Psychodynamic Therapy Debate - (Moved from the Post Interview Thread)

[Poety]

Hi all, I wanted to move this discussion to this thread to keep our post interview thread focused and to allow more open discussion about psychodynamic therapy - its uses, how its appropriate, when its not (ie during interviews) etc.

Please keep this alive we have great talks going on in there!! I'll start with my first response to MBK


Quoted by MBK2003 in the Post Interview Thread : "I think there are two ideas floating around in this discussion, 1) inappropriate questions during interviews (many of the above examples are grossly inappropriate), and 2) the inherent value of training in psychodynamic psychotherapy. Certainly some interviewers may have the hammer-nail approach which is to say that someone sitting in front of them they will treat more like a patient than like a residency applicant, using all of their tools. I had a CBT therapist ask me about how my self esteem would be affected if a patient suicided? Would I blame myself? Would I develop irrational rituals for my other depressed or suicidal patients to overcompensate?

With regard to the value of psychodynamics, outside of the limited frame of insight-oriented psychotherapy, some of the smartest and most highly regarded psychopharmacologists I've met use psychodynamics to understand more about their patient's response or lack of response to medications. It's also very helpful to being able to identify and work with your own countertransferences in a psychopharm practice - am I making a change in meds now because the patient will benefit or because the patient is looking for me to not fail him like his father did and I don't want to tolerate his devalution of me if I fail to act? As much as it would be great if everyone responded to medications exactly as they should based on reuptake inhibition and receptor occupancy, perception of treatment efficacy also plays a very important role in symptom improvement or lack of."

Hi MBK, I appreciate your post and response - but I would ask wouldn't all of medicine have a bit of countertransferance re: any pharmacology then? I completely understand the difference in the respect that we are going to be psychiatrists but I also think there is a point where we should be able to practice without having to constantly check/double check and keep re-evaluating our reasons for our decisions. I may be the only person who is thinking along these lines but I thought I would throw that in there. Can you tell me your thoughts on this?

I'd also like to move this conversation of the thread to a new thread. I will start it as "Psychodynamic therapy, the risks, the benefits and when it is appropriate"

I'm just doing this because I feel partly responsible for taking this thread in this direction and for the sake of future applicants, I'd like to keep it limited to post interview reviews

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[Doc Samson]

Hi MBK, I appreciate your post and response - but I would ask wouldn't all of medicine have a bit of countertransferance re: any pharmacology then? I completely understand the difference in the respect that we are going to be psychiatrists but I also think there is a point where we should be able to practice without having to constantly check/double check and keep re-evaluating our reasons for our decisions. I may be the only person who is thinking along these lines but I thought I would throw that in there. Can you tell me your thoughts on this?

Of course transference affects the efficacy of any medical treatment. There's a whole bunch of literature on how the pt's view of their internist/surgeon/OB can influence their reaction to any intervention. I know a lot of ED docs who refuse to wear scrubs to work because of studies that show that if they wear a collar and tie they are less likely to get sued. The whole concept of "bedside manner" is based on the idea that if people feel cared for (no matter what you're doing for them pharmacologically), they're going to feel better.

That said... (and I can't emphasize this strongly enough) no-one is "doing psychodynamic therapy" in the interview setting. What people are referring to in this regard is likely the sense that their answers (and emotional reactions) are being taken at more than face value, and are being "interpreted" in some way. This is not therapy. This is not a match violation. This is simply someone paying attention to things in a way that you're probably not used to. As I've mentioned before, different strokes for different folks. If you don't think you'd like to train in a program with an emphasis on psychodynamic treatment, don't rank programs with that emphasis. I would note that the "religious" zealotry that posters have referenced in terms of psychodynamic treatment is now more frequently a hallmark of those who are opposed to it (for whatever reason). In my experience psychodynamic therapists tend to be open to other forms of treatment, and willing to incorporate aspects of other therapies in an eclectic fashion depending on whatever needs the individual patient has.

 

[Poety]

Hi DS, ok so we agree on that subject, then why would one feel its important to evaluate every aspect of the patient -doctor relationship constantly even when it comes down to prescribing meds like MBK said "do I not want to fail him like his father did" etc.... Do you think this is a bit over the top?

OPD you're in practice, care to chime in too?

