Psychiatry and Freud

[AntiKarateKid]

I'm in medical school and am currently most interested in becoming a psychiatrist. However, when I completed my psychiatry block in MS2 last year, something confused me. The professors were very big on Freud. Giving him credit for seemingly everything and upon questioning, defended him vigorously.

There were psychiatrists who had promoted the idea of the unconscious before him. Psychiatrists were publishing in scientific journals before him. Platonism was alive at his time, and Plato already had a division of reason, emotion, and appetitite influencing our behavior and as the philosopher of science, Popper, pointed out, Freudian models of interpretation were pseudoscience since they did not really make predictions but retroactively reinterpreted reality to suit their model after the fact. Not to mention that many of his theories about women and penis envy, homosexuality and absentee fathers, etc are trash. Yet he's this superstar in my professors' eyes.

Am I going to be forced to join a Freud admiration club in residency and beyond?

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[WisNeuro]

Am I going to be forced to join a Freud admiration club in residency and beyond?

Not if you want to practice evidence based medicine.

 

[Armadillos]

It may be more of an indictment against my own lack of reading, but I probably know less about Freud and his theories than an undergrad who just took a psychology class.

I do plan to learn more about this stuff at some point to get more well rounded but for now there are way more important things for me to focus on.

 

[singasongofjoy]

I certainly hope he is not representative of the rest of the faculty where you are. My bet is you're not going to run into that again.

 

[Mad Jack]

I'm in medical school and am currently most interested in becoming a psychiatrist. However, when I completed my psychiatry block in MS2 last year, something confused me. The professors were very big on Freud. Giving him credit for seemingly everything and upon questioning, defended him vigorously.

There were psychiatrists who had promoted the idea of the unconscious before him. Psychiatrists were publishing in scientific journals before him. Platonism was alive at his time, and Plato already had a division of reason, emotion, and appetitite influencing our behavior and as the philosopher of science pointed out, Freudian models of interpretation were pseudoscience since they did not really make predictions but retroactively reinterpreted reality to suit their model after the fact. Not to mention that many of his theories about women and penis envy, homosexuality and absentee fathers, etc are trash. Yet he's this superstar in my professors' eyes.

Am I going to be forced to join a Freud admiration club in residency and beyond?

Freud isn't big with most psychiatrists these days.

 

[singasongofjoy]

It may be more of an indictment against my own lack of reading, but I probably know less about Freud and his theories than an undergrad who just took a psychology class.

I do plan to learn more about this stuff at some point to get more well rounded but for now there are way more important things for me to focus on.

I wouldn't spend too much time there if you're trying to be more well-rounded. There is a lot else to read too. FWIW during the entire 5 years I spent getting a PhD in psychology, I spent about a total of 1.25 class periods talking about Freud, and 1 day of that was in a history of psychology class.

 

[Merovinge]

I'm in medical school and am currently most interested in becoming a psychiatrist. However, when I completed my psychiatry block in MS2 last year, something confused me. The professors were very big on Freud. Giving him credit for seemingly everything and upon questioning, defended him vigorously.

There were psychiatrists who had promoted the idea of the unconscious before him. Psychiatrists were publishing in scientific journals before him. Platonism was alive at his time, and Plato already had a division of reason, emotion, and appetitite influencing our behavior and as the philosopher of science, Popper, pointed out, Freudian models of interpretation were pseudoscience since they did not really make predictions but retroactively reinterpreted reality to suit their model after the fact. Not to mention that many of his theories about women and penis envy, homosexuality and absentee fathers, etc are trash. Yet he's this superstar in my professors' eyes.

Am I going to be forced to join a Freud admiration club in residency and beyond?

It does depend where you train. If your higher ups have significant associations with psychoanalytic institutes it can border on religious levels of devotion to Freud or his subsequent followers ideas. Most residents coming into training have pretty limited interest in psychodynamic therapy (and certainly not analytic therapy) so you should not be a fish out of water with your co-residents. Just watch your mouth around the old guard, it can definitely get you into trouble (happened to a... friend I know).

 

[Amygdarya]

Short answer:
You will hardly ever hear Freud's name mentioned in psychiatry nowadays (and it's fine if you have a strictly practical approach to psychiatry), but I believe that dismissing his ideas entirely without first finding out how they came about and what they mean (and not what the lay people believe they mean) is a form of intellectual laziness.

Long answer:
My home psychiatry residency program is one of the most, if not the most, psychodynamically oriented in the country. Since I'm very interested in psychotherapy in general and curious about psychodynamics in particular, I asked to audit a didactic course on psychoanalytic theories of mind for psych residents this semester. The course is taught by a top analyst and psychoanalysis educator and a top historian of psychoanalysis. Both of them are highly intelligent people who don't accept any of Freud's - or any other theorist's - ideas blindly, and encourage their students to critically evaluate these ideas themselves. Re Freud: their overall point is that while Freud's ideas were not necessarily entirely original, what Freud excelled at was synthesizing ideas coming from different fields of knowledge, as well as tirelessly updating his theories. So I mean, even people like them, who are basically the blue blood of contemporary psychoanalysis, are by no means dogmatic in their approach or blindly admiring Freud.

