NYT: "Have you ever been in psychotherapy, doctor?"

Almost all doctoral programs in clinical psychology require you to complete a certain amount psychotherapy yourself while in grad school. Both to see what its is like to be in the other chair, and work on issues that could affect your interactions with patients and skills as a therapist. Is this required in many residency programs?

erg923 said:

Almost all doctoral programs in clinical psychology require you to complete a certain amount psychotherapy yourself while in grad school. Both to see what its is like to be in the other chair, and work on issues that could affect your interactions with patients and skills as a therapist. Is this required in many residency programs?

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Someone else can correct be if I'm wrong, but I don't believe any psychiatry program requires residents to do psychotherapy anymore. I would guess that some of the more psychoanalytic oriented programs may encourage it, though. My program certainly does not require nor necessarily encourages it. However, we can get "training psychotherapy" at a higly discounted rate and have a list of therapists that are available for this purpose.

Personally, I plan to start this some time next year. My thoughts are that it is important, at a minimum, to know what your patients go through and, more importantly, learn about your own "blind spots" that may contribute to countertransference issues. If I were a PD, however, I'd have a difficult time requiring residents to do this, as many do not buy into psychodynamic theories anymore.

I'm not sure why psychodynamic orientations would have anything to do with it though. Psychotherapy isn't necessarily psychodynamic in nature (i.,e Gestalt, Rogerian, CBT). Most of it these days isn't psychodynamically oriented actually. My clinical psychology doctoral program is in no way is psychodynamically oriented, thank goodness. I think the main reasons why it is required (in my field) is to get a feel for what it is like for patients to be in that situation, and perhaps more importantly, to assist you in addressing issues that could be adversely affecting your life and your potential to provide quality therapy. If you by the premise, you by the joke, so to speak. If we are pushing psychotherapy as healthy and helpful for people, why should we be adverse to engaging in the process ourselves?

This is a facet of psychiatry that I think about a lot. I'm currently trying to decide between family med and psychiatry. I've been in and out of therapy since I was 18 for anxiety and depression, and my husband thinks that this means I wouldn't be any good at psychiatry. I tend to think that my history offers me a good deal of insight. Plus, I know my limitations and weaknesses well by this point and have no problem asking for help when I need it.

I do also agree that going through a round of therapy would help residents understand the intimacy of a therapeutic relationship. But, what should you say when a patient asks about your history? I guess I could just throw it back at them and try to figure out why it's important to them. What would you guys do?

"I do also agree that going through a round of therapy would help residents understand the intimacy of a therapeutic relationship. But, what should you say when a patient asks about your history? I guess I could just throw it back at them and try to figure out why it's important to them. What would you guys do?"

One of my mentors always says "everything is grist for the therapy mill." I really like that saying. You develop a "therapeutic frame" of things that you are willing to disclose and things you are not. Stick to this the best you can, as appropriate boundaries in the therapeutic relationship is important. When clients ask inappropriate questions about my life, or things I am not willing to disclose, I simply use it as "grist for the therapy mill." Why do they need to know this? How do they find it useful? Could this be part of their pathology, or is it just more benign? I certainly don't throw these things back at them directly, but I do couch these questions in rather stealthy ways so i can see if their is anything clinically significant to them.

erg923 said:

I'm not sure why psychodynamic orientations would have anything to do with it though. Psychotherapy isn't necessarily psychodynamic in nature (i.,e Gestalt, Rogerian, CBT). Most of it these days isn't psychodynamically oriented actually. My clinical psychology doctoral program is in no way is psychodynamically oriented, thank goodness. I think the main reasons why it is required (in my field) is to get a feel for what it is like for patients to be in that situation, and perhaps more importantly, to assist you in addressing issues that could be adversely affecting your life and your potential to provide quality therapy. If you by the premise, you by the joke, so to speak. If we are pushing psychotherapy as healthy and helpful for people, why should we be adverse to engaging in the process ourselves?

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Yes, of course a lot of what is taught is not psychodyamic. However, if one is going to engage in therapy to help learn about countertransference issues, then going through a strict CBT therapy, for example, would not get into those issues and wouldn't be help to that end. I suppose it has to do with what you want out of the experience.