 

[MBK2003]

Quoted by MBK2003 in the Post Interview Thread :
Hi MBK, I appreciate your post and response - but I would ask wouldn't all of medicine have a bit of countertransferance re: any pharmacology then? I completely understand the difference in the respect that we are going to be psychiatrists but I also think there is a point where we should be able to practice without having to constantly check/double check and keep re-evaluating our reasons for our decisions. I may be the only person who is thinking along these lines but I thought I would throw that in there. Can you tell me your thoughts on this?

I think that you can consider psychodynamics in all prescribing, but psychiatry is unique in medicine just based on the shear size of the placebo response. I can't think of too many other medications for which people who think they might be getting the drug will have a 30-50% improvement in symptoms just with placebo alone - certainly not with antihypertensives, chemotherapeutics, or hypoglycemics is that response so consistently there. I think that in my limited experience, thinking more in depth about the psychodynamics of the interaction comes into play when dealing with patients who are treatment-resistant, or for whom you've tried a number of meds and they suffer intolerable side effects at low doses. Certainly during my first visit with patients who are suffering their first Major Depressive Episode, I don't sit there paralyzed with indecision wondering about whether starting an SSRI is really an enactment of their rescue fantasy. Primary care providers are well suited to diagnosing and treating garden variety, uncomplicated MDD, but what separates out the psychiatrist from the FP is the ability to undertstand and deal with the patient who fails several treatments for their MDD or who develops intolerable side effects on Lexapro 2.5mg, Zoloft 12.5mg, and Effexor 37.5mg. Those are situations where clearly an understanding of the patient's developmental history, object relations, fantasies about medications, and transference/countertransference issues go a long way toward being able to successfully treat the patient.

 

[Poety]

Wow, thats a great way of putting things in perspectives MBK. I see where you are coming from. So my next question would be, do you do this with all your patients? Is it practical to do this?

The more discussion that ensues re: psychodynamic therapy leads me to believe I may not be a be big psychodynamic person - I'm probably more along the CBT, DBT and mixed modalities type. Ofcourse it is necessary to recognize our own countertransferances and the like, but I would think that would be more of an issue on the therapy aspect not biological- you brought up some great points though to think about.

 

[MBK2003]

Wow, thats a great way of putting things in perspectives MBK. I see where you are coming from. So my next question would be, do you do this with all your patients? Is it practical to do this?QUOTE]

I think it's practical to do this for most of the cases I see in psychopharm clinic. For instance, I saw a patient several weeks ago for a new eval who wanted continued treatment for insomnia, on review of systems however there was clear evidence for bipolar II with fairly impairing hypomanic episodes. The patient was initially agreeable to considering treatment for mood disorder, but then decided they didn't want to start Lithium or Depakote for a number of reasons related to potential side effects. If I was not thinking psychodynamically, I might have said, "Listen, you have bipolar II and I can't treat your insomnia if you continue to have cycling mood." An alternative method is the more careful exploration of patient's reasons for wanting to continue the self-destructive hypomanic episodes, fantasies about medications (including prominent fear they will no longer be creative on medications), and significant fear of no longer having that hypomanic euphoria. In this setting I can reasonably say to the patient, "I hear your concerns, how about we continue monthly psychopharm visits to follow-up on your insomnia" and then use those opportunities to explore/motivate patient to consider a trial of mood stabilizers.

The more discussion that ensues re: psychodynamic therapy leads me to believe I may not be a be big psychodynamic person - I'm probably more along the CBT, DBT and mixed modalities type. Ofcourse it is necessary to recognize our own countertransferances and the like, but I would think that would be more of an issue on the therapy aspect not biological- you brought up some great points though to think about.

I would argue that even people who are strict CBT or IPT therapists, utilize a psychodynamic understanding of the patient to understand motivation for treatment, use of resistances (they are there in CBT, why else would people repeatedly not do the homework?), and countertransference to illuminate the inner psychic experience of either the patient or the significant people in their life. For example, the frustration felt when dealing with the help-rejecting complainer who either doesn't do the homework or rejects all approaches to confront their distorted cognitions - this is likely how everyone else in their life experiences them. That must be so isolating for the patient and their family, no wonder the spouse is considering leaving.

