Psychoanalysis

[strangeglove]

It's important to distinguish between psychoanalysis and psychodynamic psychotherapy, as some of you on this thread are doing, but it helps to be crystal clear about this.

Psychoanalysis is a long-term, highly intensive form of treatment meant for the treatment of neurotic-level personality pathology in higher functioning individuals. In other words, there is no DSM diagnosis for which psychoanalysis is indicated, so any discussion of it's efficacy as compared to CBT and other brief, symptom-focused psychotherapies is apples vs. oranges (not to derail the thread into a discussion of the relative merits of these two fine fruits). To be qualified as an analyst requires formal analytic training (no residency teaches you how to be an analyst) and usually undergoing one's own analysis is part of this. The patients are usually those who can afford to pay for multiple weekly sessions completely out of pocket since, as some have pointed out here, insurances do not reimburse for psychoanalysis. The treatment (superficially) involves lying on the couch and free associating in order to uncover unconscious conflict rooted in early life experiences, with the analyst providing little to no supportive intervention since anxiety and other forms of psychic pain during analytic process are considered part of the therapeutic process, and are not to be contained/mitigated/alleviated (this is one reason why it is only meant for higher-functioning patients).

Psychodynamic psychotherapy, in contrast, is a form of psychotherapy that can exist on a spectrum from being very "analytic", i.e. focused on insight and uncovering unconscious conflict or very supportive, depending on how the patient is functioning at any given moment in the treatment. Very little time is spent in psychodynamic psychotherapy dealing with Oedipal conflicts, etc. Unlike psychoanalysis, psychodynamic psychotherapy has indications for depression, generalized anxiety, panic disorder and social phobia. Psychodynamic psychotherapy has a very large evidence basis. Indeed, there are some recent, well-designed studies demonstrating non-inferiority compared to CBT. Insurance companies will reimburse for psychodynamic psychotherapy, as much as they will for CBT, etc. (though the amount of this reimbursement is so small as to make the argument that one form of psychotherapy is preferable for psychiatrists to do over another almost laughable). We are all supposed to learn psychodynamic psychotherapy in residency, and this is what most residencies tend to focus on, often at the expense of CBT, etc.

The psychodynamic model of the mind is a framework for understanding the human psyche that is shared by psychodynamic psychotherapy and psychoanalysis. It involves a developmental view of psychopathology and symptom formation in which unconscious conflict rooted in early childhood experience gives rise to rigid, ingrained patters of thinking and feeling in adulthood. It also involves a model of "ego function", where we all possess abilities in things like regulating affect, social relationships, reality testing, cognitive functioning, that help us to negotiate these conflicts. Within this framework, constructs that CBT addresses, like cognitive distortions and low motivation, can be formulate as "ego deficits," that can be addressed with supportive elements of the psychodynamic treatment. Most importantly, the psychodynamic model addresses the relationship between the doctor and the patient, which, as those of you who have taken care of patients know, is a major determinant of whether our patient's get better, whether they are getting CBT, IPT, MI, psychodynamic psychotherapy, or even medications. I view the psychodynamic model of the mind as a core conceptual framework that allows you to more effectively engage in whatever treatment you elect to do in a given patient, which ultimately is going to depend upon his/her specific symptoms and goals. CBT, etc., do not provide such a comprehensive view. Thus, I think there is some validity to teaching psychodynamic psychotherapy as the core modality in psychiatry residency, especially since most psychiatrists will never do formal psychotherapy with their patients after residency.

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[Shikima]

Thanks for this.

 

[erg923]

We are all supposed to learn psychodynamic psychotherapy in residency, and this is what most residencies tend to focus on, often at the expense of CBT, etc.

I have noticed this as well. Why do you think this is about?

Given the time contraints of modern psychiatric practice, as well as the reimbursment system/limit on sessions by insurance, wouldn't it makes the most sense for the psychotherapy training that residents do get to be brief, manualized treatments such as social skills for schizophrenia, CBT for insomonia (can be done in 4 half hours sessions), behavioral activation for depression, in-vivo exposure for panic and anxiety, etc? This would also make their psychotherapy training consistent with the hardline empirical, evidence-based focus of the rest of their training/medicine, no?

