Psychoanalytic/psychodynamic internships?

[DynamicDidactic]

What about mentalization therapy for BPD? It has some good support behind it.

not nearly as strong empirical support, particularly over another active treatments. Furthermore, I do not believe there is any support for reducing suicide attempts compared to an active treatment.

When you are suicidal, do you want the best therapy or the second best?

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[CheetahGirl]

DD, What about when your (the client's) problems are long-withstanding?! You need to learn some skills (said like a rapper from the Bronx). Therapy should teach some skills.

(For the purpose of making a separate point b/c these methods may not be appropriate for some suicidal high-risky/impulsive pts), Irrespective of suicidality - PE is skills-based and works and yes, you can join w/ the patient and move thru some horrific material by developing that strong patient-therapist alliance with your strong dynamic training background (quite quickly and easily) and facilitate some major change in a fairly short-term, efficacious manner. And you don't want to go there with Foa (she's mainly CBT but her approach can be integrated well with majority of orientations). Her theories are sound. It works for most w/ respect to attrition and other confounding variables.

Likewise, DBT (going back to Linehan)/Mentalization (TFP a la Fonagy and Target/British School) are mounting some nice empirical data as we speak. This is all progressive, but yielding highly significant reliability and validity, mind you.‎

 

[smalltownpsych]

DD, What about when your (the client's) problems are long-withstanding?! You need to learn some skills (said like a rapper from the Bronx). Therapy should teach some skills.

(For the purpose of making a separate point b/c these methods may not be appropriate for some suicidal high-risky/impulsive pts), Irrespective of suicidality - PE is skills-based and works and yes, you can join w/ the patient and move thru some horrific material by developing that strong patient-therapist alliance with your strong dynamic training background (quite quickly and easily) and facilitate some major change in a fairly short-term, efficacious manner. And you don't want to go there with Foa (she's mainly CBT but her approach can be integrated well with majority of orientations). Her theories are sound. It works for most w/ respect to attrition and other confounding variables.

Likewise, DBT (going back to Linehan)/Mentalization (TFP a la Fonagy and Target/British School) are mounting some nice empirical data as we speak. This is all progressive, but yielding highly significant reliability and validity, mind you.‎

Don't forget about Kernberg who has a very nice text on how to use TFP for BPD. I find that it doesn't conflict with DBT either. I find that it really helps with the interpersonal component of DBT. I also prefer the term of pathological internalized object relations as opposed to a more CBT equivalent like maladaptive schema or pattern of relating. It just seems to capture the complexity of the construct better and fits very well with the concept of invalidating environment.

 

[smalltownpsych]

Its all about the science.

http://blogs.uw.edu/brtc/files/2014...agnostic-emotion-dsyreguation-A-pilot-RCT.pdf

The background of that article includes the other sources of similar research.

When I started grad school no one had really heard of Linehan or DBT yet. The "science" at the time had no treatments and I was taught to stay away from those patients. I agree that science is key and at the core of what we do but throughout our field and medicine in general we are often flying blind. Everyday I am working with an n=1 sometimes I have strong research to point me in right direction but usually it's not so clear. Even if I had a treatment that was 90 percent effective (oh how I wish), I still have to figure out how to help the guy sitting across from me who is one of the 10%.

 

[DynamicDidactic]

I'm actually unsure if anything is even being asked of me anymore.

I am advocating to move away from treatment based on outdated, not empirically supported modes. Particularly for serious disorders like eating disorders and suicidal BPD. I'm advocating for practitioners to not be lazy by staying updated on the science and examining their own biases when it comes to treatment.

 

[Fan_of_Meehl]

I'm actually unsure if anything is even being asked of me anymore.

I am advocating to move away from treatment based on outdated, not empirically supported modes. Particularly for serious disorders like eating disorders and suicidal BPD. I'm advocating for practitioners to not be lazy by staying updated on the science and examining their own biases when it comes to treatment.

I can't speak for others but I am interested in everyone's thoughts and experiences (especially experiences) in applying the specific empirically-supported behavior-change techniques/protocols (including Linehan's DBT philosopy and approach) as well as the other theoretical traditions (Kernberg, others?). I can get peer-reviewed articles from Sciencedirect and Medline and books from Amazon. Although getting references from others on this board is something I find immensely useful (because it's a free forum for exchanging information among colleagues), translating basic scientific findings (from controlled outcome studies) or well-reasoned and often integrative theory (from books such as Linehan's on DBT) into one's clinical practice is not always straightforward and the clinician's experiences in attempting to successfully apply these techniques/theory is something that is rarer for me to be able to access via the published professional literature. I realize that 'the plural of anecdote is not data' but I see this board as more of an unstructured laid back opportunities for us to share our experiences in trying to be scientist-practitioners (or whatever your particular brand of professional practice is) in our daily practice.