I also think that medical students wanting to go into psychiatry have an incomplete understanding of psychodynamic psychotherapy, how it looks, how it feels to be the therapist, and what it's like in the room. I know that I did as a medical student, because you can't really know it until you do it. Certainly very few people would sign up to "be the brass monkey in the corner of the room" as one of my attending describes the perception of technical neutrality. Frankly, psychodynamic therapy (as opposed to strict Freudian psychoanalysis) can be a very interactional therapy. Yes, at times it's difficult to sit there with the patient discussing how they want to destroy you and their fantasized life about you, but it's also fascinating to look at the primary process. E.g. I ran over session with the patient before you and now while you deny being upset about my starting late, you are talking about how your mother favored your brother over you, as if you think I favor my other patient over you and that's why I let him run over time and into your session. I used to think I would never be a psychodynamic therapist, but my experience in residency has changed that dramatically for me. Does that mean I would probe resident applicants about their parents? No. Does that mean I would probe them more about their experience of the psychiatric issues associated with treating medically ill patients? Absolutely.

Just my two cents, anyway.

 

[Poety]

Wow, thats a great way of putting things in perspectives MBK. I see where you are coming from. So my next question would be, do you do this with all your patients? Is it practical to do this?QUOTE]

I think it's practical to do this for most of the cases I see in psychopharm clinic. For instance, I saw a patient several weeks ago for a new eval who wanted continued treatment for insomnia, on review of systems however there was clear evidence for bipolar II with fairly impairing hypomanic episodes. The patient was initially agreeable to considering treatment for mood disorder, but then decided they didn't want to start Lithium or Depakote for a number of reasons related to potential side effects. If I was not thinking psychodynamically, I might have said, "Listen, you have bipolar II and I can't treat your insomnia if you continue to have cycling mood." An alternative method is the more careful exploration of patient's reasons for wanting to continue the self-destructive hypomanic episodes, fantasies about medications (including prominent fear they will no longer be creative on medications), and significant fear of no longer having that hypomanic euphoria. In this setting I can reasonably say to the patient, "I hear your concerns, how about we continue monthly psychopharm visits to follow-up on your insomnia" and then use those opportunities to explore/motivate patient to consider a trial of mood stabilizers.




I would argue that even people who are strict CBT or IPT therapists, utilize a psychodynamic understanding of the patient to understand motivation for treatment, use of resistances (they are there in CBT, why else would people repeatedly not do the homework?), and countertransference to illuminate the inner psychic experience of either the patient or the significant people in their life. For example, the frustration felt when dealing with the help-rejecting complainer who either doesn't do the homework or rejects all approaches to confront their distorted cognitions - this is likely how everyone else in their life experiences them. That must be so isolating for the patient and their family, no wonder the spouse is considering leaving.


I also think that medical students wanting to go into psychiatry have an incomplete understanding of psychodynamic psychotherapy, how it looks, how it feels to be the therapist, and what it's like in the room. I know that I did as a medical student, because you can't really know it until you do it.

Certainly very few people would sign up to "be the brass monkey in the corner of the room" as one of my attending describes the perception of technical neutrality. Frankly, psychodynamic therapy (as opposed to strict Freudian psychoanalysis) can be a very interactional therapy. Yes, at times it's difficult to sit there with the patient discussing how they want to destroy you and their fantasized life about you, but it's also fascinating to look at the primary process. E.g. I ran over session with the patient before you and now while you deny being upset about my starting late, you are talking about how your mother favored your brother over you, as if you think I favor my other patient over you and that's why I let him run over time and into your session. I used to think I would never be a psychodynamic therapist, but my experience in residency has changed that dramatically for me. Does that mean I would probe resident applicants about their parents? No. Does that mean I would probe them more about their experience of the psychiatric issues associated with treating medically ill patients? Absolutely.

Just my two cents, anyway.

Great thoughtful post MBK, and I agree with the bold and red above 100%~

I guess perhaps I feel like my head would explode were I to analyze every detail of everything all the time. However, I appreciate having the knowledge to understand and utilize this skill if I want. Ethically I wouldn't feel bound to having to use it, but I'd like it more like a tool for ready accesss Does that make sense?

 

[PublicHealth]

Primary care providers are well suited to diagnosing and treating garden variety, uncomplicated MDD, but what separates out the psychiatrist from the FP is the ability to undertstand and deal with the patient who fails several treatments for their MDD or who develops intolerable side effects on Lexapro 2.5mg, Zoloft 12.5mg, and Effexor 37.5mg. Those are situations where clearly an understanding of the patient's developmental history, object relations, fantasies about medications, and transference/countertransference issues go a long way toward being able to successfully treat the patient.

