how much psychodynamic training to get?

[deleted957339]

I'm a PGY-3. My residency does not require us to get extensive psychodynamic training. I don't necessarily want to have my own psychodynamic patients as an attending, but I really do see the utility in (at least some) psychodynamic training - I think it's a good framework/way of looking at patients even if you are not seeing them in a psychodynamic therapy context. I often find myself enjoying psychodynamic supervision, but I would love to not have to do it anymore. And I don't particularly enjoy the therapy sessions - sometimes I even dread them.

All of this is to say - should I continue to see psychodynamic patients during my fourth year? I don't WANT to, but I recognize this may be the type of thing that is "good for me." In addition, I also recognize that people after residency pay good money for supervision and I'm getting it for free.

So in short - I'd be okay with the idea of forcing myself to do one more year of psychodynamic therapy and supervision. But I would LOVE to not do it. I find a lot of value in reading psychodynamic texts and would likely continue to do that but experience is a separate thing and possibly something I should just make myself continue. Any thoughts?

---

Members don't see this ad.

 

[Sushirolls]

If there is any chance of doing a cash only practice in your future career, then stick it out and do the year.

 

[LadyHalcyon]

Can you be more specific about what you don't like about psychodynamic sessions and how this differs from CBT/Emotion focused/humanistic (insert whatever) sessions?

 

[splik]

It is good to expose yourself to things you don't like, or even dread in training. If it feels easy, it means you aren't learning anything. At the same time, you should be mindful about what it is you don't like or dread about it. Is it just not a good fit with your way of working with patients? Do you not have the attention span or ability to sit with patients and listen deeply with them? Do you dread being confronted with your own inadequacy as a therapist? or is it that you have hateful patients who fill you with dread and whom you despise? Or patients who have no hope in hell of benefiting from these sessions with you? Remember, it is not possible to treat patients you do not like. I really did not like psychodynamic therapy for my first 3 training cases as a residents because I had to most toxic patients that were unlikeable, and had limited ability to benefit from treatment with me. In addition, these patients were too disturbed for a neophyte therapist to be working with (if they were able to benefit from therapy at all). When I later had more appropriate patients, I really enjoyed the work and saw the wonders of psychotherapy. So consider that you might need to terminate with your patients if they are the problem and find more appropriate patients.

If you do not see yourself doing any psychotherapy in the future, then I would consider not having psychodynamic cases as a PGY-4 but definitely continue with psychodynamic supervision (it should not be necessary to have such therapy cases for you to have patients you can discuss in supervision). I would also strongly recommend personal psychotherapy as this will give you the best chance to gaze at how you bring your own psychopathology into the clinic. Finally, if you have a psychodynamically oriented process group to discuss challenging patients or those who stir up a powerful countertransference I would recommend that.

For my first year out of training, I could not bear the thought of having any patients of my own. Now I do have a small neuropsychiatric practice and I do not prescribe any meds but I do see patients for psychotherapy. I did have 2 hours of psychoanalytic supervision during my residency, and a weekly process group, and saw several patients for dynamically oriented therapy including for twice weekly therapy however.

 

[clausewitz2]

It is good to expose yourself to things you don't like, or even dread in training. If it feels easy, it means you aren't learning anything. At the same time, you should be mindful about what it is you don't like or dread about it. Is it just not a good fit with your way of working with patients? Do you not have the attention span or ability to sit with patients and listen deeply with them? Do you dread being confronted with your own inadequacy as a therapist? or is it that you have hateful patients who fill you with dread and whom you despise? Or patients who have no hope in hell of benefiting from these sessions with you? Remember, it is not possible to treat patients you do not like. I really did not like psychodynamic therapy for my first 3 training cases as a residents because I had to most toxic patients that were unlikeable, and had limited ability to benefit from treatment with me. In addition, these patients were too disturbed for a neophyte therapist to be working with (if they were able to benefit from therapy at all). When I later had more appropriate patients, I really enjoyed the work and saw the wonders of psychotherapy. So consider that you might need to terminate with your patients if they are the problem and find more appropriate patients.

If you do not see yourself doing any psychotherapy in the future, then I would consider not having psychodynamic cases as a PGY-4 but definitely continue with psychodynamic supervision (it should not be necessary to have such therapy cases for you to have patients you can discuss in supervision). I would also strongly recommend personal psychotherapy as this will give you the best chance to gaze at how you bring your own psychopathology into the clinic. Finally, if you have a psychodynamically oriented process group to discuss challenging patients or those who stir up a powerful countertransference I would recommend that.

For my first year out of training, I could not bear the thought of having any patients of my own. Now I do have a small neuropsychiatric practice and I do not prescribe any meds but I do see patients for psychotherapy. I did have 2 hours of psychoanalytic supervision during my residency, and a weekly process group, and saw several patients for dynamically oriented therapy including for twice weekly therapy however.

I would go so far as to say everyone ought to have at least one twice weekly case during residency, regardless of modality (people sometimes forget the old school CBT protocols start out with twice a week). It is a vastly different experience then seeing someone just a few times a month, when the session is not primarily spent catching up on what had transpired in the person's life since last time.