 

[Fan_of_Meehl]

When I started grad school no one had really heard of Linehan or DBT yet. The "science" at the time had no treatments and I was taught to stay away from those patients. I agree that science is key and at the core of what we do but throughout our field and medicine in general we are often flying blind. Everyday I am working with an n=1 sometimes I have strong research to point me in right direction but usually it's not so clear. Even if I had a treatment that was 90 percent effective (oh how I wish), I still have to figure out how to help the guy sitting across from me who is one of the 10%.

I' sure there's a tremendous amount of overlap and agreement between, say, Linehan and some psychodynamic folks (ya'll mentioned Kernberg) regarding best practices with people who have the borderline personality disorder diagnosis. Are there any pertinent points of divergence between them such that one would tell you in a given situation with a borderline patient to do X while the other would say, no...according to my theory you should do Y?

 

[CheetahGirl]

I'm actually unsure if anything is even being asked of me anymore.

I am advocating to move away from treatment based on outdated, not empirically supported modes. Particularly for serious disorders like eating disorders and suicidal BPD. I'm advocating for practitioners to not be lazy by staying updated on the science and examining their own biases when it comes to treatment.

I believe we're all saying the same thing... but some of us are disputing the notion that psychodynamic interventions/orientations are archaic and unsubstantiated (and perhaps some psychoanalytic approaches - but I cannot speak to that because I am not an analyst so I do not know what exactly their 5+ post-doc years yield as far as the science/research goes). I suppose the debate stems from the unfamiliarity of dynamic-approaches based on responses in this and previous threads, and the assumption that those of us who are dynamically-trained are still sitting behind our clients who are laying on couches, spending $225/45-minute session for 10+ years and not getting better, and doing nothing but listening and saying "um-hum, seems like you felt powerless in the presence of your mother...perhaps you are reacting in a similar way to your female boss, and this adds to your sad mood and thoughts of wanting to harm yourself?"

It is not likely that this is going on with newly-trained folks...perhaps only the old-school folks, who may or may not be updating themselves (and I hope for the benefit of their patients, they are).

 

[Nahsil]

I'm in a grad program with a lot of people interested in psychoanalysis (particularly Lacanian), and I don't think you'd find them as unreasonable, archaic, irresponsible, etc, as some of you might expect. There are legitimate critiques of the CBT and empiricist paradigm out there, if you care to look, and many psychoanalysts are operating with full consciousness of what they're doing and why they're doing it, and why they're not doing something else. I'm not one of these psychoanalysis people by the way, and I have my own axe to grind with it (namely how reductive and "closed-system" it can be with regard to conceiving of human beings; my first exposure to Freud elicited this response and it hasn't changed much). I'm also not opposed to empiricism, although I do try to exercise caution and take into account political, social-contextual, etc, factors, when dealing with something like evidence based treatment. I'd encourage people to resist black and white reactions to "supported versus non-supported treatments." People like Lisa Osbeck and Kareen Malone (a Lacanian) at my school do important research into how quantitative science is conducted--looking at its "unconscious" for instance; its assumptions and values, the features of its structure that may influence findings, etc etc. I'm not necessarily arguing for one position or another, just to keep an eye toward the larger picture.

Someone like Nancy McWilliams is probably a good person to look to for a better understanding of the modern relevance of psychoanalysis/what it has to offer.

 

[WisNeuro]

Fair enough, and I haven't seen anyone say "don't study it at all." Moreso, there are advocating that if it wants to be taken seriously as a reimbursed treatment, it needs to show some sort of efficacy for the conditions it purports to treat.

 

[smalltownpsych]

I' sure there's a tremendous amount of overlap and agreement between, say, Linehan and some psychodynamic folks (ya'll mentioned Kernberg) regarding best practices with people who have the borderline personality disorder diagnosis. Are there any pertinent points of divergence between them such that one would tell you in a given situation with a borderline patient to do X while the other would say, no...according to my theory you should do Y?

I haven't run into it. What I find is that they tend to be pretty complimentary. They both start with creating a strong therapeutic frame. They both address treatment threatening behaviors very directly. They both are very explicit and by that you are very open about treatment plan and eliciting a contract. I think that DBT is more focused on teaching skills and TFP more focused on the interpersonal as experienced in the room. i think that a mistake that many therapists do is to begin opening up too much material without making sure that client is ready for it by assessing their ability to emotionally regulate. An advantage of thinking more relationally is recognizing that the therapeutic relationship is part of that assessment of ability to regulate.

I completely agree that we can and should learn from each other about how to apply the principles discovered in the research.

 

[kestrelcry]

Can anyone recommend some pre-doctoral internships in the Northeast with quality psychodynamic/psychoanalytic training?

