understanding among all family members and preventing family and individual crises. Individual marriage and family therapists may also engage in psychotherapy of a nonmedical nature with appropriate referrals to psychiatric resources. In addition, professionals engage in research and teaching in the overall field of human development and interpersonal relationships.
A LMFT must have a masters degree (M.A., M.S., etc) which normally involves 2 years of study beyond an undergraduate degree. During school, LMFTs-in-training normally complete 400+ clock hours of supervised psychotherapy experience. Prior to licensure, the Commonwealth requires an applicant to receive a passing score an examination and have had a minimum of two full-time years of supervised experience.


Psychiatrists are licensed physicians in Massachusetts by the Board of Registration in Medicine. I was not able to locate a specific legal definition of a psychiatrist from the Commonwealth. According the the American Psychiatric Association:
A psychiatrist is a physician who specializes in the diagnosis, treatment, and prevention of mental illnesses and substance use disorders. It takes many years of education and training to become a psychiatrist: He or she must graduate from college and then medical school, and go on to complete four years of residency training in the field of psychiatry. (Many psychiatrists undergo additional training so that they can further specialize in such areas as child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, psychopharmacology, and/or psychoanalysis.) 
A psychiatrist must have a medical degree (M.D., D.O.) which normally involves four years of medical school beyond an undergraduate degree. A psychiatrist-in-training then completes a rotating internship (one to four years) divided between a number of different medical settings; a psychiatric residency lasting four to six years; and receive passing scores on several different exams. 

Tuesday, December 22, 2009

Tuesday's Tweet

What is certain is that I am sometimes this, sometimes that. Sometimes pleased, sometimes not; sometimes confident, sometimes not; sometimes compassionate, sometimes not. The ice doesn't melt at my whim. It doesn't melt no matter how well I understand its origins or believe I understand its origins. It may not melt despite my persistent efforts to change the circumstances that I believe to be maintaining it. In such cases what else is there to do but shiver and go on about living? -- David K. Reynolds

Friday, December 18, 2009

Friday News Roundup

Since signing up for Twitter I've become deluged with information. Some of it is rather banal ("I'm heading out for  a cup of coffee") while other is much more interesting (breaking news from the environmental summit). In an effort to slow down the flow of information enough for me to understand it I'm going to experiment with aggregating tweets that I find most interesting and post it here on a Friday News Roundup.   Think of it as a companion to the Wednesday Smile that I post on Maggie's blog.

  • Doodling Improves Memory and Concentration. Jackie Andrade had 40 participants listen to a monotone two and a half minute phone message. Each were told the message would be dull , they should not memorize it, but they should write down the names of the people who would be attending the party that the message discussed. Half the participants were instructed to doodle as they listened . The study indicated that those who doodled could remember more names (7.8 for doodlers vs 7.1 for nondoodlers, which represented a significant difference). When presented with a surprise memory test later, those who doodled remembered 29 percent more details. It has long been taught that multitasking reduces productivity: this research suggests otherwise. 
  • Evidence Does Not Support Theory of Different Learning Styles. It has become common belief that people exhibit different learning styles (visual, auditory, etc.). An industry full of tests to measure these styles and educational tools to teach to these styles has grown. However a report that reviews the existing literature finds that while there are many studies that show the existence of different kinds of learns, those studies have not used research methods that would make their findings credible. The article concludes that research has not shown that people learn differently, at least in the ways the learning-styles proponents claim, and thus the widespread use of learning-style tests and associated teaching tools is a wasteful use of educational resources.
  • Antidepressants Help Suicidal Youth. Many parents have expressed concerns about their adolescents taking antidepressants. The FDA required a black box warning on antidepressants about suicide risks with youth and there was significant reports in the media. This is however much  more complicated than a black box warning. A study from Ohio State found that the use of antidepressants in adolescents was related to a dramatic reduction in hospital readmissions.

Wednesday, December 16, 2009

Brain Music Therapy

Now here is an interesting article. The Department of Homeland Security is examining an existing biofeedback technology to help with sleep. They are investigating the use of brain music therapy which has been in use since the early 1990s to treat medication conditions such as insomnia. Apparently brain waves are recorded and run through algorithms that analyze the waves and translate them into a music composition. According to the company Human Bionics, which sells this technology, these musical compositions are effective and scientifically proven treatments for stress, insomnia, anxiety, and depression. The technology has also been "found to increase productivity and concentration, and help reduce headaches."

I've not done the background research to see if these claims are reasonably true. The sample clip, however, makes for pretty music (though a bit repetitive).

Friday, December 11, 2009

Office Views

Starting psychotherapy can be an anxiety provoking experience in-and-of itself. I have found that  much of this anxiety can be quenched with knowledge--or at least it has seemed that way from my experience. Over the years I've answered numerous questions that people have had about therapy. Most of them fall into two different categories: logistical or technical.

Logistical questions include how to find my office, where to park, whether to knock on the door or not, and so on. Questions of the technical nature have included how to use medical insurance for therapy, how therapy is done, and whether therapy works.

From time to time I'm going to post some answers to these types of questions on my blog. If you are reading this and have a question, enter a comment on this post or e-mail me. You can ask your question anonymously via the comment feature and I'll do my best to answer it in a future blog posting. To easily locate blog entries of this nature, look for blog posts labeled "starting therapy."

I've already complied answers to many questions about health insurance. You can locate that on my private practice website.

Saturday, December 5, 2009

Valuing Psychotherapy

A recent study published in the August issue of the Archives of General Psychiatry report that between 1996 and 2005 the rate of people reporting they have used antidepressants increased by 75%. During the same time period there was a 35% decrease in the use of psychotherapy. It was reported that only 32% of people taking antidepressants saw a psychologist or social worker.