I respectfully disagree. My therapy was very CBT and it helped me immensely with the personal issues of mine that i was projecting onto some of my clients (roughly how you're thinking of countertransference I assume). I am not psychodynamic, so I dont really buy the idea of "countertransference" in its classic form (i.e., the true psychoanalytic definition of it). If you buy the premise, you buy the whole joke, and I don't by alot of psychodynamic theory. What is quite obvious however, is that your own biases and personal experiences can contribute and interfere with your ability to work optimally with a client. This is roughly equatable to "countertransference", although the true Freudian definition has quite a bit more to it than that. As I said, my therapist and I worked on my "issues" and helped me to look at my client in a different way. Thus, significantly improving my ability to work with him.

erg923 said:

I respectfully disagree. My therapy was very CBT and it helped me immensely with the personal issues of mine that i was projecting onto some of my clients (roughly how you're thinking of countertransference I assume). I am not psychodynamic, so I dont really buy the idea of "countertransference" in its classic form (i.e., the true psychoanalytic definition of it). If you buy the premise, you buy the whole joke, and I don't by alot of psychodynamic theory. What is quite obvious however, is that your own biases and personal experiences can contribute and interfere with your ability to work optimally with a client. This is roughly equatable to "countertransference", although the true Freudian definition has quite a bit more to it than that. As I said, my therapist and I worked on my "issues" and helped me to look at my client in a different way. Thus, significantly improving my ability to work with him.

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Good points. I purposely avoided using the term "psychoanalysis", but rather used "psychodyanamic" to distinguish between a hard-line Freudain theory and more modern views.

erg923 said:

... I am not psychodynamic, so I dont really buy the idea of "countertransference" in its classic form (i.e., the true psychoanalytic definition of it). If you buy the premise, you buy the whole joke, and I don't by alot of psychodynamic theory. What is quite obvious however, is that your own biases and personal experiences can contribute and interfere with your ability to work optimally with a client. This is roughly equatable to "countertransference", although the true Freudian definition has quite a bit more to it than that.

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Chimed said:

Good points. I purposely avoided using the term "psychoanalysis", but rather used "psychodyanamic" to distinguish between a hard-line Freudain theory and more modern views.

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In defining Freudianism as "hard-line" and a "joke," I think you are setting up a straw man that may be easy to set afire but does not reflect modern psychoanalytic theory. Countertransference does have two basic definitions, for example, but most analytically-oriented people use the broader definition that would conform exactly to your stressing the way "biases and personal experiences can contribute and interfere with your ability to work optimally with a client." The more strict definition does require the "buying" of transference and countertransference, but I don't really see how you can be a psychiatrist and not believe in such basic analytic theories. CBT can be helpful, but it tends to be aggressively anti-insight and anti-defense in that stright CBT tends to stress that you can offer advice/observations (e.g., psychoeducation, stress-reduction techniques, cycles of behavior/thinking) and then the patient will use these and act reasonably. Many people don't, which is why--even if you only dispense medications--it can be useful to understand why people don't take their medications or come in for sessions, etc. This may be why the NY Times article could be written by Richard Friedman, who runs Cornell's division of psychopharmacology and not their outpatient psychotherapy group.

By the way, I enjoyed the comment, "I am not psychodynamic," since such a view conforms to my favorite river, Denial. Your point of view may not be "psychodynamic," but you are a simmering cauldron of defenses, impulses, and conflicts, which is what makes us interesting, gets us in trouble, and guarantees our future job security as psychiatrists.

"but I don't really see how you can be a psychiatrist and not believe in such basic analytic theories. "

First off, I'm not a psychiatrist, I am clinical psychologist. Second, someone want to comment on this blanket statement please....

I might argue that NO ONE should just BELIEVE in theories. In proper science, theories should be testable and falsifiable. Perhaps you could propose a proper experimental paradigm for psychoanalysis that has eluded other researchers over the past century?

He was using the example of countertransference, in the broader definition, affecting how we might see and treat patients. This "theory" might not be amenable to a testable hypothesis, but why should it? I'm no Fruedian by any means, but I would be hard-pressed to argue that our own upbringings and experiences play no role in the treatment of the psychiatric patient.

Although psychologists seem to enjoy doing so by nature of their training, I don't feel that testing common sense attributions is very fruitful in most cases.

Anasazi23, please see my previous posts. I have no doubt our own issues and personal experiences can interfere with out ability to work optimally with our clients. I do not consider this to be "countertransferece." It is simply, your issues interfering with your ability to be a therapist...thats all. When you assume this phenomena is ""countertransference," then by definition of the term, you are buying into the core elements of psychoanalytic theory (i.e., unconscious conflict and projection). Remember, by definition, true countertransference is suppose to be an unconscious process.