Oh, also, I've heard the New Jersey VA has a fairly psychodynamic bent to it.

 

[Fan_of_Meehl]

I haven't run into it. What I find is that they tend to be pretty complimentary. They both start with creating a strong therapeutic frame. They both address treatment threatening behaviors very directly. They both are very explicit and by that you are very open about treatment plan and eliciting a contract. I think that DBT is more focused on teaching skills and TFP more focused on the interpersonal as experienced in the room. i think that a mistake that many therapists do is to begin opening up too much material without making sure that client is ready for it by assessing their ability to emotionally regulate. An advantage of thinking more relationally is recognizing that the therapeutic relationship is part of that assessment of ability to regulate.

I completely agree that we can and should learn from each other about how to apply the principles discovered in the research.

Awesome reply...this was exactly what I was looking for. Thanks!

 

[dynamicpsyd]

Can anyone recommend some pre-doctoral internships in the Northeast with quality psychodynamic/psychoanalytic training?

Pennsylvania Hospital in Philadelphia.

 

[dynamicpsyd]

Can anyone recommend some pre-doctoral internships in the Northeast with quality psychodynamic/psychoanalytic training?

In addition to Pennsylvania Hospital:

Reading Hospital (Reading, PA)
Danielson Institute of Boston University
Cambridge Health Alliance/Harvard
Institute of Living/Hartford Hospital
Tuttleman Counseling Services (Temple University Counseling Center)

 

[jade1234]

Anxiously steps ONE toe into this debate....

One article that might be interesting to read is this one: Wachtel, P. (2010), Beyond “ESTs” problematic assumptions in the pursuit of evidence-based practice, Psychoanalytic Psychology, 27: 251–272.

Note that this author is very passionate about his stance, like many of the people on this thread. However I still think his arguments are worth considering.

Cautiously walks out...

 

[hereandnow]

Here is the definitive list:

http://www.apadivisions.org/division-39/leadership/committees/grad-students/internships.aspx

Sometimes, as a therapist, I am struck with the terror of not knowing what to do. It is so tempting to want to know that what I am doing is right. To reach for a manual and stave off my anxiety. I may even sometimes demonize good clinicians who veer from my ideology -- as if by doing so I could insulate myself from wrongdoing. But I gain nothing by pretending to know more than I do. It is in the letting go, in the being vulnerable myself and human, I believe, that a relationship can begin. And that, at least, in my opinion, is how real therapy begins. Good luck on your path.

 

[WisNeuro]

I like Wechtel, he has an amazing stache, but I think sometimes he uses a lot of words to say not much at all. I'll see your Wechtel and raise you a Lillienfeld.

As an aside, people may want to read up on the difference between EST and EBP, sometimes people set up the EST argument to try and refute both, but they are not equivalent terms.

http://www.uwyo.edu/psychology/_files/docs/deacon psyc 4500/lilienfeldresistancetoebp.pdf

 

[Buzzwordsoldier]

When will we drop psychoanalysis as an acceptable training modality? I can accept psychodynamic as having little support but psychoanalytic is just straight up hooey. Not only is there no support but the theory behind it is almost completely accepted as being bonkers. Doesn't every intro psych course nowadays basically acknowledge that all the stages and parent sexual stuff of Freud's as a wacky artifact of the past?

BWS here, rendered damn near digitally apoplectic by the deep irony in DD's post. I guess you answered your first question by posing your second -- kindly consider, we may never be "done with psychoanalysis" (whatever it would mean to be done with something so elemental) so long as people continue to demonize Freud.

 

[Buzzwordsoldier]

I respect some of the empirically supported dynamic work, but I'm with DD on analysis. Show me some good efficacy studies and I may change my mind....

Thus risking missing the very gist of psychoanalysis. Do not be so quick to dismiss what was essentially society's healing response to heretofore unknown atrocity.

 

[erg923]

Thus risking missing the very gist of psychoanalysis. Do not be so quick to dismiss what was essentially society's healing response to heretofore unknown atrocity.

Uh, what?

 

[Buzzwordsoldier]

Uh, what?

Come come. Psychoanalysis thrived in the post-war era for a reason, Erg. But enough for now. I'm off to enjoy the day. Join me in that endeavor or not, chi se ne frega.

 

[futureapppsy2]

Come come. Psychoanalysis thrived in the post-war era for a reason, Erg. But enough for now. I'm off to enjoy the day. Join me in that endeavor or not, chi se ne frega.

At that time, we didn't have the other (very well empirically supported) treatments we have now. You're still getting the common factors of emotional support but now we can provide those and evidence-based techniques that we know promote symptom reduction and improve functioning (PE, ACT, CPT, etc). Just because it was what we had back then and it sort of worked for some people doesn't mean we should revert back to it when there's no evidence suggesting that it's more (or even as or almost) effective as the treatments we have now.