Re Freud's ideas not being evidence-based medicine: not entirely true. I mean, hardly anyone practices classic Freudian psychoanalysis now to start with, there have been a lot of new developments in the field since Freud's death. Just check out Mitchell&Black's book "Freud and beyond" - or at least read the intro chapter that dispels some of the big myths about psychoanalysis, including the ones that psychiatrists still worship Freud and follow him to the letter. And modern psychodynamic psychotherapy that is the result of these developments has actually been proven to be effective for a number of psychiatric disorders (see Shedler's review in 2010 American Psychologist, or Leichsenring's meta-analysis in 2008 JAMA, among others; there've been a bunch of clinical trials - mostly European - showing comparable effectiveness of CBT and long-term psychodynamic psychotherapy and possibly higher effectiveness if PDPT in more complex disorders).
Also, there's been a lot of evidence supporting at least some of psychoanalytic ideas coming from cognitive neuroscience research lately.

Bottom line:
Read. Expand your knowledge. And make your own conclusions based on what you've learned.

P. S. - Oh, and funny thing is, even at an institution like this, I don't remember Freud being mentioned at all in any of our medical student psychiatry classes.

 

[HarryMTieboutMD]

I agree with the above in the importance of parsing Freud's writings/classic psychoanalysis and psychodynamic therapy in its current incarnation.

No one of any serious academic merit uses Freudian interpretations in a clinical sense, though concepts like transference, countertransference, defense mechanisms (really Anna Freud's pet project), etc are fundamental concepts for just interacting with patients.

Most analysts left in academia who live and breathe Freud are old perverts who likely sleep with their patients (and hit on younger trainees) a la Schlomo Dove in Mount Misery. Because they have been around for so long (fortunately my department kicked them out in the 60s) and are tenured, departments have a hard time getting rid of them. Like a lot of other way too old doctors who can't seem to spend time away from the hospital, they criticize anything new as bad medicine/laziness/etc, mostly because they don't like change.

 

[erg923]

I agree with the above in the importance of parsing Freud's writings/classic psychoanalysis and psychodynamic therapy in its current incarnation.

No one of any serious academic merit uses Freudian interpretations in a clinical sense, though concepts like transference, countertransference, defense mechanisms (really Anna Freud's pet project), etc are fundamental concepts for just interacting with patients.

Most analysts left in academia who live and breathe Freud are old perverts who likely sleep with their patients (and hit on younger trainees) a la Schlomo Dove in Mount Misery. Because they have been around for so long (fortunately my department kicked them out in the 60s) and are tenured, departments have a hard time getting rid of them. Like a lot of other way too old doctors who can't seem to spend time away from the hospital, they criticize anything new as bad medicine/laziness/etc, mostly because they don't like change.

Freud hit on/articulated some very universal elements of the human existence and it relation to "problems in living"/psychopathology...no doubt.

100+ years later, clinical psychology/psychiatry has found more pragmatic, efficient and less ridiculous ways of addressing and ameliorating these concerns.

 

[clausewitz2]

I have actually cited Freud in a peer-reviewed paper before. But, uh, it was his early work on pure word-deafness from when he was still mostly a neurologist.

Which is a bit like citing Piaget on molluscs, I suppose.

 

[splik]

Freud - love him! Yes he was a sex-obsessed miserable hysteric who hated women, hated Americans, bullied his patients, had zero boundaries, excommunicated any followers who had the temerity to question him, ignored his patients' traumatic pasts, and peddled unfalsifiable and unverifiable theories but, as Jung put it, he was "the neurologist, who brought psychology to psychiatry." Yes plenty of people describe concepts similar to the unconscious thousands of years before Freud, but they were not psychiatrists. Psychiatry was largely an intellectual bereft wasteland with no concept of mind at all. The psychologist Hans Eysenck who was no fan of Freud said "what is true about psychoanalysis is not new, and what is new about psychoanalysis is not true." Even if that were the case, Freud certainly popularized ideas that have completed altered the shape of our cultural landscape today.

Freud was a failed neuroanatomist and neurologist. He knew that the neurology of his day would never provide of meaningful concept or understanding of mind and so he turned to psychology. He knew, and lamented, that his case reports "lack the serious stamp of science" as he said. He believed that one day we would understand the neuroanatomical substrates of mind, desire and motivation. His concepts are best not taken literally. Psychoanalysis is metaphor par excellance. So concerned was he with the unscientific nature of his work that he outline a potential way forward in "Project for a Scientific Psychology."

Freud was a storyteller and his case histories should be treated no differently than that of many 19th century novelists who were exploring similar concepts in their writing. He was at his best as cultural commentator. Civilization and Its Discontent, stands, imho, as one of his most important (if not the most important) offerings.