 

[SourceOfDenial]

Do you talk in supervision about why you dread therapy? I'd also question the quality of your supervision--the 'good supervisors' I had as a trainee were really not good once I compared them to supervisors I saw out of training.

The only thing worse than a bad therapist is a therapist who doesnt want to be there. Given that one of core skills of any good therapy is offering a safe and supportive container, don't struggle with an approach that doesnt speak to you. There are a million modalities for understanding people and systems, psychiatrists are wed to psychoanalysis or psychodynamic because thats what we were taught. I mean you could learn logotherapy, buddism, cbt, internal family systems, somatic experiencing, yoga, equine, meaning making, attachment, transpersonal, eft, act, cbt, etc etc etc. Some are techniques for specific problems, some are ways of understanding people. There is no one 'right way' to get to most of what drives human suffering. You create a roadmap with your client and meet them where they are.

You are served by learning many different frameworks/ways of thinking, but if you dont want to carry psychodynamic patients, then don't do it.

Finally, the thought that you carry some psychodynamic patients in residency and then become competent by the end of it is a fallacy. I listened to an old therapy tape recently from early in my third year and cringed. Learning and change doesnt stop when you finish residency, and you dont suddenly become an 'expert' when walk out of residency on July 1.

 

[nitemagi]

What kind of psychodynamic supervision are you getting?

 

[whopper]

First when you say "psychodynamic" do you mean psychotherapy? Reason why I ask is psychodynamic psychotherapy is a very specific type of psychotherapy. It doesn't cover for example DBT, CBT, and other forms of therapy. IMHO I think psychodynamic therapy is largely not needed in today's society. We don't live in the Freud/Victorian days where people were virgins until birth, 1/3 of women died in childbirth, and women literally fainted if you told them they were attractive.

Now that said, psychotherapy should be well taught in any psych program including psychodynamic therapy and there are patients who are in need of that specific psychotherapy. I tend to emphasize need for this specific type of therapy if they have issues ranging from their childhood with plenty of unsatisfied drives.

 

[nitemagi]

First when you say "psychodynamic" do you mean psychotherapy? Reason why I ask is psychodynamic psychotherapy is a very specific type of psychotherapy. It doesn't cover for example DBT, CBT, and other forms of therapy. IMHO I think psychodynamic therapy is largely not needed in today's society. We don't live in the Freud/Victorian days where people were virgins until birth, 1/3 of women died in childbirth, and women literally fainted if you told them they were attractive.

Now that said, psychotherapy should be well taught in any psych program including psychodynamic therapy and there are patients who are in need of that specific psychotherapy. I tend to emphasize need for this specific type of therapy if they have issues ranging from their childhood with plenty of unsatisfied drives.

This is a gross conflation of psychoanalysis, psychoanalytic theory, and psychodynamic therapy. And even psychoanalytic theory and psychoanalysis has many schools. You're referring primarily to what some would describe nowadays as ego psychology (more freudian). You might appreciate object relations/Kleinian school, the middle school, self-psychology, Bionian, Lacanian, all of which is still psychoanalysis and doesn't have ****all to do with Freud (though he's still taught as a foundational reference).

Psychodynamic therapy can draw from different theories, but is often very relational, human, and engaged, and not involving psychoanalytic technique like free association. Most people who see a psychodynamically oriented therapist just feel like they're having a conversation and being listened to.

 

[whopper]

Fair enough, although I'd add any type of psychotherapy also fits your description in the second paragraph. I get though why in the first paragraph you're pointing out that my description is very narrow cause it is.

 

[nitemagi]

Fair enough, although I'd add any type of psychotherapy also fits your description in the second paragraph. I get though why in the first paragraph you're pointing out that my description is very narrow cause it is.

I'd disagree when it comes to CBT and DBT. Most people getting CBT, reviewing homework (for those who actually do it), doing a root cause/chain analysis, or in DBT doing skill coaching based on the manual (what 1:1 DBT is supposed to be) don't often feel as conversational. In psychodynamic, the relationship in the therapy is the tool of change, when properly utilized.

 

[deleted957339]

I'm referring specifically to psychodynamic psychotherapy. We also learn other modalities, but I'm asking specifically about psychodynamic because the time frame of therapy is longer so there may be utility in continuing a longer course of treatment (as long as possible while in residency).

I receive both group and individual supervision and both are (objectively) excellent. And I enjoy supervision - I also like psychodynamic psychotherapy and have learned a lot from it. But I do not look forward to my therapy sessions, which partially reflects on my current patient and the slow nature of our progress, but also other things - such as my overall level of commitment to other things (which probably compromises my attention span), as well as the involvement of my own experience into the therapy. I do have my own psychotherapist but I'm a work in progress (we probably all are) - and I don't like how my therapy practice/supervision sometimes cuts a little too close for my own personal comfort. Maybe it'll get better as I move closer to enlightenment (lol) and/or gain more experience. But for right now, I don't enjoy the emotional aspect and how it really, really forces me to look at my own personal emotional crap. Don't get me wrong - I'm actively looking at my crap and working on it because I'm a psychiatrist and it's important. But it's just another aspect that is uncomfortable for me.