That sounds cute, but how many psychiatrists actually do psychotherapy nowadays? Sure, you can cite some psychoanalytic dinosaurs from the 1950s Harvard/Mass Mental era, but really, how many young psychiatrists REGULARLY use psychotherapy? Why do psychotherapy for an hour and make $100 when you can do four 15-minute med checks and make $600? Simple economics, man.

 

[OldPsychDoc]

Hi DS, ok so we agree on that subject, then why would one feel its important to evaluate every aspect of the patient -doctor relationship constantly even when it comes down to prescribing meds like MBK said "do I not want to fail him like his father did" etc.... Do you think this is a bit over the top?

OPD you're in practice, care to chime in too?

I wouldn't touch this topic with a ten-foot penis.


[Oh great--that was my 400th post, and I spent it on a cheap phallic reference! ]

 

[nortomaso]

I think that proponents and opponents of pscyhodynamic psychotherapy alike would agree that it involves an interaction between clinician and patient that is contrived and not entirely within the realm of common sense or common everyday experience. The same could be said of pretty much any therapy-- psycho or pharmaco and certainly ECT. In other words, psychodynamic psychotherapy is a clinical intervention. As such, I think it should be evaluated for efficacy, but more importantly yet, for safety. I've never understood how some write off psychological interventions all together as fluff; I think that hey can be quite potent. But then they can also be dangerous. How do we know that what is being practiced under the name of psychodynamic psychotherapy is not exacerbating conditions or creating new ones?

 

[Poety]

I think that proponents and opponents of pscyhodynamic psychotherapy alike would agree that it involves an interaction between clinician and patient that is contrived and not entirely within the realm of common sense or common everyday experience. The same could be said of pretty much any therapy-- psycho or pharmaco and certainly ECT. In other words, psychodynamic psychotherapy is a clinical intervention. As such, I think it should be evaluated for efficacy, but more importantly yet, for safety. I've never understood how some write off psychological interventions all together as fluff; I think that hey can be quite potent. But then they can also be dangerous. How do we know that what is being practiced under the name of psychodynamic psychotherapy is not exacerbating conditions or creating new ones?

I agree with this and I'm also concerned about the ramifications of breaking down someones defense mechanisms that ware innately in place to protect people from traumatic experiences. I love psych for the mere fact that it is just if not more as invasive as surgery - but I do worry about how far we should be taking it and what the outcomes can be if we aren't careful.

psychodynamic therapy can be a bit of a double edged sword - it can be very useful in identifying the aspects that are driving an individual patient's behaviors and reactions - but I think that working in someones subconscious can be frightening - maybe even too invasive. I just don't have the experience to be able to answer these questions. LIke I said before, the tools are nice to have, but how much should really be using the tools and should there be limits to their use?

 

[Poety]

I wouldn't touch this topic with a ten-foot penis.


[Oh great--that was my 400th post, and I spent it on a cheap phallic reference! ]

OPD Yer getting soft pffftttt

 

[PublicHealth]

OPD Yer getting soft pffftttt

If you're referring to OPD's ten-foot penis, I think it's better that it remains soft...for the safety of his patients!

 

[LM02]

I think that you can consider psychodynamics in all prescribing, but psychiatry is unique in medicine just based on the shear size of the placebo response. I can't think of too many other medications for which people who think they might be getting the drug will have a 30-50% improvement in symptoms just with placebo alone - certainly not with antihypertensives, chemotherapeutics, or hypoglycemics is that response so consistently there. I think that in my limited experience, thinking more in depth about the psychodynamics of the interaction comes into play when dealing with patients who are treatment-resistant, or for whom you've tried a number of meds and they suffer intolerable side effects at low doses. Certainly during my first visit with patients who are suffering their first Major Depressive Episode, I don't sit there paralyzed with indecision wondering about whether starting an SSRI is really an enactment of their rescue fantasy. Primary care providers are well suited to diagnosing and treating garden variety, uncomplicated MDD, but what separates out the psychiatrist from the FP is the ability to undertstand and deal with the patient who fails several treatments for their MDD or who develops intolerable side effects on Lexapro 2.5mg, Zoloft 12.5mg, and Effexor 37.5mg. Those are situations where clearly an understanding of the patient's developmental history, object relations, fantasies about medications, and transference/countertransference issues go a long way toward being able to successfully treat the patient.

