Psychiatrists, what are your thoughts on psychoanalysis/psychodynamic therapy?

[Tom4705]

Do you believe it has any clinical value? Are any of you analysts? In most clinical psychology circles it's frowned upon and seen as pseudoscientific but psychoanalytic programs/institutes seem to be going strong in major coastal cities with a large number of analysts being psychiatrists. Just wanted to see if there's any positive reception for it from the psychiatrists perspective.

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[aquatic ape]

I think it’s the treatment of choice for many patients, but also useless for many. Main issue is cost and skill, but i also think the idea of paying someone and not getting instantly palatable “advice” is a barrier for a lot of people, including a lot of psychiatry trainees. I suspect this will continue to get worse and it will continue to be a niche

 

[ObsequiousAplomb]

The people who frown upon it, as the OP mentioned, are usually members of a different school of thought. Imo, psychoanalysis has 100x the value of EMDR and other fad therapies. CBT was invented to be a "good enough," cheaper, non-inferior alternative to psychoanalysis. The only reason CBT is seen as more evidence-based is that it's simplistic and manualized enough to fit better into studies.

 

[splik]

I think the first thing is not to conflate psychodynamic and psychoanalytic therapies with psychoanalysis. Psychoanalysis proper involves 3-5 times week session, traditionally lying on the couch with treatment being open-ended often for many years. There are now a range of less intensive and often shorter-term therapies based on these principles which are more commonly used in clinical practice.

There is quite a good deal of evidence for the use of psychodynamic/analytic psychotherapies, which is not the case for psychoanalysis proper. But that is to miss the point. Psychoanalysis eschews positivistic approaches and thus cannot be subject to RCTs in the same way as other therapies. Freud was long concerned that his case histories "lack[ed] the serious stamp of science" but he mused that was necessarily so since the purpose was the connect the patient's suffering with their life story in order to glean insights into problems that were impervious to the clinical and neuropathological methods of the day.

What I will say is that whatever one thinks of psychoanalysis as a treatment, the fundamental of the analytic approach are relevant whatever therapy you're providing: what's past is prologue, our subjectiveness is unique and should be respected, we are less aware of our motivations that we like to think, and our past relationships play out in clinical relationships.

This last tenet is especially important - transference. I'll give you an example. I treated a patient with exposure therapy, and we hit an impasse. The patient became resistant to further in vivo exposures. When we explored what was happening it became clear that the patient felt distressed by the "clinical" nature of this treatment which activated a negative maternal transference. The patient's mother had been emotionally cold and withholding, mocking the patient for being "sensitive" and "emotional". Once this was explored and addressed, the patient was able to benefit further from exposures. Even though the core treatment was behavioral, an understanding of the patient's early development and feelings about the therapist, were essential to the patient engaging in treatment.

 

[clozareal]

I would encourage you to read The Efficacy of Psychodynamic Psychotherapy.

 

[tr]

Psychodynamic therapy seems to have some demonstrable efficacy and some patients prefer that modality, so I'm happy that there are others out there who use it.

Personally it did not fit well for me at all. I like having a stated goal, a method to achieve the goal, and a means to determine whether we are moving in the right direction. In the exposure I had during training, I felt the methods of psychodynamic therapy were not well defined and there was not much of an objective measure of correct application or of patient progress, making it difficult to teach and learn.

Psychoanalysis I have no direct exposure to, but IMO any therapy that requires the patient to already have a high baseline level of functioning and takes hundreds of therapy hours to move them to a slightly higher? level of functioning is not something I have much use for.

What I will say is that whatever one thinks of psychoanalysis as a treatment, the fundamental of the analytic approach are relevant whatever therapy you're providing: what's past is prologue, our subjectiveness is unique and should be respected, we are less aware of our motivations that we like to think, and our past relationships play out in clinical relationships.

I don't think of these elements as 'belonging' to analysis. I would say they are cross-cutting elements of good therapy that are not specific to any modality.

 

[Liquid8]

Personally it did not fit well for me at all. I like having a stated goal, a method to achieve the goal, and a means to determine whether we are moving in the right direction. In the exposure I had during training, I felt the methods of psychodynamic therapy were not well defined and there was not much of an objective measure of correct application or of patient progress, making it difficult to teach and learn.

I feel like I went through a similar experience. While a lot of medicine followed a “see one/do one/teach one approach,” psychodynamic therapy felt very unstructured in comparison. Aside from some introductory sessions on the initial assessment period and framing the scope of therapy it always felt like we were being thrown into the deep end. There can be value in the approach, but it’s not something I could do all the time.

 

[Merovinge]

I think the first thing is not to conflate psychodynamic and psychoanalytic therapies with psychoanalysis. Psychoanalysis proper involves 3-5 times week session, traditionally lying on the couch with treatment being open-ended often for many years. There are now a range of less intensive and often shorter-term therapies based on these principles which are more commonly used in clinical practice.