While this study only looked at people taking antidepressant medications and did not look at people who were in therapy who were not taking antidepressants, the numbers are troubling. It has been shown repeatedly that if you are depressed and want to feel better quicker, using both antidepressants and psychotherapy is the most effective treatment.

What  might account for this drop in the use of psychotherapy? Some suggest that out-of-pocket costs to patients are a barrier. A co-pay for medication might be as low as $10 a month while insurance coverage for psychotherapy might have a deductible of $500 or even more than $2000 before coverage begins. It is also suggested that comparatively low insurance reimbursement by insurance companies to psychotherapists has lead to declining use of psychotherapy. This second factor is likely complicated: low reimbursement rates move more psychotherapists to cancel contracts with insurance companies. This increases the fee to patients because they would then have to pay the entire cost of their treatment rather than a portion.

While the article did not discuss this, my guess is that individuals with HMOs are probably the least likely to be in psychotherapy: traditionally these plans have are the most restrictive (small lists of therapists from which to choose, many of those therapists are not taking new patients, session limits, etc.). I'm anticipating some, but not all, of this inequity will change once the mental health parity law goes into full effect (see, here, here, or here).

What does depression cost? The National Institute of Mental Health has estimated that the annual cost of depressive illnesses in the United States was about $27 billion dollars. $17 billion of that figure represents time lost from work. An MIT study in 1990 found the depression costs the nation $43.7 billion. This later figure puts the costs of depression on par with illnesses such as HIV/AIDS, cancer, and coronary heart disease.

Despite these figures, it seems that society as a whole--as well as individuals--are not willing to spend money on psychotherapy.
  • Significant investment. Depending on geographic region and the training of the psychotherapist, a therapy appointment can cost anywhere between $80 and $200+. 
  • No quick fixes. While  many people feel better after just a few short sessions, enduring change can take more time. Medication offers the allure of a quick fix, though in reality antidepressants can take three of four weeks to take effect.
  • Mysterious. Therapists spend most of their time in private one-on-one conversations. Most people are left to Hollywood or talk shows to learn about psychotherapy. 
  • Not a cookbook. With the increase of cognitive behavioral therapies, many develop the notion that psychotherapy is a technology/commodity that one can learn from a workbook. While this is a whole lot less mysterious, it cookbook approaches really don't help teach the value of the investment in psychotherapy. Why spend money for therapy when you can get the book from the library?
Psychotherapy represents an important investment in health, wellness, life, and society. How do we get the news out there? I've got two really important ideas:
  • Psychotherapists need to get out of the office and into the streets. We need to talk about what we do, be comfortable in talking about the value of what we do, and find more ways to offer our knowledge and skills to society.
  • Clients, when comfortable, need to talk with those they care about and tell them how they have found psychotherapy valuable. 
For more, try reading, here, here, here, or here.

Friday, December 4, 2009

Parity Law Part Two

Yes, another week has gone by and the Irreverent Psychologist is still thinking about mental health parity laws. I'm still contacting insurance companies here in Massachusetts trying to get an articulation how the law is going to be implemented.

To read the actual law, go here.

A recent study reviewed the successes and failures of the California parity law during the 2000 to 2005 time period. Among the findings:

  • Costs of parity were in line or below the projections.
  • Most health plans lifted limits on the annual number of days allowed for both inpatient treatments and the number of visits allowed for outpatient treatment.
  • Concerns were raised that insurance companies might use the medical necessity clauses to control costs in an arbitrary way.
  • Consumers had difficulty finding therapists from individuals who were contracted with the specific insurance company.
  • Doctors expressed concern that treatment would no longer be paid for if a patient improved an no longer met the criteria for a particular diagnosis: even if stopping therapy would was not in the best interest of the patient. 
To read more about this study go to the LA Times blog or the abstract of the article.

Wednesday, December 2, 2009

Psychotherapy Training in Psychiatrists

Ever wonder what kind of psychotherapy training psychiatrists get in medical school? Apparently it isn't a lot. If I wasn't sitting down when I read this article I very well might have fallen out of my chair.

I was recently forward an article from The Psychiatric Times. I'm just going to bullet point the things that shocked me:
  • residents must have an equivalent of 12 months of full-time, organized, continuous, supervised clinical experience in the assessment, diagnosis, and treatment of outpatients in both short-term and long-term care
  • forty medical schools in the US and Canada report some limited instruction in psychotherapy as part of the curriculum 
  • the instruction occurred at varying times throughout the four years of medical school and was often part of a one hour session
I'm beyond shocked and am going to have to phone a psychiatrist friend or two. While I'm sure the article is true, I'm feeling the need to do my own fact checking. I know many talented psychiatrists that I would comfortably refer a loved one to for psychotherapy. Surely they must have had more than the minimum training.

As a comparison, they average psychologist has had at least 1,200 hours of training while in school, a 2,000 hour internship, and an additional 2000 hours of training after earning their doctoral degree. That's just work experience, not classroom instruction.

My no means am I posting this to suggest that psychologists are better than psychiatrists. I've not personally done a comparison of how the two different fields train students to do psychotherapy.
I am posting this because I am shocked. I am reminded how important it is to be an informed client. 

Don't be afraid to ask your therapist about their training. In light of this information, I think it's important to know if a psychiatrist has done the minimum training or if they have sought additional education and experience.

Want to read the article?

Tucker, P.M., Garton, T.S., Foote, A.L., and Candler, C. (December 1, 2009). In Support of Early Psychotherapy Training. Psychiatric Times, 12.