I'm not concerned about the effect my own personal countertransference/lack of enjoyment is having on the quality of the therapy I am providing. As mentioned above, I have a lot of supervision, including going through transcripts from sessions. Multiple parties have weighed in and feel my patient is benefiting and the interactions are therapeutic. My main predicament is this: I'm also very willing to continue even though I personally don't enjoy this because like splik said, it's good to do things you don't like in residency because it means there is growth - but I can't do everything. I'm not expecting to be fully competent in therapy by the time I graduate - my question is really about how to maximally benefit from residency and the resources residency provides while I'm here, and whether or not psychotherapy supervision and patients are part of that class of things of which I should take advantage.

 

[whopper]

IMHO psychotherapy training, for real, is a years long process that should continue further after residency. What residency teaches is more of a starting process. Several large urban areas have a psychoanalytic institute that offers more training. You could also get some books and read up on it yourself. There are thousands of books out there on psychotherapy. IMHO a psychiatrist should have read at least a few, and not just the minimum residency requirement.

Also, you have to balance your desire to learn psychiatry with all of medicine especially if you haven't finished your step 3 exam. IMHO pass that exam then devote a lot more of your free-time to studying psychotherapy more in-depth.

 

[birchswing]

I actually have quite a few years of experience from the other side, receiving, psychodynamic therapy. And I find it to be a tricky wicket. I used to describe psychodynamic therapy as like sautéing vegetables and then you're left with the fond at the bottom of the pan and wonder what to do with it. (In this metaphor the sautéing are the sessions where you think you're working on the issues but you're not and the fond is the roles you find yourself enacting out which is the real substance.) I remember once getting to a point where we realized which roles we were enacting, and I said: So now what? And that was the question that could never be answered. There was a real enacting of roles, and I recognized it, but neither he nor I seemed to understand how that benefitted me.

At least with my particular therapist, what I found made me ill at ease was the idea he had that there was always something more there that we had not reached. There was a sense he imbued (and he has admitted this) of failure, which he partially attributed to himself.

It never in the moment felt like a fever dream, but thinking back on the arch of it, it did. A sisyphean task.

I never understood why the very mundane, immediately evident content, mannerisms, presentation, etc., weren't enough to work with. Instead it felt like there was something he was searching for from me, and I felt like I had vomited everything there was but none of it was worth examining—or he was uncomfortable examining what was there and so kept looking for something else. It was like I was pinned to the wall, emptied of everything, and still looking for some answer in me.

That reminds me of a therapist I saw almost 20 years ago, who hinted that he discovered something but would not reveal it. I remember almost nothing from any of the sessions. But I remember him once saying he knew something about me that I didn't know about myself and I was not yet prepared to know it. It's perhaps surprising how often I wonder what it is he thought he knew about me that I didn't know about myself. I have guesses. I even tried getting my records but it was too late and they had been destroyed, and he's now retired. It might just have been a flippant remark, but it's one of the few things I can remember him saying. I literally have almost no memory of the content of the therapy.

In my opinion, if psychodynamic therapy is tortuous and vexing (at least to the client), it's basically a dysfunctional relationship (even with the genius insight that you are enacting a dysfunctional relationship from elsewhere in your life) and something else should be tried. That's just a lay person's opinion.

 

[futuredo32]

I used my CME money my last year of residency to take a course in psychodynamic therapy at the Michigan psychoanalytic Institute.

I think it's great that you are in your own therapy. I go to psychoanalysis and feel like I have learned more about psychodynamic therapy from being a patient than I have from supervision, the course I took or any book.

 

[thoffen]

As someone getting analytic training, I'll say that the most valuable thing for me has been my own therapy.

 

[deleted736562]

I'm referring specifically to psychodynamic psychotherapy. We also learn other modalities, but I'm asking specifically about psychodynamic because the time frame of therapy is longer so there may be utility in continuing a longer course of treatment (as long as possible while in residency).

I receive both group and individual supervision and both are (objectively) excellent. And I enjoy supervision - I also like psychodynamic psychotherapy and have learned a lot from it. But I do not look forward to my therapy sessions, which partially reflects on my current patient and the slow nature of our progress, but also other things - such as my overall level of commitment to other things (which probably compromises my attention span), as well as the involvement of my own experience into the therapy. I do have my own psychotherapist but I'm a work in progress (we probably all are) - and I don't like how my therapy practice/supervision sometimes cuts a little too close for my own personal comfort. Maybe it'll get better as I move closer to enlightenment (lol) and/or gain more experience. But for right now, I don't enjoy the emotional aspect and how it really, really forces me to look at my own personal emotional crap. Don't get me wrong - I'm actively looking at my crap and working on it because I'm a psychiatrist and it's important. But it's just another aspect that is uncomfortable for me.