Contemporary psychoanalysis still owes a nod to Freud but we have moved on quite a bit since then.

This isn't the 1960s. You will not be fighting off Freudians. There is plenty of dogmatism in this pseudoscientific field. I am not sure radical behaviorists, biological psychiatrists, Neo-Kraepelinians, "clinical neuroscientists", or eclectics are any better than rabid Freudians. Dogmatism, regardless of its branding should always be rejected. The so-called eclectic approach (which is not an approach at all) should also be regarded with suspicion and disdain. Psychiatry at its best is pluralistic. We are simply too complex, and the range of mental life psychiatry encompasses, too broad, for one model to be "the answer."

I remember when I interviewed at Hopkins, where they save particular scorn from Freud and dynamic psychiatry in general, the then PD conceded, "if there's one thing those analysts know about it's sex." As George Box said, "all models are wrong, but some are useful." Even that pervert can be useful on occassion.

 

[deleted343839]

I believe that dismissing his ideas entirely without first finding out how they came about and what they mean (and not what the lay people believe they mean) is a form of intellectual laziness.

Re Freud's ideas not being evidence-based medicine: not entirely true. I mean, hardly anyone practices classic Freudian psychoanalysis now to start with, there have been a lot of new developments in the field since Freud's death.

Well, no one is advocating a wholesale rejection of psychodynamic theory. I agree that it's important, for historical and contextual reasons, to be familiar with the work of seminal theorists (in psychology, we have to have at least some exposure to this in doctoral training, usually in the form of a course or seminar called "history and systems"). Beyond that exposure, it's diminishing returns unless you are doing some rather eclectic theoretical work. In the same way, we can also appreciate the high points of Thorndike's and Watson's work for context, but then we quickly and rightly move on to the more useful incarnations of behaviorism.

 

[Crayola227]

concepts like the ego, id, transference, counter-transference, I think are useful

I think even the nuttier stuff like the Oedipus and Electra complex (Jung) have their uses

 

[smalltownpsych]

The only thing worse than the rabid Freud fans are the rabid anti-Freudians.

 

[Amygdarya]

Well, no one is advocating a wholesale rejection of psychodynamic theory. I agree that it's important, for historical and contextual reasons, to be familiar with the work of seminal theorists (in psychology, we have to have at least some exposure to this in doctoral training, usually in the form of a course or seminar called "history and systems"). Beyond that exposure, it's diminishing returns unless you are doing some rather eclectic theoretical work. In the same way, we can also appreciate the high points of Thorndike's and Watson's work for context, but then we quickly and rightly move on to the more useful incarnations of behaviorism.

I was replying to the OP who's new here and who was apparently taken aback by his professors' mentions of Freud, rather than to the enlightened audience of the subforum's regulars Or maybe I was projecting my own earlier attitude onto the OP: I started getting interested in psychiatry and psychotherapy years before medical school when I was still doing hardcore basic science research, and I read quite a bit of Beck because CBT was evidence based, while staying away from anything Freud because it was thoroughly unscientific. Now I know better - precisely because I started reading more broadly. My point is, it's fairly common now to denigrate Freud without actually knowing what he was really about. (Also, as seems to be the case with the OP, many people now learn about Freud's ideas from his critics rather than from his own - very readable - writings or from any of the reasonable historians of psychoanalysis.)

(Note to self: gotta catch up on my behaviorists)

 

[splik]

a friend of mine (who was a MD/PhD neuroscientist who is a psychiatrist) once told me "I used to think psychiatry was all about the brain. Now I know it's all about your mother."

 

[HarryMTieboutMD]

Freud - love him! Yes he was a sex-obsessed miserable hysteric who hated women, hated Americans, bullied his patients, had zero boundaries, excommunicated any followers who had the temerity to question him, ignored his patients' traumatic pasts, and peddled unfalsifiable and unverifiable theories but, as Jung put it, he was "the neurologist, who brought psychology to psychiatry." Yes plenty of people describe concepts similar to the unconscious thousands of years before Freud, but they were not psychiatrists. Psychiatry was largely an intellectual bereft wasteland with no concept of mind at all. The psychologist Hans Eysenck who was no fan of Freud said "what is true about psychoanalysis is not new, and what is new about psychoanalysis is not true." Even if that were the case, Freud certainly popularized ideas that have completed altered the shape of our cultural landscape today.

Freud was a failed neuroanatomist and neurologist. He knew that the neurology of his day would never provide of meaningful concept or understanding of mind and so he turned to psychology. He knew, and lamented, that his case reports "lack the serious stamp of science" as he said. He believed that one day we would understand the neuroanatomical substrates of mind, desire and motivation. His concepts are best not taken literally. Psychoanalysis is metaphor par excellance. So concerned was he with the unscientific nature of his work that he outline a potential way forward in "Project for a Scientific Psychology."