There is quite a good deal of evidence for the use of psychodynamic/analytic psychotherapies, which is not the case for psychoanalysis proper. But that is to miss the point. Psychoanalysis eschews positivistic approaches and thus cannot be subject to RCTs in the same way as other therapies. Freud was long concerned that his case histories "lack[ed] the serious stamp of science" but he mused that was necessarily so since the purpose was the connect the patient's suffering with their life story in order to glean insights into problems that were impervious to the clinical and neuropathological methods of the day.

What I will say is that whatever one thinks of psychoanalysis as a treatment, the fundamental of the analytic approach are relevant whatever therapy you're providing: what's past is prologue, our subjectiveness is unique and should be respected, we are less aware of our motivations that we like to think, and our past relationships play out in clinical relationships.

This last tenet is especially important - transference. I'll give you an example. I treated a patient with exposure therapy, and we hit an impasse. The patient became resistant to further in vivo exposures. When we explored what was happening it became clear that the patient felt distressed by the "clinical" nature of this treatment which activated a negative maternal transference. The patient's mother had been emotionally cold and withholding, mocking the patient for being "sensitive" and "emotional". Once this was explored and addressed, the patient was able to benefit further from exposures. Even though the core treatment was behavioral, an understanding of the patient's early development and feelings about the therapist, were essential to the patient engaging in treatment.

I really wish this was more how it was explained to me in residency. It was largely my ignorance and arrogance, but I was so defensive when getting lectured by psychoanalysts because of how wildly impractical it struck me to spend an MD psychiatrists time seeing the same relatively high functioning patient multiple times per week for years (or even decades!).

Now with some additional wisdom/real world experience, I do absolutely agree that there is real insight into many of the teachings being very relevant to all areas of not only psychotherapy but just routine clinical practice for psychiatrists.

 

[mistafab]

Psychodynamic psychotherapy is evidence-based practice.

The efficacy of psychodynamic psychotherapy - PubMed

Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as "empirically supported" and "evidence based." In addition, patients who receive psychodynamic therapy...

pubmed.ncbi.nlm.nih.gov

The training/supervision I received in doing this has been some of the most helpful growth for me as a psychiatrist, and most helpful for patients. I think having a good foundation in psychodynamics is very useful for weaving in psychotherapy into visits as well as do brief psychotherapy in ED or consult settings. Getting better at psychodynamic psychotherapy makes you better at all therapy, especially supportive or supportive-expressive psychotherapy. The reverse is not necessarily true.

Also, people get all worked up about the explanations in the psychoanalytic learning. Yet if you are in the trenches with patients, it is hard to get growth in your case /practice without getting direct supervision. Even then, you are only getting supervision with one supervisor / one perspective.

The psychoanalytic cases and explanations act as a secondary viewpoint that can give you further insights about your case, without being bounded by the highly lauded "hard science" which is not the reality when face to face with your patient.

When it comes down to it, no conversation is scientifically valid inherently. That's where all these "evidence based" psychotherapies fall short is thinking that somehow because they read what they learned in a manual that that is what makes it helpful for patients. No. What makes the therapy helpful for patients is the therapist. Psychodynamics makes you a better therapist, plain and simple.

 

[R. Matey]

Do you believe it has any clinical value? Are any of you analysts? In most clinical psychology circles it's frowned upon and seen as pseudoscientific but psychoanalytic programs/institutes seem to be going strong in major coastal cities with a large number of analysts being psychiatrists. Just wanted to see if there's any positive reception for it from the psychiatrists perspective.

'Evidence is mixed' is a far cry from pseudoscientific.

 

[comp1]

I think there's a lot of evidence that weekly (or more often) engagement with the vast majority of psychotherapies is beneficial. This certainly includes therapy with a psychodynamic focus. I'm not sure there's ever been a study demonstrating that psychotherapy was worse than nothing, which is really what it should be compared to. Personally, I think comparing the theoretical framework of a given psychotherapy against another is not really helpful or useful, particularly for efficacy. The main point is the connection between the therapist and patient.

 

[Celexa]

I would encourage you to read The Efficacy of Psychodynamic Psychotherapy.

Let's also discuss psychodynamic psychopharmacology.

Psychodynamic psychopharmacology is basically a clincial superpower. Not only did understanding it make me a vastly better and more effective clinician, but it dramatically decreased my own risk of burnout. It forever frees you from the insidious feeling that not prescribing or not making a med change is 'doing nothing', or of blaming yourself or not knowing what to do when the pt doesn't follow your recommendations. It's a tremendously empowering skill set.

This book is excellent and I highly recommend it: Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient https://a.co/d/1lLbX7X

Speaking in more general terms, I echo what others have said eloquently above. Traditional analysis is not something I do or ever will, but psychodynamic theory is alive and well and I use it every day. In addition to individual patient interactions, it is extremely useful as a CL psychiatrist in understanding team dynamics and how teams react to patients. I both use and teach it regularly.