I'm not concerned about the effect my own personal countertransference/lack of enjoyment is having on the quality of the therapy I am providing. As mentioned above, I have a lot of supervision, including going through transcripts from sessions. Multiple parties have weighed in and feel my patient is benefiting and the interactions are therapeutic. My main predicament is this: I'm also very willing to continue even though I personally don't enjoy this because like splik said, it's good to do things you don't like in residency because it means there is growth - but I can't do everything. I'm not expecting to be fully competent in therapy by the time I graduate - my question is really about how to maximally benefit from residency and the resources residency provides while I'm here, and whether or not psychotherapy supervision and patients are part of that class of things of which I should take advantage.

Maybe you should raise this issue with your supervisor? Supervision can be emotionally daunting. You're in a way exposing yourself and becoming a patient though for supervision purposes which can cause a lot of embarrassment and discomfort. Probably this is quite common, especially for a beginning therapist. A good supervisor will know how to appropriately wade through this kind of terrain.

 

[whopper]

That reminds me of a therapist I saw almost 20 years ago, who hinted that he discovered something but would not reveal it. I remember almost nothing from any of the sessions. But I remember him once saying he knew something about me that I didn't know about myself and I was not yet prepared to know it. I

sounds kind of manipulative to me. Reminds me of this scene.


The following is a true story. I figured I mentioned this years ago on the forum and don't know where I originally wrote it in the forum. While I lived in Ohio I worked in a private practice and was the only psychiatrist among many masters-level therapists. I told the therapists only to refer to me if they believed the patient/client would benefit from a psychotropic medication.

So I get a referral, see the patient, and I don't think the patient needs a medication. The person was suffering from Adjustment Disorder and it wasn't anything close to severe. The patient asked why they were referred, I wasn't told why, and told them I didn't know. So I approached the therapist and asked and she was very evasive to the point of being rude, and kept ducking me giving me a response that she had a client so she couldn't talk to me. I saw patient X 1-2x afterwards and still didn't know why that person was referred to me. After avoiding me about 3-5x I put a note in the therapist's mailbox asking why she wanted me to see patient X.

The letter was a few paragraphs long explaining the pt, and that I didn't understand why she needed a psychiatrist. The therapist, simply wrote me a letter back with ONLY 2 WORDS. "Why not?"

I was kind of ticked off at that point and the patient was expressing frustration with the lack of communication and at this point I bluntly told her that the therapist wasn't communicating with me well and simply gave me a "why not?" response back. The patient had a transference relationship with that therapist where she liked the therapist but was neutral towards me so she was only getting mad at me for the lack of communication that was further frustrating the heck out of me. She'd only talk glowingly of her therapist.

After a few weeks of this I had enough of it, confronted that therapist again and told her if she didn't give me a straight answer as to why that patient was referred I was going to tell the patient to stop seeing me cause I didn't see a point in her seeing me.

The therapist asked me for the patient's name cause she didn't remember. I told her the name, she still didn't know who it was, I asked her to pull up her records, and this is where it all gelled together. The therapist revealed she didn't keep notes ON ANY OF HER CLIENTS DESPITE THAT SHE ACCEPTED INSURANCE. (Yeah I know it's illegal). She also told me whenever a patient showed up, the only thing she'd do was sit there, and bob her head back and forth as if she cared while admitting she'd go into a daydream.

She didn't know why referred that patient to me. All of her therapy sessions were complete BS. One of the secretaries who worked there mentioned one time the therapist was subpoenaed and she showed up and literally told the judge she doesn't keep records so there was nothing to give. The judge then just let her go.

Well guess what? All of that therapist's clients seemingly loved her. They'd give comments like "She's such a good listener! I know she really cares cause she listens!" I figure of course she'd get new ones that didn't like her but therapy is the type of thing where only the ones that like you or don't know enough to realize it's BS will stick.

 

[tr]

Most people who see a psychodynamically oriented therapist just feel like they're having a conversation and being listened to.

You know, not to be inflammatory, but my impression from asking all my new patients what sort of therapy they may have had and how they liked it, is that a majority of those who received what sounded like psychodynamically oriented interventions felt like they were having a one-sided conversation with someone who offered little in the way of concrete strategies or directions for improvement, and overall judged the intervention to be of only minimal utility.

I have to ask about this because I can refer internally to either a psychodynamically-oriented or a CBT-oriented clinic, and after a discussion of what each modality offers, almost all of the patients opt for the CBT clinic.

 

[nitemagi]

You know, not to be inflammatory, but my impression from asking all my new patients what sort of therapy they may have had and how they liked it, is that a majority of those who received what sounded like psychodynamically oriented interventions felt like they were having a one-sided conversation with someone who offered little in the way of concrete strategies or directions for improvement, and overall judged the intervention to be of only minimal utility.

I have to ask about this because I can refer internally to either a psychodynamically-oriented or a CBT-oriented clinic, and after a discussion of what each modality offers, almost all of the patients opt for the CBT clinic.