While being versed in attachment theory and object relations seems prudent, don't you think knowing how to do a 4 session CBT insomina protocol is more pragmatic in everyday practice?

 

[Chimed]

It's important to distinguish between psychoanalysis and psychodynamic psychotherapy, as some of you on this thread are doing, but it helps to be crystal clear about this.

Psychoanalysis is a long-term, highly intensive form of treatment meant for the treatment of neurotic-level personality pathology in higher functioning individuals. In other words, there is no DSM diagnosis for which psychoanalysis is indicated, so any discussion of it's efficacy as compared to CBT and other brief, symptom-focused psychotherapies is apples vs. oranges (not to derail the thread into a discussion of the relative merits of these two fine fruits). To be qualified as an analyst requires formal analytic training (no residency teaches you how to be an analyst) and usually undergoing one's own analysis is part of this. The patients are usually those who can afford to pay for multiple weekly sessions completely out of pocket since, as some have pointed out here, insurances do not reimburse for psychoanalysis. The treatment (superficially) involves lying on the couch and free associating in order to uncover unconscious conflict rooted in early life experiences, with the analyst providing little to no supportive intervention since anxiety and other forms of psychic pain during analytic process are considered part of the therapeutic process, and are not to be contained/mitigated/alleviated (this is one reason why it is only meant for higher-functioning patients).

Psychodynamic psychotherapy, in contrast, is a form of psychotherapy that can exist on a spectrum from being very "analytic", i.e. focused on insight and uncovering unconscious conflict or very supportive, depending on how the patient is functioning at any given moment in the treatment. Very little time is spent in psychodynamic psychotherapy dealing with Oedipal conflicts, etc. Unlike psychoanalysis, psychodynamic psychotherapy has indications for depression, generalized anxiety, panic disorder and social phobia. Psychodynamic psychotherapy has a very large evidence basis. Indeed, there are some recent, well-designed studies demonstrating non-inferiority compared to CBT. Insurance companies will reimburse for psychodynamic psychotherapy, as much as they will for CBT, etc. (though the amount of this reimbursement is so small as to make the argument that one form of psychotherapy is preferable for psychiatrists to do over another almost laughable). We are all supposed to learn psychodynamic psychotherapy in residency, and this is what most residencies tend to focus on, often at the expense of CBT, etc.

The psychodynamic model of the mind is a framework for understanding the human psyche that is shared by psychodynamic psychotherapy and psychoanalysis. It involves a developmental view of psychopathology and symptom formation in which unconscious conflict rooted in early childhood experience gives rise to rigid, ingrained patters of thinking and feeling in adulthood. It also involves a model of "ego function", where we all possess abilities in things like regulating affect, social relationships, reality testing, cognitive functioning, that help us to negotiate these conflicts. Within this framework, constructs that CBT addresses, like cognitive distortions and low motivation, can be formulate as "ego deficits," that can be addressed with supportive elements of the psychodynamic treatment. Most importantly, the psychodynamic model addresses the relationship between the doctor and the patient, which, as those of you who have taken care of patients know, is a major determinant of whether our patient's get better, whether they are getting CBT, IPT, MI, psychodynamic psychotherapy, or even medications. I view the psychodynamic model of the mind as a core conceptual framework that allows you to more effectively engage in whatever treatment you elect to do in a given patient, which ultimately is going to depend upon his/her specific symptoms and goals. CBT, etc., do not provide such a comprehensive view. Thus, I think there is some validity to teaching psychodynamic psychotherapy as the core modality in psychiatry residency, especially since most psychiatrists will never do formal psychotherapy with their patients after residency.

Nice overview and summary. It's a psychodynamic model that I've come to appreciate after doing a child fellowship and learning developmental theories. In fact, if anyone is interested in psychodynamics, I would recommend doing a child fellowship. I can't believe I'm even saying this, but I'm seriously considering picking up some psychodynamic cases in my practice. (If you knew me, you'd know this is a big change from what I would have said 3 years ago.)