 

[TheRightMedication]

If I didnt have a psychodynamic interest my practice would be radically different. It guides the majority of every word that comes out of my mouth, and characterizes every treatment decision.

For example, talking about how patients feel about exercise, their bodies, society's claim on their bodies, what it means to bully yourself into exercise vs exercise as self love and care, ect. has been very effective in my practice. When its not, we can explore why not and have a couple more goes at it.

Ive had many cases where I observed signals from the patient in our discussion about lifestyle, psychological and historical content is revealed, and we agree I'll lay off it for X number of visits. In many of these cases, by the time X visit approaches the patient has grown more assertive and is exercising in a way that suits them that perhaps I couldnt have imagined for them.

I also get uncharacteristically enthusiastic about weight training and its growing evidence base which for reasons I dont fully understand seems to be an important part of the dynamic.

Another reason to read some psychodynamic literature is personality disorders. You've got to stay centered, and notice attempts to push, pull, or entice you off center. I really dont know how people without some sense of psychodynamics can do it.

 

[clozareal]

Psychodynamic therapy seems to have some demonstrable efficacy and some patients prefer that modality, so I'm happy that there are others out there who use it.

Personally it did not fit well for me at all. I like having a stated goal, a method to achieve the goal, and a means to determine whether we are moving in the right direction. In the exposure I had during training, I felt the methods of psychodynamic therapy were not well defined and there was not much of an objective measure of correct application or of patient progress, making it difficult to teach and learn.

I suspect you weren't taught it well. This is a misunderstanding of psychodynamic psychotherapy. The elements of a good working alliance in psychodynamic psychotherapy are: having positive regard, working together to develop well defined goals, and agreeing about the method to meet those goals. No one is saying that you can't use objective measurement rating scales in psychodynamic therapy. I'm in analytic therapy myself and these were some of the first things we talked about and what we continue to revisit every few months. I sometimes tell her that I feel like I've had a personality transplant after 3 years of working with her.

Kernberg writes that psychoanalytic technique consists of interpretation, analysis of transference and countertransference, and technical neutrality. The technique of interpretation, in and of itself, is broken down into "clarification," "confrontation," and "interpretation proper" depending on where the patient is in their level of understanding/reflective functioning.

The goals of CBT and other sorts of therapies are to alleviate symptoms of depression and anxiety. Psychodynamic therapy aims to do more: it focuses on building core psychological strengths—such as the capacity to have more fulfilling relationships, to make more effective use of one’s abilities, and to face life’s challenges with greater freedom and flexibility.

If you're looking for a list of goals about what actually constitutes good mental health that can be focused on in psychodynamic psychotherapy, here is a list in the paper I linked above:

● Is able to use his/her talents, abilities, and energy effectively and productively.
● Enjoys challenges; takes pleasure in accomplishing things.
● Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring.
● Finds meaning in belonging and contributing to a larger community (e.g., organization, church, neighborhood).
● Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others.
● Is empathic; is sensitive and responsive to other people’s needs and feelings.
● Is able to assert him/herself effectively and appropriately when necessary.
● Appreciates and responds to humor.
● Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, perceptions, and self-perceptions) and can use and benefit from it.
● Appears to have come to terms with painful experiences from the past; has found meaning in and grown from such experiences.
● Is articulate; can express self well in words.
● Has an active and satisfying sex life.
● Appears comfortable and at ease in social situations.
● Generally finds contentment and happiness in life’s activities.
● Tends to express affect appropriate in quality and intensity to the situation at hand.
● Has the capacity to recognize alternative viewpoints, even in matters that stir up strong feelings.
● Has moral and ethical standards and strives to live up to them.
● Is creative; is able to see things or approach problems in novel ways.
● Tends to be conscientious and responsible.
● Tends to be energetic and outgoing.
● Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways.
● Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions.
● Is able to form close and lasting friendships characterized by mutual support and sharing of experiences.

Psychoanalysis I have no direct exposure to, but IMO any therapy that requires the patient to already have a high baseline level of functioning and takes hundreds of therapy hours to move them to a slightly higher? level of functioning is not something I have much use for.

This is also a stereotype of psychoanalysis that it's only for high-functioning patients. Analytic therapy has a rich history of working with more severely disturbed patients, including personality disorders, dissociative disorders, trauma, etc. Some prominent analysts even wrote about their work in treating of those with schizophrenia, autism, bipolar.

 

[FlowRate]

Tongue in cheek--I think of Psychoanalysis proper as having a sprinkling of MLM/Ponzi scheme and scientology to it. "Oh yes, to become an analyst you must be fully analyzed [fully cleared of your thetans.]" I like to hyperbolically imagine that most analysts' patients are in therapy to be analysts.

My program was very psychodynamically heavy. Almost all of our behavioral supervisors were psychodynamically informed. A sizable portion of my psychodynamic supervisors were analytically trained. I think it is a helpful framework for better understanding patients and clinical situations. The example splik gave was a great one.