Instead of creating these fantastic object relations fantasies, another simple explanation for the placebo effect and/or treatment non-response: expectancy. This is a much more pragmatic and testable hypothesis.

You can actually measure patient's treatment expectancies (it's done in clinical trials all the time), and look at associations between expectancies and response to treatment. If you do a lit search you can find plenty of studies on the subject (a colleague of mine down the hall does research in this area).

For example, if a depressed patient attributes his/her depression to "a chemical imbalance," they are most likely going to dismiss psychotherapy as a viable treatment option. You can try it out with them, but it's probably not going to work. So you can conceptualize all of this in a psychodynamic way, OR you could target unrealistic attributions and expectations for treatment (a la CBT or another behavioral intervention).

With that said, I do agree with you on the issue of the therapeutic alliance. And there is research on how the therapeutic alliance interacts with treatment expectancies in predicting treatment response.

 

[Doc Samson]

That sounds cute, but how many psychiatrists actually do psychotherapy nowadays? Sure, you can cite some psychoanalytic dinosaurs from the 1950s Harvard/Mass Mental era, but really, how many young psychiatrists REGULARLY use psychotherapy? Why do psychotherapy for an hour and make $100 when you can do four 15-minute med checks and make $600? Simple economics, man.

Most of my colleagues who have graduated from residency continue to maintain some psychotherapy within their practice. Some have even gone on to do advanced psychotherapy fellowships. Why do psychotherapy over psychopharm? For the most part, because many find it to be more fun and more rewarding.

I can also echo the idea that coming into residency I had NO intention of pursuing psychodynamic training, but having experienced other modalities (including CBT, DBT, and brief) it is now my first line psychotherapy for most of my high functioning patients (excluding my patients with psychosis, PTSD, phobias, or Borderline PD). Don't knock it 'til you've tried it.

 

[Poety]

I hope I didn't infer that I wasn't into psychotherapy because I am, I think i should clarify that its the whole constantly analyzing every thing I do in my treatment that I'm not into. I would not like to train at a place that encourages this either.

At the program I am most interested in attending, part of what actually got me was this little lecture series they have that utilizes a case presentation to learn about the different parts of the id, ego, and superego and how they are working and affecting the persons behaviors - I found this fascinating to say the least and I can't wait to learn more about it on a case by case basis.

The professor explained this lecture was a way to 'explain what all the psychoanalytic terms MEAN so you can understand exactly what you're talking about with peers when you use them' I thought this was a great idea since to be honest - I really need some examples of the Id in action

edit: OPD can you please add some of your knowledge to this thread? No debating, just knowledge?

 

[PublicHealth]

Neat article that attempts to unite psychoanalytic theory with modern neuroimaging: http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=14596561&query_hl=22

Related articles from the Nobel Laureate Dr. Eric Kandel:

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=9545989&query_hl=28

http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=10200728&query_hl=28

 

[Poety]

Howard Hughes Medical Institute, Columbia University, New York, NY 10032, USA.

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.

This is from the post above - 2nd link - really fascinating stuff if I could have tolerated Columbia for that long, I would have loved to have this type of training.

 

[BKN]

Hi, I'm posting this at Poety's request. It's from a PM that I had sent to her after she asked me to look at this thread. For those of you who don't know me, I'm an EM PD and I post on the EM and General issues threads:

First, let me thank you for changing your avatar again. That guy was almost as scary as A.T.'s.

I've read the last part of the completed interviews thread and the new thread you started on "psychodynamic psychotherapy". I presume that this is what was called "psychoanalytic psychotherapy " when I was a kid. I have no idea what the other abbreviations that you'all were throwing around connote (I'm just a country boy ED doc).

My first reaction after reading was similar to oldpsychdoc"s. However, as always, ask me a simple question and you get a pageant. I found the discussion and the controversies much more interesting than the usual "how many times should I thank them, and should I send bribes". I have opinions, but I'm not sure I know what you should do. Anyway:

1. It seems to me that we are what we live. Nice young cops assigned to Watts quickly become brutalized and turn brutal. ER docs become ever more pragmatic, quicker and results oriented. I suspect, similarly, that psychiatrists become ever less doctrinaire and more introspective with time. From that assumption, I'll suggest that the physicians committing these clear match violations (and probably ADA violations) are not being clever, or malignant. I suspect that they are in fact trying to understand the applicant's personality structure and predict whether he/she would make a good, supportive psychiatrist. Whether you can do this in 20 minutes seems very debatable, but I'm not a shrink.