This is a false statement. Freud was a very astute neurologist and neuropathologist- he was the first to describe metal staining of neurons (using gold, years before Golgi and Cajal perfected the technique) and wrote wonderful descriptions of aphasia and infantile paralysis http://ispub.com/IJN/3/1/11746

It was only when Freud started doing massive amounts of cocaine following his "fellowship" with Charcot and Marie did drift away from the rigors and dogmatisms of Viennese academic medicine as Howard Markel really describes nicely in his book Anatomy of Addiction

 

[SeniorWrangler]

To paraphrase the Blues Brothers, "we do both kinds of psychiatry here, Freudian and Jungian."

If you do go into behavioral sciences, I encourage you to read some of his original clinical writings, which are keenly observed and fascinating, and not skip to the Cliff's Notes version of the theories. And then read Carl Jung, to see just how deep the rabbit hole goes.

 

[HarryMTieboutMD]

Even that pervert can be useful on occassion.

Only if your department chair values academically irrelevant faculty who don't bring in NIH money, fail to generate substantial cash flow that gets fed back into the department (from what I glean even cash only money from senior analysts with an academic appointment would not generate loads of money for the dept), and are liability issues because of almost inevitable sexual harassment lawsuits...

 

[clausewitz2]

Only if your department chair values academically irrelevant faculty who don't bring in NIH money, fail to generate substantial cash flow that gets fed back into the department (from what I glean even cash only money from senior analysts with an academic appointment would not generate loads of money for the dept), and are liability issues because of almost inevitable sexual harassment lawsuits...

So when was it that analysts murdered your family?

 

[Merovinge]

So when was it that analysts murdered you family?

I'm sure they didn't but Harry is not a fan of pseudo-science.

 

[splik]

then why did he become a psychiatrist?!

 

[Armadillos]

Only if your department chair values academically irrelevant faculty who don't bring in NIH money, fail to generate substantial cash flow that gets fed back into the department (from what I glean even cash only money from senior analysts with an academic appointment would not generate loads of money for the dept), and are liability issues because of almost inevitable sexual harassment lawsuits...

Lol funny that places can easily double your departments NIH funding and manage to have some analysts around

 

[Nasrudin]

It seems to me Freud has an archetypal significance. He seems to loom large as the old, dead father, or the authoritarian, despotic, weight of historical psychoanalytic culture.

I don't know that the revisionist approach, of the sort would castigate the founding fathers in post-modern historiographical vein, really is all that fair to him. I don't know enough of his primary works, yet, to say. But it seems the sort of thing that we could easily be ungrateful of what he and others had given us that we now take as self-evident, and to focus on the obvious flaws that are out of sync with this era.

I remember wanting to reject psychodynamic perspectives just... because. Because of my own psychodynamics...hahaha. So. I'm also not quick to seize the "evidence-based" hype train of certain easily studied and algorithmic psychotherapeutic technologies. I can already see how CBT could be demonstrated as useful.... for the one of a dozen patients who would stick with the dry and boring approach...that is smashed at them like industrialized psychological assembly line. i know, i know. it's your phd thesis, and i don't know diddley about it's wha-wh-whawha.... i get it.

 

[HarryMTieboutMD]

Lol funny that places can easily double your departments NIH funding and manage to have some analysts around

This is not even a remotely sound argument.

First of all, that our department is ~1/2 the size (in total faculty including research, clinical, and adjunct) of most major [coastal] departments (or 1/4 the size of the NY programs because they have a ton of adjunct faculty) notwithstanding, we still rank 11th in NIH funding (according to most recent data I could find). Simply, proportionally we are on par with most of the other major departments.

Second, as has been stated, analysts left in academia are vestiges of the past who are just kind of "there", and given the option, I'm sure that most department chairs would rather dispose of them

(major exception to both cases is MGH because they have money pouring in from everywhere... on the order of magnitudes more than other elite places)

 

[splik]

This is not even a remotely sound argument.

First of all, that our department is ~1/2 the size (in total faculty including research, clinical, and adjunct) of most major [coastal] departments (or 1/4 the size of the NY programs because they have a ton of adjunct faculty) notwithstanding, we still rank 11th in NIH funding (according to most recent data I could find). Simply, proportionally we are on par with most of the other major departments.

Second, as has been stated, analysts left in academia are vestiges of the past who are just kind of "there", and given the option, I'm sure that most department chairs would rather dispose of them

(major exception to both cases is MGH because they have money pouring in from everywhere... on the order of magnitudes more than other elite places)

actually MGH killed off their analysts long ago (1970s). they have walled off the others from the rest of the dept. But this is boston, there is no getting away from it and the residents will still learn alot about psychodynamic psychotherapy.

 

[HarryMTieboutMD]

actually MGH killed off their analysts long ago (1970s). they have walled off the others from the rest of the dept. But this is boston, there is no getting away from it and the residents will still learn alot about psychodynamic psychotherapy.

oops... conflated the departments at MGH and McClean- either way, lots of cash flow

 

[deleted343839]

I'm also not quick to seize the "evidence-based" hype train of certain easily studied and algorithmic psychotherapeutic technologies. I can already see how CBT could be demonstrated as useful.... for the one of a dozen patients who would stick with the dry and boring approach...that is smashed at them like industrialized psychological assembly line.