I feel increasingly out of touch the longer I go having not kept up on reading about psychodynamic theory or seeing and discussing patients in this way and should really do some shoring up of those skills.

 

[clausewitz2]

Paying attention to the transference/countertransference is a vital skill that will be helpful throughout a psychiatric career. I had this one patient who I worked with regularly for months ostensibly for social anxiety and while there was an element of that, I just found his account of his symptoms and experience utterly dull. Uncharacteristically dull. Like, "my eyes are glazing over and I'm fighting not to yawn" dull. It didn't help that he was not super talkative and I had to drag stuff out of him a lot of the time. I started dreaded seeing him on my schedule for the day, I knew it was going to be so incredibly boring.

But I had this sense that something else was going on, he was surprisingly eager to meet with me regularly for someone who apparently was not having very severe or interesting problems. So I keep digging and prying and trying to get at what was really going on. He becomes more passive and stuck, failing month after month to engage with any behavioral experiments to address his social anxiety but also apparently being so boring that he didn't even have hobbies or do anything in his spare time apart from watch TV, which he was quite clear he didn't really enjoy much (!)

I finally stopped and backed off, took him a bit more at face value, ceased trying to wrest anything out of him.

A month later, out of the blue, he mentions that he lost $80,000 playing online blackjack in the last three months, that he had struggled with problem gambling for years, and it had gotten to the point where he as an adult had asked his parents to take over his bank accounts and only give him small amounts of cash. It also turns out if you play online blackjack for 8 hours a day and hold a job, you don't have very much time left over for anything else.

He wasn't talking about the things that were actually meaningful or important to him, so of course it was dull as dishwater. And he had hidden this stuff from people for years, so of course if I feel at all invasive he is going to clam up immediately. The minute I appear to be backing off and spacing out appointments more, though, it all comes out.

 

[clausewitz2]

I also want to put in a plug for Functional Analytic Psychotherapy, a modality that comes to us from a parallel dimension where Freud didn't exist and Watson and Skinner invented psychoanalysis.

 

[Stagg737]

This is also a stereotype of psychoanalysis that it's only for high-functioning patients. Analytic therapy has a rich history of working with more severely disturbed patients, including personality disorders, dissociative disorders, trauma, etc. Some prominent analysts even wrote about their work in treating of those with schizophrenia, autism, bipolar.

Sure, but realistically the amount of time required for psychoanalysis in SMI/SPMI patients is very high while there are many other aspects of care that offer far more bang for the buck (general social interventions, medications, etc). One could argue that patients requiring higher levels of care should have psychoanalysis considered as part of their care given the amount of time exposed to MH professionals, but for some of those patients (severe psychosis or autism) the ceiling for any therapies is going to be too low to justify the amount of time psychoanalysis entails.

 

[birchswing]

I've tried two times now to write something pithy, and it devolves into a pages long essay each time. I'll try again.

Based on my experience, the pitfall of psychodynamic therapy is investing in a modality with a single, fallible person, and what is accrued at an intersubjective level is not exportable.

Because of not having something immediately interchangeable (such as with one SSRI being unavailable but another is, or a skills-based therapy that someone else can teach), the source of the therapeutic effect emanates from one particular individual (and the associated relationship) and they can not only end the therapy without an immediate alternative but also cause immense damage that cannot be repaired outside the context of that relationship entirely.

In finally making this pithy, it is lacking.

In terms of damage, I put the 15 year psychodynamic therapy I had (which was good except for the last year and a half) up there with benzodiazepines. It could have been different. But it was negative sum, in the end. It was a relationship. With one person. Who knew me, and knew things no one else ever had or probably ever will. No one else will ever have that context or the callbacks, the longitudinal conceptualization (and in this case nothing was ever written down, although I don't know how much written records help anyway). No one else will intuit things based on the years of relationship building. I had adapted to living life being able to confide and trust and change in that context. In my case, it would have been better it never happened and I had adapted without that.

I'm not saying ending is bad. But there are really bad ways to end. If I keep going on it's going to be another pages long essay.

I guess the short of it and the part that is universal is that it places too much risk with one person rather than a system. And maybe it's edge cases where it ends up going very sideways, but I think the crux of it having the potential to go sideways is that isolation with a single person over such a prolonged period of time isn't very interchangeable and gives a unique potential to do damage. If they're not good at endings, you don't know at the beginning. And it's only the two of you.

I don't think you should throw it out. But maybe decentralize it somehow.

If there's any interest in me expounding on this, I can paste what I previously cut.

If there's any interest in me shortening what I had written before, you have just read that.

 

[tr]

I suspect you weren't taught it well. This is a misunderstanding of psychodynamic psychotherapy. The elements of a good working alliance in psychodynamic psychotherapy are: having positive regard, working together to develop well defined goals, and agreeing about the method to meet those goals. No one is saying that you can't use objective measurement rating scales in psychodynamic therapy. I'm in analytic therapy myself and these were some of the first things we talked about and what we continue to revisit every few months. I sometimes tell her that I feel like I've had a personality transplant after 3 years of working with her.