I really think we are all on the same page here actually, I just think you guys are throwing around Freudian terms lightly. I guess over time things like transference and countertransference lose their true affiliations with the original theory. In my mind these terms are attached to a specific theory of behavior, and are not interchangeable.

Lastly, I might argue that testing common sense attributes is actually the purpose of empirical science. Meehls 1957 paper on clinical versus actuarial prediction while only tangentially related to this, discusses this in depth in the introduction section. Its a good read for us nerdy psychological science people...

erg923 said:

"but I don't really see how you can be a psychiatrist and not believe in such basic analytic theories. "

First off, I'm not a psychiatrist, I am clinical psychologist. Second, someone want to comment on this blanket statement please....

I might argue that NO ONE should just BELIEVE in theories. In proper science, theories should be testable and falsifiable. Perhaps you could propose a proper experimental paradigm for psychoanalysis that has eluded other researchers over the past century?

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I'll comment on it, since I said it.

Data on the unconscious? Do you seriously believe that there are no thoughts/paradigms/behavioral tendencies that lie outside of your consciousness? I don't think there are any current researchers who don't believe this. If so, you should feel free to list some references. In regards to psychotherapy research, here are a few, including some by psychologists:

Chambless DL, Baker M, Baucom DH, et al: Update on Empirically Validated Therapies II. Clinical Psychologist 5-18, 1998

Fonagy P, Jones EE, Kächele H, et al: An open door review of outcome studies in psychoanalysis. London, International Psychoanalytic Association, 2001

Lambert MJ, Bergin AE: The effectiveness of psychotherapy, in Handbook of psychotherapy and behavior change. Edited by Bergin AE, Garfield SL. New York, John Wiley & Sons, Inc, 1994, pp 143-189

Luborsky L, Singer B, Luborsky L: Comparative studies of psychotherapies. Archives of General Psychiatry 32:995-1008, 1975

Westen D, Novotny CM, Thompson-Brenner H: The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin 130(4):631-663, 2004

You are absolutely correct. However, I might argue that evidence for unconscious processes, while necessary, is in no way sufficient to support the underlying theory. I have no doubt psychoanalytic therapy has helped, and can indeed help people. However, I again might argue much of the variance in treatment outcomes is accounted for by the nature of the relationship between therapist and client, not necessarily by the technique used. I was more referring to the underly theories of behavior assumed by psychoanalytic/psychodynamic theory. I do not think these underlying theories of behavior and pathology development are amiable to experimental methods. Other theories such as behaviorism aren't perfect in this sense, but they do lend themselves nicely to empirical study at least.

But anyway, to get back to the countertransference issue, yes, it is obvious that our own issues can adversely effect our ability to work with a client. If you want to call this "countertransference", so be it....it just seems like that is a bit of misnomer to me. I kind of wish Sigmund or Anna were here to help us with all this though..dont you...

And finally, to get the thread back on track, I agree that psychotherapy of any kind for yourself is a wise investment for pychologists and psychiatrists. It is certainly educational, if nothing else, to experience the other side of the inherent power differential in a therpatic relationship. To be able to experience a clients vulnerability for a time would be quite humbling I would think. Lastly, it allows us to grow and get in touch with our own emotions (and possible bad habits) so we can provide the best therapy possible...with the least amount of...shall we say..."countertransference"....

marie337 said:

This is a facet of psychiatry that I think about a lot. I'm currently trying to decide between family med and psychiatry. I've been in and out of therapy since I was 18 for anxiety and depression, and my husband thinks that this means I wouldn't be any good at psychiatry. I tend to think that my history offers me a good deal of insight. Plus, I know my limitations and weaknesses well by this point and have no problem asking for help when I need it.

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I agree with you. I think as long as you've mostly resolved your own stuff, it's a huge advantage. Plus I think it's better to be a person who knows when they need help and asks for it than someone who denies needing help at all. I've seen both types of people in psychiatry and it's my impression that the former are excellent and the latter not so much.

I do also agree that going through a round of therapy would help residents understand the intimacy of a therapeutic relationship. But, what should you say when a patient asks about your history? I guess I could just throw it back at them and try to figure out why it's important to them. What would you guys do?

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No one's actually asked me yet. I think I would be honest that I was in therapy, but not necessarily disclose the reasons. What I have been advised in terms of self-disclosure is that you need to be very clear on why you are disclosing what you are disclosing. The goal always has to be to help the patient, never to unload your own stuff. And it gets hard to tell some times. So thusfar, I've erred on the side of non-disclosure.

erg923 said:

You are absolutely correct.

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Thanks...