"Easily studied" - you've designed and conducted therapy trials, eh?

The belief that CBT is the process of following an algorithm is a mark of poor training. By all means criticize the buzzwordy-ness and crappy implementation of CBT. Criticize the poorly prepared, overly technique-driven therapists who equate the treatment manual with the process, and their oblivious, box-checking employers. But sit with a skilled therapist who understands how to work with verbal behavior and how to engage patients in meaningful behavioral experiments, and you may change your opinion. Once you know what you're doing, CBT affords an enormous amount of creativity for the therapist. On the other hand, a superficial understanding yields far better dystopian metaphors.

Perhaps it is because one of my early clinical supervisors was fond of control mastery theory, but I've always felt skeptical of drawing very sharp lines to contrast dynamic and cognitive-behavioral therapy processes.

 

[Merovinge]

"Easily studied" - you've designed and conducted therapy trials, eh?

The belief that CBT is the process of following an algorithm is a mark of poor training. By all means criticize the buzzwordy-ness and crappy implementation of CBT. Criticize the poorly prepared, overly technique-driven therapists who equate the treatment manual with the process, and their oblivious, box-checking employers. But sit with with a skilled therapist who understands how to work with verbal behavior and how to engage patients in meaningful behavioral experiments, and you may change your opinion. Once you know what you're doing, CBT affords an enormous amount of creativity for the therapist. On the other hand, a superficial understanding yields far better dystopian metaphors.

Perhaps it is because one of my early clinical supervisors was fond of control mastery theory, but I've always felt skeptical of drawing very sharp lines to contrast dynamic and cognitive-behavioral therapy processes.

Absolutely, the difference between a psychologist who has done nothing but CBT for >10 years for predominantly depression/anxiety (that is not psychotic patients) and seeing them do their magic in that population is quite the feat. Workbooks make up such a small bit of the whole shebang.

 

[Nasrudin]

"Easily studied" - you've designed and conducted therapy trials, eh?

The belief that CBT is the process of following an algorithm is a mark of poor training. By all means criticize the buzzwordy-ness and crappy implementation of CBT. Criticize the poorly prepared, overly technique-driven therapists who equate the treatment manual with the process, and their oblivious, box-checking employers. But sit with a skilled therapist who understands how to work with verbal behavior and how to engage patients in meaningful behavioral experiments, and you may change your opinion. Once you know what you're doing, CBT affords an enormous amount of creativity for the therapist. On the other hand, a superficial understanding yields far better dystopian metaphors.

Perhaps it is because one of my early clinical supervisors was fond of control mastery theory, but I've always felt skeptical of drawing very sharp lines to contrast dynamic and cognitive-behavioral therapy processes.

I don't have a negative opinion of it. I'm referring to the institutional push for evidence based therapies and grants therein as a research engine that, to some extent, justifies itself. That and I'm responding to the camp based competition of specific therapy modalities. My CBT supervisor is dope, and I will have no insinuation stand uncontested, that I think she isn't.

Also. I'm trying to figure out the root of your retort---"dry and boring."--I think. I meant that only as applied for standardized research. Which seeks to hold everything constant, and apply a universal technique.

My point is that, people are unique. And any technique immediately becomes something off map as it blends into the therapist/patient dyad.

 

[Nasrudin]

I'd also like to point out. That if my provocation predicts so easily a response, then that's my point. I don't buy into the war of modalities mindset that would gravitate towards a thread with Freud in the title.

I knew the type of Type A, research heavy psychologists, that frequent this forum are more likely the disciples of Aaron Beck and crew, and probably came up during the backlash against psychoanalysis. so...bingo. If a goofball like me can read your hand... what does that say.

 

[smalltownpsych]

I'd also like to point out. That if my provocation predicts so easily a response, then that's my point. I don't buy into the war of modalities mindset that would gravitate towards a thread with Freud in the title.

I knew the type of Type A, research heavy psychologists, that frequent this forum are more likely the disciples of Aaron Beck and crew, and probably came up during the backlash against psychoanalysis. so...bingo. If a goofball like me can read your hand... what does that say.

I don't know if Type A is really an apt descriptor, but there are definitely different personality types in the field of psychology and I tend to be the outlier/goofball these days so can appreciate the sentiment.

 

[deleted343839]

That if my provocation predicts so easily a response, then that's my point

Look, you're not the first to make a caricature of a system of therapy, and I'm not the first to call it out. That's a theme of this thread, no?

I'll admit that your "industrialized psychological assembly line" quip recalls too many conversations with poorly trained psychologists who are coming up with excuses to resist normal things like measuring their own outcomes, etc. The pro-RxP arguments that emanate from the same crowd are more frequent but less interesting and my responses to them are more blunt. Yes, the response to any of it is Sisyphean. Next interpretation, please...