It's definitely possible that I just had a bad early exposure. My first two therapy preceptors in residency were both psychodynamically oriented. Certainly there was never any discussion of therapy goals, or any kind of structured method to achieve them. There was a lot of reassurance about presumed efficacy, and handwaving about "creating a holding environment" and whatnot.

Kernberg writes that psychoanalytic technique consists of interpretation, analysis of transference and countertransference, and technical neutrality. The technique of interpretation, in and of itself, is broken down into "clarification," "confrontation," and "interpretation proper" depending on where the patient is in their level of understanding/reflective functioning.

Neutral stance seems unlikely to be helpful for all but the most secure individuals. I recall using this approach early on in my training because I thought I was supposed to (probably due to cultural seepage and having read some Freud in high school). My experience since then has been that unconditional positive regard, while perhaps more difficult for the therapist to maintain, is more helpful for most people.

Attention to transference and countertransference I would consider universal, trans-modality techniques.

Interpretation is broad enough that it could mean almost anything, including responses that could range from transformatively helpful to totally counterproductive.

The goals of CBT and other sorts of therapies are to alleviate symptoms of depression and anxiety. Psychodynamic therapy aims to do more: it focuses on building core psychological strengths—such as the capacity to have more fulfilling relationships, to make more effective use of one’s abilities, and to face life’s challenges with greater freedom and flexibility.

Any of these goals can also be pursued with CBT. The goal is defined by the patient, with assistance provided by the therapist if needed.
My thought is that the defining characteristics of CBT are the explicit delineation of a therapy goal, the use of targeted methods to achieve it, and the use of some means of feedback on progress that is not entirely dependent on the therapist's intuition.

I have not met any psychodynamically oriented psychotherapists who use any of the above elements. Perhaps that is a reflection of my limited exposure. On the other hand, if they were doing all three of the above, I would say they were doing CBT (or a CBT-based modality).

Let's also discuss psychodynamic psychopharmacology.

Psychodynamic psychopharmacology is basically a clincial superpower. Not only did understanding it make me a vastly better and more effective clinician, but it dramatically decreased my own risk of burnout. It forever frees you from the insidious feeling that not prescribing or not making a med change is 'doing nothing', or of blaming yourself or not knowing what to do when the pt doesn't follow your recommendations. It's a tremendously empowering skill set.

This I was taught as a CBT/MI technique. "Sitting with open hands"

I think MI may win for the most universally useful thing I ever learned actually. "Roll with resistance" is genius. It works for psychiatric patients, oppositional toddlers, hostile colleagues, and irritating family members alike.

 

[Celexa]

It's definitely possible that I just had a bad early exposure. My first two therapy preceptors in residency were both psychodynamically oriented. Certainly there was never any discussion of therapy goals, or any kind of structured method to achieve them. There was a lot of reassurance about presumed efficacy, and handwaving about "creating a holding environment" and whatnot.



Neutral stance seems unlikely to be helpful for all but the most secure individuals. I recall using this approach early on in my training because I thought I was supposed to (probably due to cultural seepage and having read some Freud in high school). My experience since then has been that unconditional positive regard, while perhaps more difficult for the therapist to maintain, is more helpful for most people.

Attention to transference and countertransference I would consider universal, trans-modality techniques.

Interpretation is broad enough that it could mean almost anything, including responses that could range from transformatively helpful to totally counterproductive.



Any of these goals can also be pursued with CBT. The goal is defined by the patient, with assistance provided by the therapist if needed.
My thought is that the defining characteristics of CBT are the explicit delineation of a therapy goal, the use of targeted methods to achieve it, and the use of some means of feedback on progress that is not entirely dependent on the therapist's intuition.

I have not met any psychodynamically oriented psychotherapists who use any of the above elements. Perhaps that is a reflection of my limited exposure. On the other hand, if they were doing all three of the above, I would say they were doing CBT (or a CBT-based modality).


This I was taught as a CBT/MI technique. "Sitting with open hands"

I think MI may win for the most universally useful thing I ever learned actually. "Roll with resistance" is genius. It works for psychiatric patients, oppositional toddlers, hostile colleagues, and irritating family members alike.