 

[touchpause13]

???

The slur for lesbians is spelled with a y

 

[vistaril]

I have noticed this as well. Why do you think this is about?

Given the time contraints of modern psychiatric practice, as well as the reimbursment system/limit on sessions by insurance,

what are these limits on sessions by insurance you speak of? Several people on here have commented that the way to go is do weekly visits(52/yr) out of network and once the pt pays a deductible you can rack up 5 figure therapy charges to insurance. You mean it's really not that easy?

 

[strangeglove]

I have noticed this as well. Why do you think this is about?

Given the time contraints of modern psychiatric practice, as well as the reimbursment system/limit on sessions by insurance, wouldn't it makes the most sense for the psychotherapy training that residents do get to be brief, manualized treatments such as social skills for schizophrenia, CBT for insomonia (can be done in 4 half hours sessions), behavioral activation for depression, in-vivo exposure for panic and anxiety, etc? This would also make their psychotherapy training consistent with the hardline empirical, evidence-based focus of the rest of their training/medicine, no?

While being versed in attachment theory and object relations seems prudent, don't you think knowing how to do a 4 session CBT insomina protocol is more pragmatic in everyday practice?

Basically, the psychodynamic framework is a more comprehensive model of the mind than CBT models, etc., since it has room to include constructs such as motivation, goal-setting, reality testing, etc., under the rubrick of "ego functions," whereas CBT does not really have room to include things like unconscious conflict or transference. In other words, you can do CBT for depression while maintaining a psychodynamic understanding why the patient tends to become depressed whenever they end a relationship. Also, the psychodynamic way of thinking about patients is helpful for understanding how our patients' feelings towards us (and our feelings toward them) impacts their treatment, even if their treatment does not involve formal psychotherapy. For example, it helps you to understand why some patients will drop out of your psychopharmacology practice right after you return from your maternity leave. This is clinically very useful, since it helps you to keep such patients in treatment, on their medications, and doing well. It also helps you to understand the importance of good boundaries, such as not telling patients about how great your pregnancy experience was. Psychiatrists who think they can just use their "nice personality" to deal with these things are usually in for a rude awakening.

It's of course a great idea to learn CBT and a lot of other short-term treatments and use these in your clinical practice. These interventions can be very useful in specific situations, especially if your primary goal is symptom relief. However, there is much more to psychiatry than symptom relief, such as helping patients to have better relationships and function better in their jobs, even when they are not highly symptomatic. This is especially important since so many of our patients suffer from personality disorders that we as a specialty are so fond of treating like mood disorders and (BTW, DBT is not necessarily the most effective treatment for Borderline PD; it's just the one that has been embraced whole-heartedly by insurance companies and other groups who care primarily about getting folks out of the hospital as quickly as possible). And to say that only CBT is "hardline empirical, evidence based" is ignoring the rather significant literature on the efficacy of psychodynamic psychotherapy for anxiety and mood disorders.

 

[notdeadyet]

While being versed in attachment theory and object relations seems prudent, don't you think knowing how to do a 4 session CBT insomina protocol is more pragmatic in everyday practice?

Because brief, manualized treatments are by definition easy to teach and easy to learn, especially with practice…. Psychodynamics takes a lot more instruction and more supervision as you develop.

And either/or is a false dichotomy. Without a good foundation in psychodynamics, you aren't going to be providing as solid cbt as you would otherwise. And having good foundation in the cognitive behavioral model will help you with therapy that isn't pure cbt. Programs that teach one vs the other are doing a disservice to residents.


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[erg923]

Because brief, manualized treatments are by definition easy to teach and easy to learn, especially with practice…. Psychodynamics takes a lot more instruction and more supervision as you develop.

And either/or is a false dichotomy. Without a good foundation in psychodynamics, you aren't going to be providing as solid cbt as you would otherwise. And having good foundation in the cognitive behavioral model will help you with therapy that isn't pure cbt. Programs that teach one vs the other are doing a disservice to residents.