If a goofball like me can read your hand... what does that say.

Not only am I a scientist (who functions primarily as a clinician), but since becoming a psychologist I've starting caring for someone with special mental health needs, which has sharpened my intolerance for bullsh*t and pseudoscience. I demand more of the mental health professions.

How do you do it, Sherlock?

 

[Nasrudin]

I'd also like to point out. That if my provocation predicts so easily a response, then that's my point. I don't buy into the war of modalities mindset that would gravitate towards a thread with Freud in the title.

I knew the type of Type A, research heavy psychologists, that frequent this forum are more likely the disciples of Aaron Beck and crew, and probably came up during the backlash against psychoanalysis. so...bingo. If a goofball like me can read your hand... what does that say.

Look, you're not the first to make a caricature of a system of therapy, and I'm not the first to call it out. That's a theme of this thread, no?

I'll admit that your "industrialized psychological assembly line" quip recalls too many conversations with poorly trained psychologists who are coming up with excuses to resist normal things like measuring their own outcomes, etc. The pro-RxP arguments that emanate from the same crowd are more frequent but less interesting and my responses to them are more blunt. Yes, the response to any of it is Sisyphean. Next interpretation, please...



Not only am I a scientist (who functions primarily as a clinician), but since becoming a psychologist I've starting caring for someone with special mental health needs, which has sharpened my intolerance for bullsh*t and pseudoscience. I demand more of the mental health professions.

How do you do it, Sherlock?

Well i'm trying to learn basic techniques. And am finding the application of them is anything but uniform, when I'm actually listening to my patients. I see the studies on CBT and I think hmmm?.... if approached formulaically like a study it's not going to have much personal meaning to them. So I use the manual or protocol for a certain problem only loosely. And I discuss my work with recordings with my supervisor every week. I feel blessed because she's inspiring and anything by algorithmic. But we still try to hold a CBT frame.

I mean, look there's some heavy papers, that I've seen but can't recall, i'm sure you've seen them, that call into question the actual practice differences between practitioners of specific stylistic monikers. I think most forms are better than placebo. Maybe that puts me in a relational camp, loosely, for now. With particular interests in meaning orientations, self-authoring, psychodynamics, and CBT. But I've yet to find a clean application of just CBT without involving other modes of working with patients. So... idk. I don't know really how I'm doing it just yet.

How should I be doing it? How do you measure your outcomes?

Or better yet, do you have a single recommendation for a book, on a particular, Evidence Based, therapy that you think it would be criminal not to have read?

I think that would be more productive than our multi-thread head butting.

 

[Nasrudin]

Also, what does your word, pseudoscience, apply to? I think there's good evidence for psychodynamic therapy. Am I wrong?

 

[Nasrudin]

Also. haha. Also, I'm not sure why I should hate pseudoscience. Art is f@ckscience. Philosophy is whereScience. Music is invisible-science. Relationships are inscrutableScience. All of them are meaningful. Without them we would be barren or dead. Why should I force the meaning of therapeutic patient interactions into science or not science?

 

[3lefts]

Also. haha. Also, I'm not sure why I should hate pseudoscience. Art is f@ckscience. Philosophy is whereScience. Music is invisible-science. Relationships are inscrutableScience. All of them are meaningful. Without them we would be barren or dead. Why should I force the meaning of therapeutic patient interactions into science or not science?

I am wary of pseudoscience because psychiatry has a long history of doctors who thought they were doing the right thing putting their patients through treatments that were ineffective, harmful or even human rights violations. I respect evidence based guidelines as a starting point for a more personalized and nuanced framework of treatment, even knowing that every
patient cannot be the average person in the average situation in the average trial.


Sent from my iPad using SDN mobile

 

[Nasrudin]

I am wary of pseudoscience because psychiatry has a long history of doctors who thought they were doing the right thing putting their patients through treatments that were ineffective, harmful or even human rights violations. I respect evidence based guidelines as a starting point for a more personalized and nuanced framework of treatment, even knowing that every
patient cannot be the average person in the average situation in the average trial.


Sent from my iPad using SDN mobile

OK. So what specifically in our purvey is pseudoscience that should be abhorrent?

You guys are just saying that word without being specific as if you're casting a spell.

 

[deleted343839]

Or better yet, do you have a single recommendation for a book, on a particular, Evidence Based, therapy that you think it would be criminal not to have read?

I really don't. There are so many ways to learn about the empirical foundations of psychotherapy.

Also, what does your word, pseudoscience, apply to? I think there's good evidence for psychodynamic therapy. Am I wrong?

No; I agree with you. I'm referring to a way of thinking that provides a veneer of scientific plausibility but serves a primarily emotional function, usually by way of shutting down competing explanations and ways of evaluating them. There are some obvious harms that can come from this. But I would argue that there are scientific and pseudoscientific ways of thinking about behavioral and cognitive therapies, psychodynamic therapy, and all the rest. There is not always a clear demarcation and we have to be aware of that tension. That does not negate the other qualities of our work, be they aesthetic, spiritual, cultural, or otherwise, but if we are to distinguish ourselves from other kinds of "healers" we're obliged to be disciplined about our scientific orientation and question our thinking a lot.