It is a fundamental truth that there is a deep resonance between all effective psychotherapy modalities, core universal truths to effectively engaging a patient in psychotherapeutic change, and so to a certain degree we sometimes pointlessly argue over the superiority of modalities when those core truths are what matters. It is the same as how all human languages have nouns, adjectives, verbs, and identifiable structural relationships between them, however much they differ when spoken. For example if we really got down into the nuts and bolts what I call my neutral stance is probably spitting distance from what you call unconditional positive regard.... Arrived at from different directions (if by neutral stance you mean the therapist maintaining a flattened, non-emotive affect, that's not what I was taught at all). Same thing regarding rolling with resistance etc. Side note: so many times when I am explaining to a staff member how to deal with a challenging personality disordered inpatient I see a light go on in their head "oh, you mean it's like what I am supposed to do with my toddler! I can do that!". Indeed, tremendously useful

I could talk about applications if therapy modalities for hours but in deference to both other obligations and the nature of an internet forum, I'll just say that some patients really benefit from the less explicitly structured, and also generally less explicitly time limited, nature of a psychodynamic approach. However, that doesn't mean that (as others have said) a skilled psychodynamic practitioners doesnt have a sense of direction and a plan. The exploratory and mainly information gathering period is often longer for the psychodynamic approach--but even within that the practitioner should have a clear sense of what directions they are exploring with the patient and why. A lighter hand on the reins doesn't mean NO hand on the reins. And longer doesn't mean indefinite. There's a big difference between it taking a year to get into some of the deeper issues and someone getting no benefit from a decade of repetitive interactions with any of several types of problematic therapists. And I've absolutely encountered psychoanalytic/psychodynamic supervisors who provided no supervision other than endless repetitions of "be curious" and "why do you think that is?" without ever helping the learner gain a deeper understanding of therapeutic technique. Thats a reflection of a poor supervisor, not an indictment of the modality.

 

[clausewitz2]

It is a fundamental truth that there is a deep resonance between all effective psychotherapy modalities, core universal truths to effectively engaging a patient in psychotherapeutic change, and so to a certain degree we sometimes pointlessly argue over the superiority of modalities when those core truths are what matters. It is the same as how all human languages have nouns, adjectives, verbs, and identifiable structural relationships between them, however much they differ when spoken. For example if we really got down into the nuts and bolts what I call my neutral stance is probably spitting distance from what you call unconditional positive regard.... Arrived at from different directions (if by neutral stance you mean the therapist maintaining a flattened, non-emotive affect, that's not what I was taught at all). Same thing regarding rolling with resistance etc. Side note: so many times when I am explaining to a staff member how to deal with a challenging personality disordered inpatient I see a light go on in their head "oh, you mean it's like what I am supposed to do with my toddler! I can do that!". Indeed, tremendously useful

I could talk about applications if therapy modalities for hours but in deference to both other obligations and the nature of an internet forum, I'll just say that some patients really benefit from the less explicitly structured, and also generally less explicitly time limited, nature of a psychodynamic approach. However, that doesn't mean that (as others have said) a skilled psychodynamic practitioners doesnt have a sense of direction and a plan. The exploratory and mainly information gathering period is often longer for the psychodynamic approach--but even within that the practitioner should have a clear sense of what directions they are exploring with the patient and why. A lighter hand on the reins doesn't mean NO hand on the reins. And longer doesn't mean indefinite. There's a big difference between it taking a year to get into some of the deeper issues and someone getting no benefit from a decade of repetitive interactions with any of several types of problematic therapists. And I've absolutely encountered psychoanalytic/psychodynamic supervisors who provided no supervision other than endless repetitions of "be curious" and "why do you think that is?" without ever helping the learner gain a deeper understanding of therapeutic technique. Thats a reflection of a poor supervisor, not an indictment of the modality.

By the same token, though, 'CBT is just a superficial therapy where you mindlessly apply a manual and never get into anything deep' is the result of a therapist doing CBT badly rather than the modality itself.

 

[Celexa]

By the same token, though, 'CBT is just a superficial therapy where you mindlessly apply a manual and never get into anything deep' is the result of a therapist doing CBT badly rather than the modality itself.

Of course. I certainly didn't mean to imply CBT is superficial. It definitely is not.

At the end of the day the skill of the therapist is what matters the most--including whether the therapist has the skill to identify if they do or do not have the right skill set for what the patient needs.

 

[SmallBird]

A slight tangent, but for those who don't learn psychodynamic therapy/theory, how do you work through the myriad issues that come up in the course of regular psychiatric practice that are otherwise major barriers to care? I have worked with some doctors who formulaically offer medication, and if a patient refuses, they basically give up or if needed file for involuntary meds. I find that as someone who only does inpatient work I rely heavily on psychodynamic theory to make sense of the ways in which two patients with the same diagnosis can be very different, and as a lens through which to understand and address the range of behaviors/beliefs that interfere with treatment. MI can achieve this for some more specific issues but it is, in my view, less rich and individualized.

 

[tr]

A slight tangent, but for those who don't learn psychodynamic therapy/theory, how do you work through the myriad issues that come up in the course of regular psychiatric practice that are otherwise major barriers to care? I have worked with some doctors who formulaically offer medication, and if a patient refuses, they basically give up or if needed file for involuntary meds. I find that as someone who only does inpatient work I rely heavily on psychodynamic theory to make sense of the ways in which two patients with the same diagnosis can be very different, and as a lens through which to understand and address the range of behaviors/beliefs that interfere with treatment. MI can achieve this for some more specific issues but it is, in my view, less rich and individualized.