Yeah it really varies. I personally do both, and I think it's valuable to be able to think and function from multiple mindsets. I had a patient once who came to me for therapy. Anxiety. Depression. Terribly messy family situation with enmeshment and inverted family hierarchy, no sense of independence.

He told me when he walked in that he didn't want to me to just be a listener, or be empathic, or any of that "therapy." Meaning a more psychodynamic or interpersonal approach. He said he wanted me to help him strategize, give him concrete homework and plans, etc. Basically asking for CBT without knowing that's what it was called. So we did CBT. For months. Zero progress. Every approach led to fighting the process, sabotaging. It was like dealing with an oppositional teen, where everything you try you get a "no" without it even being considered. Zero progress in 4 months and it felt like a LOT of effort on my part.

I realized I was caught in a "trying to fix it" approach. (Youtube the video "it's not about the nail.") He said he wanted concrete approaches, but his actions didn't reflect that. So I switched gears and decided to try a more supportive, empathic, and psychodynamically oriented approach, with an understanding of his larger formulation including family dynamics. It was like a switch was flipped. Not only was he cooperative, pleasant, engaged, but tapped into emotions he was fighting, started talking about how helpful the sessions were, and most importantly, spontaneously started making big life changes that he was previously fighting, without my ever having to guide him on the process. He made dramatic improvements in all domains of life in less than 2 months.

The lesson(s) for me: Patients don't often know what they need, and you do them a disservice by just giving them what they say they want. Our role as sophisticated clinicians is not just to see the whole picture, but to reconceptualize when the approach isn't working, think from a different mindset, and try something new.

 

[tr]

Yeah it really varies. I personally do both, and I think it's valuable to be able to think and function from multiple mindsets. I had a patient once who came to me for therapy. Anxiety. Depression. Terribly messy family situation with enmeshment and inverted family hierarchy, no sense of independence.

He told me when he walked in that he didn't want to me to just be a listener, or be empathic, or any of that "therapy." Meaning a more psychodynamic or interpersonal approach. He said he wanted me to help him strategize, give him concrete homework and plans, etc. Basically asking for CBT without knowing that's what it was called. So we did CBT. For months. Zero progress. Every approach led to fighting the process, sabotaging. It was like dealing with an oppositional teen, where everything you try you get a "no" without it even being considered. Zero progress in 4 months and it felt like a LOT of effort on my part.

I realized I was caught in a "trying to fix it" approach. (Youtube the video "it's not about the nail.") He said he wanted concrete approaches, but his actions didn't reflect that. So I switched gears and decided to try a more supportive, empathic, and psychodynamically oriented approach, with an understanding of his larger formulation including family dynamics. It was like a switch was flipped. Not only was he cooperative, pleasant, engaged, but tapped into emotions he was fighting, started talking about how helpful the sessions were, and most importantly, spontaneously started making big life changes that he was previously fighting, without my ever having to guide him on the process. He made dramatic improvements in all domains of life in less than 2 months.

The lesson(s) for me: Patients don't often know what they need, and you do them a disservice by just giving them what they say they want. Our role as sophisticated clinicians is not just to see the whole picture, but to reconceptualize when the approach isn't working, think from a different mindset, and try something new.

That's fair, and honestly when you look at the small body of research that has compared CBT to psychodynamic, they are both effective, just the psychodynamic takes a little longer to work.

At the same time, you also imply this idea that CBT cannot be supportive or empathic, and this I must vehemently disagree with. The version of CBT that I was trained in and have found most highly effective explicitly incorporates empathy upfront, before implementing any of the 'techniques' that people associate with CBT, as well as an upfront assessment of motivation, including a motivational-interviewing approach to sussing out aspects of outcome resistance that the patient may not be at all aware of. The techniques are the very last step and once you've done the empathy and the motivation assessment, honestly 90% of the work is done. The techniques just finish off the job. There is also an explicit technique for recognizing and managing interpersonal obstacles and bringing attention to the patient-therapist relationship when it is necessary and important for the progress of the therapy.

Personally I think if you leave empathy, motivation, and (*when appropriate*) the patient-therapist relationship out of CBT, you're probably not doing a very good job.

The 'stuckness' that you describe is super familiar to me and is a big fat clue that the therapist needs to back off techniques and address either motivation, patient-therapist relationship, or both. That 'effortful' feeling is *so important* to pay attention to. A great way to address it is with an I-Feel/Inquiry approach: "You know, as we're working on this, I'm getting this feeling of being really stuck and a little bit frustrated. I'm wondering if you're feeling that too, and if so, if we could investigate together what that's about."

I consider the defining aspect of CBT to be the structure and the goal-oriented approach. That is, there is a specific goal for this therapy, and we are going to structure the approach towards achieving the goal. Just because you have a defined goal and a structure does *not* mean that you should abandon interest in the patient-therapist relationship, which *time and again has been shown to be the most important predictive factor in therapeutic success, entirely independent of the specific modality that is employed.*

 

[nitemagi]

That's fair, and honestly when you look at the small body of research that has compared CBT to psychodynamic, they are both effective, just the psychodynamic takes a little longer to work.