Really cant agree with the bolded. I do CBTish interventions most of the day when i see patients (I have a 70/30 clinical admin split) and, frankly, I am not versed in ANY psychdyamic therapies, although I am in the overall theory. My lack of familarity with dynamic case conceptualization in no ways impact my ability to conceptualize a case from a CBT perspective since core and intermidiary beliefs have roots in/from development and environment.

 

[¯\_(ツ)_/¯]

so you think. have you done case-control studies to prove that you were able to provide as efficient a cbt therapy without dynamics as you are able to provide with a solid training in dynamics?

 

[erg923]

so you think. have you done case-control studies to prove that you were able to provide as efficient a cbt therapy without dynamics as you are able to provide with a solid training in dynamics?

lol. Whats the dependent variable?

 

[strangeglove]

Really cant agree with the bolded. I do CBTish interventions most of the day when i see patients (I have a 70/30 clinical admin split) and, frankly, I am not versed in ANY psychdyamic therapies, although I am in the overall theory. My lack of familarity with dynamic case conceptualization in no ways impact my ability to conceptualize a case from a CBT perspective since core and intermidiary beliefs have roots in/from development and environment.

Aaron Beck was trained as an analyst.

 

[erg923]

Yes. I am aware. What's the connection here though? Has he made the claim that his dynamic training made him a superior (however we measure/quantify that) CBT therapist than those who were not? If so, I was not aware.

 

[michaelrack]

Really cant agree with the bolded. I do CBTish interventions most of the day when i see patients (I have a 70/30 clinical admin split) and, frankly, I am not versed in ANY psychdyamic therapies, although I am in the overall theory. My lack of familarity with dynamic case conceptualization in no ways impact my ability to conceptualize a case from a CBT perspective since core and intermidiary beliefs have roots in/from development and environment.

It's been a while since I have done any psychotherapy other than very limited CBT for insomnia, and that was more behavioral than cognitive. However, my understanding of CBT is that when you get to a deeper level (modification of core beliefs), some psychodynamic concepts are involved.

 

[erg923]

It's been a while since I have done any psychotherapy other than very limited CBT for insomnia, and that was more behavioral than cognitive. However, my understanding of CBT is that when you get to a deeper level (modification of core beliefs), some psychodynamic concepts are involved.

I'm pickin up what you're layin down there, yea. Although CBTers probably wouldnt use that language or label it as such. But I agree that any "explorative" work you are going to be doing alot of work around attachment, family or origin, development issues, etc.

 

[notdeadyet]

My lack of familarity with dynamic case conceptualization in no ways impact my ability to conceptualize a case from a CBT perspective since core and intermidiary beliefs have roots in/from development and environment.

With all do respect, I think that's a bit of a circular argument, no? You have no idea if lack of psychodynamic training affects how you approach a CBT case any more than someone without cognitive behavioral training could say it doesn't affect how they approach a psychodynamic case.

Just tossing that out there. The further I get along, the more I find that the folks (not saying you, erg) who are sticklers for one modality or another are really limiting themselves in the depth of treatment they can provide their patients. Doing manualized therapy and check-box psychiatry doesn't draw on psychodynamics, but we can offer a lot more than check-box psychiatry. For a lot of CBT cases, when I'm trying to treat the affliction rather than the symptoms, I personally find having psychodynamics influencing my formulation and approach is extremely helpful.

 

[Siggie]

Psychoanalysis

Erg923,

That is to say, 1 test could get to "set" someones real "popular" (social) IQ, but still psychologist/psychiatrist use it anyway (and not one -real- psychoanalyst could ever think of them as part of the Real, but just something merely Symbolic).

 

[erg923]

Psychoanalysis

Erg923,

That is to say, 1 test could get to "set" someones real "popular" (social) IQ, but still psychologist/psychiatrist use it anyway (and not one -real- psychoanalyst could ever think of them as part of the Real, but just something merely Symbolic).

What?!