I find MI perfect for this. I actually can't picture how a psychodynamic approach would be used in most of this type of situation. 'Interpretation,' for example, seems highly unlikely to be useful with a hostile, non-psychologically-minded patient.

Whenever some tension or disagreement arises I usually back up to MI mode. I'm not sure what you mean by it's not individualized? The content is always specific to the particular patient.

 

[Tom4705]

The people who frown upon it, as the OP mentioned, are usually members of a different school of thought. Imo, psychoanalysis has 100x the value of EMDR and other fad therapies. CBT was invented to be a "good enough," cheaper, non-inferior alternative to psychoanalysis. The only reason CBT is seen as more evidence-based is that it's simplistic and manualized enough to fit better into studies.

In what way does Psychoanalysis have more value than those other therapies, and how does one measure such a metric if it can't be adequately put into studies? I ask as someone absolutely fascinated with Psychoanalysis

 

[Tom4705]

I would encourage you to read The Efficacy of Psychodynamic Psychotherapy.

I'm definitely gonna check it out! Thanks!

 

[Tom4705]

Getting better at psychodynamic psychotherapy makes you better at all therapy, especially supportive or supportive-expressive psychotherapy. The reverse is not necessarily true.

Could you explain this a bit more?

 

[Tom4705]

I've tried two times now to write something pithy, and it devolves into a pages long essay each time. I'll try again.

Based on my experience, the pitfall of psychodynamic therapy is investing in a modality with a single, fallible person, and what is accrued at an intersubjective level is not exportable.

Because of not having something immediately interchangeable (such as with one SSRI being unavailable but another is, or a skills-based therapy that someone else can teach), the source of the therapeutic effect emanates from one particular individual (and the associated relationship) and they can not only end the therapy without an immediate alternative but also cause immense damage that cannot be repaired outside the context of that relationship entirely.

In finally making this pithy, it is lacking.

In terms of damage, I put the 15 year psychodynamic therapy I had (which was good except for the last year and a half) up there with benzodiazepines. It could have been different. But it was negative sum, in the end. It was a relationship. With one person. Who knew me, and knew things no one else ever had or probably ever will. No one else will ever have that context or the callbacks, the longitudinal conceptualization (and in this case nothing was ever written down, although I don't know how much written records help anyway). No one else will intuit things based on the years of relationship building. I had adapted to living life being able to confide and trust and change in that context. In my case, it would have been better it never happened and I had adapted without that.

I'm not saying ending is bad. But there are really bad ways to end. If I keep going on it's going to be another pages long essay.

I guess the short of it and the part that is universal is that it places too much risk with one person rather than a system. And maybe it's edge cases where it ends up going very sideways, but I think the crux of it having the potential to go sideways is that isolation with a single person over such a prolonged period of time isn't very interchangeable and gives a unique potential to do damage. If they're not good at endings, you don't know at the beginning. And it's only the two of you.

I don't think you should throw it out. But maybe decentralize it somehow.

If there's any interest in me expounding on this, I can paste what I previously cut.

If there's any interest in me shortening what I had written before, you have just read that.

I am DEFINITELY interested in reading the whole of what you wrote. Post it if you can!

Also just to be clear, were you talking about psychodynamic therapy or psychoanalysis proper? Because I was under the understanding that psychodynamic therapy is meant to be much shorter in duration while still focusing on tenants from psychoanalysis (transference, unconscious mind, etc)

 

[Tom4705]

I've absolutely encountered psychoanalytic/psychodynamic supervisors who provided no supervision other than endless repetitions of "be curious" and "why do you think that is?" without ever helping the learner gain a deeper understanding of therapeutic technique. Thats a reflection of a poor supervisor, not an indictment of the modality.

That's interesting. How would one go about finding a supervisor that is helpful/competent? Especially at an analytic institute?

 

[Tom4705]

I find MI perfect for this. I actually can't picture how a psychodynamic approach would be used in most of this type of situation. 'Interpretation,' for example, seems highly unlikely to be useful with a hostile, non-psychologically-minded patient.

Whenever some tension or disagreement arises I usually back up to MI mode. I'm not sure what you mean by it's not individualized? The content is always specific to the particular patient.

What is MI?

 

[usoggyojimbo]

Despite being towards the end of residency at a program that seems to be more psychodynamically oriented than many, I feel like I don't have a good understanding of what of psychodynamic therapy is. It always seems to be defined in vague, uncertain ways that's hard for me to explain or understand myself.

 

[tr]

What is MI?

Motivational Interviewing

 

[mistafab]

This is somewhat related - but to address folks who felt like they had poor psychodynamic training - and the folks who are starting/early residency who want to get gud.