I think that would be more productive than our multi-thread head butting.

I admit my error of getting hooked into this convo. Won't happen again.

 

[splik]

Only if your department chair values academically irrelevant faculty who don't bring in NIH money, fail to generate substantial cash flow that gets fed back into the department (from what I glean even cash only money from senior analysts with an academic appointment would not generate loads of money for the dept), and are liability issues because of almost inevitable sexual harassment lawsuits...

I was talking about Freud when I said "that pervert"
I find it bizarre that you seem to think that psychoanalysts are inevitable sexual harassment lawsuits when you didn't even train at a place with any analysts. Fact is, your biological psychiatrist friends are more likely to be sex pests than psychoanalysts by virtue of sheer number. We all know these senior faculty who grope everyone. They aren't necessarily analysts, and if they are, it is by virtue of age. Being an analyst is not a qualification for being a sex pest. It's usually white matter disease, neurofibrillary tangles, alcohol, or spirochetes than facilitate this. Occassionally its malignant narcissism or frank psychopathy.

And at the top programs the senior analysts most certainly did bring in grant money. In fact they may well have brought in NIMH money in the days before the NIMH became academically irrelevant. There are more sources of funding that NIMH and many private organizations do fund psychotherapy research (increasingly necessary in this age when the NIMH shuns psychotherapy). I can think of several analysts who brought, and continue to bring in grant money. They also wrote books, and provide consulting services, in some cases to corportations. In the old days you got a pure faculty position with the university and thus were not pressured to bring in the money like you are now. Really, this is a problem with the ridiculous expectations we have of faculty at academic medical centers.

 

[clausewitz2]

I was talking about Freud when I said "that pervert"
I find it bizarre that you seem to think that psychoanalysts are inevitable sexual harassment lawsuits when you didn't even train at a place with any analysts. Fact is, your biological psychiatrist friends are more likely to be sex pests than psychoanalysts by virtue of sheer number. We all know these senior faculty who grope everyone. They aren't necessarily analysts, and if they are, it is by virtue of age. Being an analyst is not a qualification for being a sex pest. It's usually white matter disease, neurofibrillary tangles, alcohol, or spirochetes than facilitate this. Occassionally its malignant narcissism or frank psychopathy.

And at the top programs the senior analysts most certainly did bring in grant money. In fact they may well have brought in NIMH money in the days before the NIMH became academically irrelevant. There are more sources of funding that NIMH and many private organizations do fund psychotherapy research (increasingly necessary in this age when the NIMH shuns psychotherapy). I can think of several analysts who brought, and continue to bring in grant money. They also wrote books, and provide consulting services, in some cases to corportations. In the old days you got a pure faculty position with the university and thus were not pressured to bring in the money like you are now. Really, this is a problem with the ridiculous expectations we have of faculty at academic medical centers.

"...a problem with the ridiculous expectations we have of faculty in academia generally."

FTFY

 

[clausewitz2]

I really don't. There are so many ways to learn about the empirical foundations of psychotherapy.



No; I agree with you. I'm referring to a way of thinking that provides a veneer of scientific plausibility but serves a primarily emotional function, usually by way of shutting down competing explanations and ways of evaluating them. There are some obvious harms that can come from this. But I would argue that there are scientific and pseudoscientific ways of thinking about behavioral and cognitive therapies, psychodynamic therapy, and all the rest. There is not always a clear demarcation and we have to be aware of that tension. That does not negate the other qualities of our work, be they aesthetic, spiritual, cultural, or otherwise, but if we are to distinguish ourselves from other kinds of "healers" we're obliged to be disciplined about our scientific orientation and question our thinking a lot.



I admit my error of getting hooked into this convo. Won't happen again.

Well put. It is always sort of going through my mind when working with someone new "okay, what can I do that a priest/houngan/seidrkona could not do for this person?"

 

[Nasrudin]

Well put. It is always sort of going through my mind when working with someone new "okay, what can I do that a priest/houngan/seidrkona could not do for this person?"

Whereas I wonder why we feel existential plight to distinguish ourselves from them, such that Tony Robbins must be shady, the local priest must be doing something other than what we're doing, the shamanic ritual has to be creepy or inherently corrupt, the motivational expertise of the basketball coach is just whoopity-do, the charisma of the special forces commander has absolutely nothing to do with effectively influencing a patient, etc.

I think more than just evidence based research, we need our own behavioral economics, to delineate what we're doing and perhaps more importantly why. Or why not, to these other things I mention.

 

[clausewitz2]

Whereas I wonder why we feel existential plight to distinguish ourselves from them, such that Tony Robbins must be shady, the local priest must be doing something other than what we're doing, the shamanic ritual has to by creepy or inherently corrupt, the motivational expertise of the basketball coach is just whoopity-do, the charisma of the special forces commander has absolutely nothing to do with effectively influencing a patient, etc.