At the same time, you also imply this idea that CBT cannot be supportive or empathic, and this I must vehemently disagree with. The version of CBT that I was trained in and have found most highly effective explicitly incorporates empathy upfront, before implementing any of the 'techniques' that people associate with CBT, as well as an upfront assessment of motivation, including a motivational-interviewing approach to sussing out aspects of outcome resistance that the patient may not be at all aware of. The techniques are the very last step and once you've done the empathy and the motivation assessment, honestly 90% of the work is done. The techniques just finish off the job. There is also an explicit technique for recognizing and managing interpersonal obstacles and bringing attention to the patient-therapist relationship when it is necessary and important for the progress of the therapy.

Personally I think if you leave empathy, motivation, and (*when appropriate*) the patient-therapist relationship out of CBT, you're probably not doing a very good job.

The 'stuckness' that you describe is super familiar to me and is a big fat clue that the therapist needs to back off techniques and address either motivation, patient-therapist relationship, or both. That 'effortful' feeling is *so important* to pay attention to. A great way to address it is with an I-Feel/Inquiry approach: "You know, as we're working on this, I'm getting this feeling of being really stuck and a little bit frustrated. I'm wondering if you're feeling that too, and if so, if we could investigate together what that's about."

I consider the defining aspect of CBT to be the structure and the goal-oriented approach. That is, there is a specific goal for this therapy, and we are going to structure the approach towards achieving the goal. Just because you have a defined goal and a structure does *not* mean that you should abandon interest in the patient-therapist relationship, which *time and again has been shown to be the most important predictive factor in therapeutic success, entirely independent of the specific modality that is employed.*

That's fair. I do try to be empathic in everything I do. And this may have come from my sleep deprived brain in being less articulate than I intended. It was exactly as you identify -- the goal oriented nature of the therapy, which he asked for, that was also the factor limiting improvement. Once I focused only on understanding, support, empathy and observation, without goals, that's when things reversed and the improvement began.

 

[ara96]

I'm surprised how little therapy training there is in some programs. I pretty much just had to read manuals on my own. My program was very pharm heavy.

 

[splik]

I'm surprised how little therapy training there is in some programs. I pretty much just had to read manuals on my own. My program was very pharm heavy.

Unfortunately the majority of psych programs do not have the infrastructure to provide therapy training in one or more modalities. As evinced by the above comments even psychiatrists have odd ideas about what psychodynamic therapy or CBT actually is

 

[LadyHalcyon]

From a mechanism of change standpoint, CBT and psychodynamic are very different. That being said, if it weren't for buzz words such as automatic thoughts, core beliefs, etc... I doubt many observers could easily identify the exact modality being used in a session. I think people conflate psychodynamic with psychoanalysis, which is a completely different beast with a unique conceptualized mechanism of change as well. I consider myself a psychodynamic/interpersonal psychologist. Levinson's Time-Limited Dynamic Psychotherapy integrates Bowlby's attachment theory , interpersonal, and emotion-focused therapy. It is meant to approximately 12 sessions, give or take. Obviously this is only one example of a psychodynamic therapy, but psychodynamic really is a mash of other modalities (just like ACT and DBT, but I will leave than rant for another day). Most clinicians likely conceptualize from one or two theories, but utilize many different types of intervention in the room with a patient.

Psychodynamic supervision can be extremely challenging though. It often feels very uncomfortable, and similar to individual therapy. In the past it has tapped into deep insecurities, which made me question my competency as a clinician (not at all fun for an over-achieving graduate student). Although that kind of supervion is extremely helpful, it is also difficult to tolerate. I'm wondering if your aversion to psychodynamic therapy is more of an aversion to psychodynamic supervision, especially if your supervisor watches video. Either way, I imagine I would feel anxious before a session if I were anxious about supervision. It would be difficult for me to not let my anxiety spill over onto the patient, or perhaps the modality itself.

 

[tr]

That's fair. I do try to be empathic in everything I do. And this may have come from my sleep deprived brain in being less articulate than I intended. It was exactly as you identify -- the goal oriented nature of the therapy, which he asked for, that was also the factor limiting improvement. Once I focused only on understanding, support, empathy and observation, without goals, that's when things reversed and the improvement began.

Without knowing your patient at all, I'll just say that what you describe sounds like a pattern that occurs when the patient has some powerful unexplored resistance to the identified goal that hasn't been addressed.

This is like the woman who says she wants to stop binge eating, but underneath is terrified of that outcome because bingeing is where she gets comfort and stress relief. Or the man who says he wants to overcome his procrastination, but underneath fears that then he would have to face his achievements on their own merits and possibly find them wanting.

When this type of unexpressed resistance is present, it often results in the therapy getting 'stuck,' with patient and therapist both getting increasingly frustrated.