1. If you are interested in psychodynamics, I recommend you get involved with the local psychoanalytic institute and get supervision through them. A good therapist might not be a good teacher - so the institute will probably help you find someone actually good at teachign this stuff. Many have practicums for practicing professionals (i,e, MDs or PhDs) that include lectures or a longitudinal therapy training that can fit around your schedule.
2. Therapy, psychodynamics especially, is an area where the more you read, the better you will get. period. It shows. You cant hide it.
3. You don't have to be good at psychodynamics to be a good therapist. However, you should try to get gud at at least one psychotherapy modality during your residency. You probably can't be great at everything, but you can get decent over your 4 years of residency.

For my journey to at least journeyman level - I took a psychodynamic lecture series outside my program. I read some fundamental psychodynamic books / papers. I had a supervisor from the analytic institute for a year working on my therapy cases. And for supervision, I did the recordings and dictated sessions.

You will get what you put in. Put in the effort on at least one modality, and you can use that pretty much in any setting. For me, psychodynamics has been by far my most important growth in training. I have never been analyzed myself, and I've never been to therapy as a patient. But you can get pretty good just by putting in some effort. I can't imagine being very good at psychodynamics if I had just taken the basic lectures with my program and "winged it" with some generic therapy supervisor.

 

[romanticscience]

Do you believe it has any clinical value? Are any of you analysts? In most clinical psychology circles it's frowned upon and seen as pseudoscientific but psychoanalytic programs/institutes seem to be going strong in major coastal cities with a large number of analysts being psychiatrists. Just wanted to see if there's any positive reception for it from the psychiatrists perspective.

I have a strong psychodynamic background, having completed two years of local institute training and two years of transference-focused psychotherapy training (TFP).

I think certain therapies evolved to help a particular problem but then become overly generalized to be used with everything. This may be what is happening with EMDR, which I believe is the current psychoanalysis.

Psychoanalysis which later evolved into psychodynamic, was originally developed for dissociative conditions (e.g., hysterical). Freud was essentially treating functional neurological symptom disorders. Free association, clarification, confrontation, and interpretation were very effective for people who dissociated or split the connections between thoughts--emotions--behaviors--situations.

In my opinion, transference-focused therapy or hypnosis are the best tools for working with dissociative phenomena. MI +/- CBT works pretty much more efficiently for everything else (i.e., neurotic conditions). However, it's pretty tough to do MI with someone who splits or dissociates; you may ask them what they want to work on, but they're not aware. What they need to work on emergencies [I'm not going to change this; too ironic, meant to say "emerge"] in the transference. It's annoying that many psychodynamic therapists don't even do the analytic or expressive techniques; most "psychodynamic" therapy in the community is essentially "supportive psychodynamic therapy." I actually shifted away from TFP because...IT'S HARD WORK having patients angry with you all the time and having to set limits.

I'm probably missing a bunch; these are my off-the-cuff opinions. I'm odd and actually think hypnosis is the original dynamic therapy. Though, I do have support.

 

[clozareal]

I find MI perfect for this. I actually can't picture how a psychodynamic approach would be used in most of this type of situation. 'Interpretation,' for example, seems highly unlikely to be useful with a hostile, non-psychologically-minded patient.

This is an incorrect application of interpretation. You wouldn't do it with someone who doesn't have reflective functioning and especially if they are in a non-mentalizing mode. You have to be able to take a very active stance at time and take control when needed since the patient may feel out of control. Mentalization based therapy (a modern form of psychodynamic treatment) would encourage clinicians to "stop," "rewind," and "explore" early when there is evidence of non-mentalizing.

The neutral stance isn't saying that you don't have unconditional positive regard for the patient, it's that you're approaching the patient's ideas, conflicts, what they are saying with curiosity and a "not knowing" stance, asking them to elaborate and let it come into sharper focus and letting them feel it (i.e., clarification).

In this case, I wouldn't go to confrontation (i.e., tactfully bringing unconscious thoughts, emotions, behaviors into patient's awareness), or interpretation (i.e., hypothesizing or playing around with meanings of certain thoughts, emotions, actions to see if they fit or not). That would destabilize the patient.

Motivational interviewing is great when there is ambivalence with working toward a certain goal, but in inpatient settings there is often antagonistic goals or lack of insight here. It often requires the patient to at least have some baseline level of desire or motivation, but is of two minds about it. Inpatients are of one mind about wanting to just get out of the hospital and that there is nothing wrong with them.

 

[SmallBird]

I find MI perfect for this. I actually can't picture how a psychodynamic approach would be used in most of this type of situation. 'Interpretation,' for example, seems highly unlikely to be useful with a hostile, non-psychologically-minded patient.

Whenever some tension or disagreement arises I usually back up to MI mode. I'm not sure what you mean by it's not individualized? The content is always specific to the particular patient.

It sounds like MI supports a rich clinical process for you. I find dynamic therapy to be the cornerstone of how I describe psychological formulations in acute settings. I judge how well an approach is working based on how much of the clinical data it’s able to draw on and integrate into the formulation, versus an approach which relies on deductively finding the one or two data points on which the theory relies.