I think more than just evidence based research, we need our own behavioral economics, to delineate what we're doing and perhaps more importantly why. Or why not, to these other things I mention.

One major reason that I think we need to be distinguishing ourselves from these folks is mainly because if we accept that we are doing basically the same thing, why should we get paid? Gotta have a lot more hustle to make psychiatry money as a motivational speaker, and obviously most professional religious folks are not rolling in cash. If we are simply overeducated shamans, we are mainly superfluous. I recognize that morbidity and mortality from psychiatric disorders is not decreasing nearly as rapidly as anyone would like, but I refuse to believe that we have made no advances whatsoever in behavioral health that are not shared by Tony Robbins or Bill Belichick (I recognize it's a different sport, but the man is clearly an evil motivational genius of some variety).

 

[splik]

"behavioral health" pssh wash your mouth out!!! we wont condone such language here!

 

[clausewitz2]

"behavioral health" pssh wash your mouth out!!! we wont condone such language here!

Forgive me for my sins, for I am in the benighted wasteland of my off service months and lo, I have fallen into the error of excessive medical framing of the Great Work.

 

[smalltownpsych]

Maybe I'm just a bit too eastern in my thinking but I think it is less either/or and more both/and. I am a scientist and a healer/coach/motivator/armchair philosopher. That's what gives me the edge. The relationship and the technique are important although sometimes I focus on either the relationship or technique too much and forget the other. It is hard to walk the middle path. On the one hand the shamans are calling me to let go and use the force, on the other hand, the systems are telling me to use measurable goals, specific techniques, and chart the results. Linehan has done a good job of navigating this by separating psychotherapy from the teaching and training of skills. Most devotees and proponents of DBT don't really know that though.

 

[HarryMTieboutMD]

I was talking about Freud when I said "that pervert"
I find it bizarre that you seem to think that psychoanalysts are inevitable sexual harassment lawsuits when you didn't even train at a place with any analysts. Fact is, your biological psychiatrist friends are more likely to be sex pests than psychoanalysts by virtue of sheer number. We all know these senior faculty who grope everyone. They aren't necessarily analysts, and if they are, it is by virtue of age. Being an analyst is not a qualification for being a sex pest. It's usually white matter disease, neurofibrillary tangles, alcohol, or spirochetes than facilitate this. Occassionally its malignant narcissism or frank psychopathy.

And at the top programs the senior analysts most certainly did bring in grant money. In fact they may well have brought in NIMH money in the days before the NIMH became academically irrelevant. There are more sources of funding that NIMH and many private organizations do fund psychotherapy research (increasingly necessary in this age when the NIMH shuns psychotherapy). I can think of several analysts who brought, and continue to bring in grant money. They also wrote books, and provide consulting services, in some cases to corportations. In the old days you got a pure faculty position with the university and thus were not pressured to bring in the money like you are now. Really, this is a problem with the ridiculous expectations we have of faculty at academic medical centers.

I wasn't referring to the old pervert doctors, irrespective of specialty (though they mostly end up being surgeons) who hit on residents/med students/nurses, etc, though none of my "biological" (whatever that means) older attendings to that, though they have their fair amount of lovable quirks)

I was referring to the well known practice of analysts sleeping with patients (https://www.psychologytoday.com/blog/impromptu-man/201206/sex-patients-revisited ), and I seriously doubt that this practice has been completely abandoned, especially in the blueblood private practice market in NYC. It's probably harder to get away with it in an academic setting, but I'm guessing for the older analysts who have been following patients for decades, it's still not uncommon.

Besides, the "biological" psychiatrists prefer to take money from pharma and not report it rather than engage in sex crimes...

Sure, analysts used to be well funded when analysis dominated academic medicine, but now that is definitely NOT the case. And if an analyst has NIH money, it's definitely the exception and not the rule; he or she apparently has done some extra training (research wise) to develop a solvent (career/funding wise) skillset beyond listening to himself/herself talk to impressionable med students/residents.

And its a conceptual error to conflate psychotherapy research with analysts' (lack of) NIH funding. Our most well funded faculty member (a geropsychiatrist incidentally) has a received a lot of funding- and has conducted- a substantial amount of psychotherapy research in addition to his "biological" studies.

 

[Eivuwan]

I was referring to the well known practice of analysts sleeping with patients (https://www.psychologytoday.com/blog/impromptu-man/201206/sex-patients-revisited ), and I seriously doubt that this practice has been completely abandoned, especially in the blueblood private practice market in NYC. It's probably harder to get away with it in an academic setting, but I'm guessing for the older analysts who have been following patients for decades, it's still not uncommon.

Besides, the "biological" psychiatrists prefer to take money from pharma and not report it rather than engage in sex crimes.

The article you linked does not support your implication that these therapists slept with their patient because they are analysts.