When a patient is truly comfortable with and desirous of the goal and is well connected with the therapist, it's like sailing on a smooth sea with a powerful breeze, almost like you are in 'flow' together. Like the latter two months that you describe.

When I get that 'stuck' sense I know I need to back off techniques and inquire about the problem. Usually it's either motivational (about the goal) or relational (about us) in nature. I would still call this CBT, although it sounds like in your conceptualization you think of it as switching modalities.

 

[ara96]

Unfortunately the majority of psych programs do not have the infrastructure to provide therapy training in one or more modalities. As evinced by the above comments even psychiatrists have odd ideas about what psychodynamic therapy or CBT actually is

I feel like I'm never going to be good at anything other than supportive therapy and I worry what will happen when I practice. I feel underconfident.

 

[nitemagi]

Without knowing your patient at all, I'll just say that what you describe sounds like a pattern that occurs when the patient has some powerful unexplored resistance to the identified goal that hasn't been addressed.

This is like the woman who says she wants to stop binge eating, but underneath is terrified of that outcome because bingeing is where she gets comfort and stress relief. Or the man who says he wants to overcome his procrastination, but underneath fears that then he would have to face his achievements on their own merits and possibly find them wanting.

When this type of unexpressed resistance is present, it often results in the therapy getting 'stuck,' with patient and therapist both getting increasingly frustrated.

When a patient is truly comfortable with and desirous of the goal and is well connected with the therapist, it's like sailing on a smooth sea with a powerful breeze, almost like you are in 'flow' together. Like the latter two months that you describe.

When I get that 'stuck' sense I know I need to back off techniques and inquire about the problem. Usually it's either motivational (about the goal) or relational (about us) in nature. I would still call this CBT, although it sounds like in your conceptualization you think of it as switching modalities.

100% right. The trick is that the patient may not acknowledge this, and if we get caught up in what they say they want vs. looking at what they really want, then therapy might never go anywhere.

 

[FlowRate]

I'm naturally a relatively skeptical person, so one of the hardest things about learning any form of therapy, for me, is that they all have a big component of obvious BS. The underlying common factors of therapy are the most important part and are probably why all of those patients keep seeing whopper's inept therapist colleague (although maybe the common factors are the necessary substrate on which the modality acts.)

 

[whopper]

I'm not implying you got this impression from my post but I'm writing it here just to clarify. Psychotherapy can be a very important and valid part of mental health treatment.

Just that people who misuse it have a lot of room for BS, but that can be with any field where the expert gives data that the layperson has problems verifying for themselves. You could go to a car mechanic, for example, and they could mislead you into paying a lot more money and make the problem with your car seem worse than it really is.

My first few years of practice I've noticed a lot of people have a wrong idea of what we do. I've noticed this becoming less over the years. E.g. I've had patients who changed their phone numbers and when we couldn't get in contact with them they'd respond, "well if you're a psychiatrist shouldn't you be able to figure out what my new number would've been without me telling you?" I haven't had one of those for a few years. (What I used to do was respond, literally, "Psychiatrists aren't psychics. If I were I'd be in a casino at least once a week.") People now seem to understand better that what we do works on physiological/cognitive levels and not on artsy-fartsy/"what is the sound of one hand-clapping" stuff.

 

[tr]

100% right. The trick is that the patient may not acknowledge this, and if we get caught up in what they say they want vs. looking at what they really want, then therapy might never go anywhere.

Hm. I think it's a tiny bit paternalistic to imagine that we can know what patients want if they don't tell us.
We can guess at alternative, unarticulated emotions and motivations, and we can use Inquiry skillfully to help the patient articulate those emotions and motivations, but until the patient explicitly confirms that our guesses are correct, I don't think we should take specific actions based only on those guesses.

 

[SourceOfDenial]

100% right. The trick is that the patient may not acknowledge this, and if we get caught up in what they say they want vs. looking at what they really want, then therapy might never go anywhere.

Hm. I think it's a tiny bit paternalistic to imagine that we can know what patients want if they don't tell us.
We can guess at alternative, unarticulated emotions and motivations, and we can use Inquiry skillfully to help the patient articulate those emotions and motivations, but until the patient explicitly confirms that our guesses are correct, I don't think we should take specific actions based only on those guesses.

A tiny bit?

 

[deleted736562]

I'm not implying you got this impression from my post but I'm writing it here just to clarify. Psychotherapy can be a very important and valid part of mental health treatment.

Just that people who misuse it have a lot of room for BS, but that can be with any field where the expert gives data that the layperson has problems verifying for themselves. You could go to a car mechanic, for example, and they could mislead you into paying a lot more money and make the problem with your car seem worse than it really is.

My first few years of practice I've noticed a lot of people have a wrong idea of what we do. I've noticed this becoming less over the years. E.g. I've had patients who changed their phone numbers and when we couldn't get in contact with them they'd respond, "well if you're a psychiatrist shouldn't you be able to figure out what my new number would've been without me telling you?" I haven't had one of those for a few years. (What I used to do was respond, literally, "Psychiatrists aren't psychics. If I were I'd be in a casino at least once a week.") People now seem to understand better that what we do works on physiological/cognitive levels and not on artsy-fartsy/"what is the sound of one hand-clapping" stuff.