 

[MB8]

Awesome reply...this was exactly what I was looking for. Thanks!

While DBT does have a strong component of teaching skills, there is a whole conceptualization and relational side as well. For instance, the therapist has to know when and where a client falls on a dialectical dilemma (e.g., active passivity vs. apparent competence), and then know how to relate to the client based on where they are (e.g., "benevolent demanding" when client is in active passivity mode vs. "nurturing" when client is in apparent competence).

 

[PsychBiker]

Some things cannot be objectified nor empirically validated, but that does not mean they are not real nor valuable nor effective; I feel really ambivalent about saying this as, years ago, I would have immediately dismissed anyone who spoke this way.

Not every kind of therapy has (and may never have) evidence to support it in the ways some people on this board require them to. For example, in some forms of therapy, if you attempt to objectify an individual's experience so you can measure it, then you have completely undone all previous psychotherapeutic work (e.g. validating one's experiences as meaningful regardless of others' judgement of it). Points like this could be belabored on and refuted ad nauseum - and to what end?

I have come to see that some things need to actually be experienced to be understood, and so it is of no use to anyone to argue about it, which I think is what Buzzwordsoldier was alluding to.

"Who cares" indeed.

 

[futureapppsy2]

Some things cannot be objectified nor empirically validated, but that does not mean they are not real nor valuable nor effective; I feel really ambivalent about saying this as, years ago, I would have immediately dismissed anyone who spoke this way.

Not every kind of therapy has (and may never have) evidence to support it in the ways some people on this board require them to. For example, in some forms of therapy, if you attempt to objectify an individual's experience so you can measure it, then you have completely undone all previous psychotherapeutic work (e.g. validating one's experiences as meaningful regardless of others' judgement of it). Points like this could be belabored on and refuted ad nauseum - and to what end?

I have come to see that some things need to actually be experienced to be understood, and so it is of no use to anyone to argue about it, which I think is what Buzzwordsoldier was alluding to.

"Who cares" indeed.

IMO, this is the kind of thinking that leads to things like everyone's favorite raven dissertation (which I've actually skimmed, and I cannot figure out who on earth thought that was appropriate for a clinical psych dissertation, because it is weird and random and has pretty much nothing to do with clinical psychology or research). Yes, there are some things that are difficult to measure, but that doesn't mean that people should be doing moonbeam therapy because feels, and they know in their heart it works and whatever else. We are health care professionals. We should use science, in conjunction with clinical and situational judgment.

 

[PsychBiker]

To be clear, I do not advocate moonbeam therapy.

 

[Therapist4Chnge]

To be clear, I do not advocate moonbeam therapy.

..that's because it is Moonbeam AND RAINBOW therapy! I mean...everyone knows moonbeams work (and have for decades), but the rainbows...those are the extra special part that requires a $1,000+ seminar and "special training" to work even BETTER!

 

[Fan_of_Meehl]

Some things cannot be objectified nor empirically validated, but that does not mean they are not real nor valuable nor effective; I feel really ambivalent about saying this as, years ago, I would have immediately dismissed anyone who spoke this way.

Not every kind of therapy has (and may never have) evidence to support it in the ways some people on this board require them to. For example, in some forms of therapy, if you attempt to objectify an individual's experience so you can measure it, then you have completely undone all previous psychotherapeutic work (e.g. validating one's experiences as meaningful regardless of others' judgement of it). Points like this could be belabored on and refuted ad nauseum - and to what end?

I have come to see that some things need to actually be experienced to be understood, and so it is of no use to anyone to argue about it, which I think is what Buzzwordsoldier was alluding to.

"Who cares" indeed.

I too have changed my views over the years in the directions that you outline...while still adhering broadly and consistently to the
'empirically-supported therapies' matched to diagnosis, taking into consideration the individual case formulation of the client as well as motivational/relationship factors. No matter how detailed and well-authored, the manualized protocols do not 'implement themselves.' And, when I say that good therapy is a blend of art and science, what I mean by 'art' is the skillful micro-adjustments and customized application of the principles of the empirically-supported therapies to the individual case in real time. By analogy, a skilled surgeon uses 'art' in the application of standardized approaches to perform an operation (and the outcome of an operation can depend greatly on the surgeon implementing it)...it doesn't mean that the surgeon isn't using 'evidence-based medicine' in practicing her/his 'art.' Skilfully blending motivational interviewing, behavioral activation, and just good old fashioned therapeutic relationship-enhancing factors into a first session with patient presenting with alcoholism and clinical depression represents the application of this 'artistry' whereas approaching the same case from nothing more than a Rogerian approach would, to me, represent substandard (at least in terms of being a few decades behind standard of practice and the literature) care for a doctoral level practitioner.