A tiny bit?

I don't think it's paternalistic to assume there are unconscious processes which, by definition, the patient is not aware of, and that these are the root of the issues that bring the patient in rather than the "articulated" goal or focus. Many times this is a distraction. Waiting for the patient to "recognize" it before following on your judgement doesn't seem like a practical way to conduct treatment and may do more harm than good. This is maybe at the heart of therapy. At the end of the day you have the tools to try your best to understand what is going on and your obligation is to act in the patient's best interest.

 

[nitemagi]

Hm. I think it's a tiny bit paternalistic to imagine that we can know what patients want if they don't tell us.
We can guess at alternative, unarticulated emotions and motivations, and we can use Inquiry skillfully to help the patient articulate those emotions and motivations, but until the patient explicitly confirms that our guesses are correct, I don't think we should take specific actions based only on those guesses.

You never know you're right. You can form hypotheses and act on them, especially when working with the overt requests seems to go nowhere. These are pretty basic process vs. content issues, conscious vs. unconscious patterns. It's our job to manage both, and to be looking out for the patient's blind spots. Otherwise everyone could do therapy via self-help books.

 

[tr]

I don't think it's paternalistic to assume there are unconscious processes which, by definition, the patient is not aware of, and that these are the root of the issues that bring the patient in rather than the "articulated" goal or focus.

Of course not, and my posts up above discuss the methods I use for identifying these processes and explicitly bringing them to the patient's attention. I do this *systematically,* with every patient, at the start of therapy, and if therapeutic progress stalls later on, I return to this process.
My point is that it is necessary to seek confirmation/clarification from the patient directly.
Acting on formed hypotheses *without* patient buy-in is, as I said, paternalistic and likely to lead to ruptures in the therapeutic alliance.

You never know you're right.

Of course you do. It's when the patient says, "Oh my gosh, I never thought about it that way but you're totally right!"

 

[nitemagi]

Of course not, and my posts up above discuss the methods I use for identifying these processes and explicitly bringing them to the patient's attention. I do this *systematically,* with every patient, at the start of therapy, and if therapeutic progress stalls later on, I return to this process.
My point is that it is necessary to seek confirmation/clarification from the patient directly.
Acting on formed hypotheses *without* patient buy-in is, as I said, paternalistic and likely to lead to ruptures in the therapeutic alliance.

Well, duh.

Of course you do. It's when the patient says, "Oh my gosh, I never thought about it that way but you're totally right!"

Not necessarily. There are plenty of suggestible or overly agreeable patients who will agree to what your suggestions whether they're accurate or not. The entire false memory syndrome epidemic of the 1980s was a manifestation of exactly that.

When presenting interpretations, I "hold them lightly," presenting them as an idea, inviting disagreement and exploration, but not pushing.

Even calling my case above, which clearly outlines an immediate improvement through changing of strategy away from the overtly asked for approach to an alternative, explained just that.

I think you're constructing a straw man argument here, calling what I outlined above as paternalistic.

 

[tr]

I think you're constructing a straw man argument here, calling what I outlined above as paternalistic.

That was in response to your statement that "if we get caught up in what they say they want vs. looking at what they really want, then therapy might never go anywhere," which seemed to imply that you treat based on your interpretations regardless of whether patients confirm them. If that's not what you meant, I respectfully withdraw my comment.

 

[nitemagi]

That was in response to your statement that "if we get caught up in what they say they want vs. looking at what they really want, then therapy might never go anywhere," which seemed to imply that you treat based on your interpretations regardless of whether patients confirm them. If that's not what you meant, I respectfully withdraw my comment.

Fair. If I was to qualify, verbal communication is not the only communication I examine. When someone says one thing but their body language or behaviors indicate otherwise, I'm less prone to take their words at face value. My key point is to not get lost in the verbiage of a patient, and include the non-verbals, including the nature of how they engage, as communication of their feelings on a subject.

 

[deleted736562]

Of course you do. It's when the patient says, "Oh my gosh, I never thought about it that way but you're totally right!"

Many times patients will tell you, yes you got it, only to please you. Sometimes they sense that you're looking for validation and come back the next session and wreck the whole thing. Sometimes the resistance is so intense that it may take months for them to get to a certain realization. Or the classical example of pts with NPD who will say no to everything. Sometimes it's not even about the content of the interpretation but all you're looking for is to develop a connection.

There are many ways to gauge if you're on the right track. Tracking the affect and body language is one way, are they coming to the sessions, are they telling you more, is there any kind of improvement in their lives. All of these are approximations.

I think the problem with your argument is that you're assuming that there's a line between "taking action" and "seeking confirmation". It's as much of an intervention as any I could think of. In that way, you are acting on your hypothesis. It may work in certain cases but in other cases it doesn't get you anywhere. It doesn't mean your hypothesis is wrong.