2. It seems to me your concern that opening defenses on sensitive subjects may be detrimental to the applicant is entirely justified. I feel somewhat ambivalent about it though because if a potential psychiatrist has such vulnerabilities, he probably should know it before he makes the decision to train in this. I also think, most likely have a fair degree of insight into the fact that they have a problem, even if they couldn't state it clearly. In fact, I think that's why many people are attracted to mental health professions and it's reflected in some of the posts.

3. As to whether you should do anything about this, it's your call. My opinion is that the individuals conducting these kind of interviews are well aware of the ADA and the match rules. I suspect that they don't care and believe that their purpose (deciding who is and who is not a good candidate to be a psychiatrist) is more important than employment law. If you do in fact report them to the match or the chairman of their department, I suspect their response would be to say hmm. . ., shrug and go about their business without change.

4. I'l put on my research designer and statistician hat about the use of insight psychotherapy debate. Since we are talking about changing personality and relation to the world, I would want to do a study with at least three arms and lasting many years. I would take "ideal" candidates, that is young and intelligent. The therapies would be
1. some form of placebo to allow for normal maturation.
2. drugs
3. insight psychotherapy.
As you can imagine, such a trial would involve huge numbers, complex outcome variables, many years and lots of money. That's why it's never been done definitively and the fighting continues.

 

[Doc Samson]

Hi, I'm posting this at Poety's request. It's from a PM that I had sent to her after she asked me to look at this thread. For those of you who don't know me, I'm an EM PD and I post on the EM and General issues threads:

First, let me thank you for changing your avatar again. That guy was almost as scary as A.T.'s.

I've read the last part of the completed interviews thread and the new thread you started on "psychodynamic psychotherapy". I presume that this is what was called "psychoanalytic psychotherapy " when I was a kid. I have no idea what the other abbreviations that you'all were throwing around connote (I'm just a country boy ED doc).

My first reaction after reading was similar to oldpsychdoc"s. However, as always, ask me a simple question and you get a pageant. I found the discussion and the controversies much more interesting than the usual "how many times should I thank them, and should I send bribes". I have opinions, but I'm not sure I know what you should do. Anyway:

1. It seems to me that we are what we live. Nice young cops assigned to Watts quickly become brutalized and turn brutal. ER docs become ever more pragmatic, quicker and results oriented. I suspect, similarly, that psychiatrists become ever less doctrinaire and more introspective with time. From that assumption, I'll suggest that the physicians committing these clear match violations (and probably ADA violations) are not being clever, or malignant. I suspect that they are in fact trying to understand the applicant's personality structure and predict whether he/she would make a good, supportive psychiatrist. Whether you can do this in 20 minutes seems very debatable, but I'm not a shrink.

2. It seems to me your concern that opening defenses on sensitive subjects may be detrimental to the applicant is entirely justified. I feel somewhat ambivalent about it though because if a potential psychiatrist has such vulnerabilities, he probably should know it before he makes the decision to train in this. I also think, most likely have a fair degree of insight into the fact that they have a problem, even if they couldn't state it clearly. In fact, I think that's why many people are attracted to mental health professions and it's reflected in some of the posts.

3. As to whether you should do anything about this, it's your call. My opinion is that the individuals conducting these kind of interviews are well aware of the ADA and the match rules. I suspect that they don't care and believe that their purpose (deciding who is and who is not a good candidate to be a psychiatrist) is more important than employment law. If you do in fact report them to the match or the chairman of their department, I suspect their response would be to say hmm. . ., shrug and go about their business without change.

4. I'l put on my research designer and statistician hat about the use of insight psychotherapy debate. Since we are talking about changing personality and relation to the world, I would want to do a study with at least three arms and lasting many years. I would take "ideal" candidates, that is young and intelligent. The therapies would be
1. some form of placebo to allow for normal maturation.
2. drugs
3. insight psychotherapy.
As you can imagine, such a trial would involve huge numbers, complex outcome variables, many years and lots of money. That's why it's never been done definitively and the fighting continues.

There is a HUGE difference between asking someone if they have bipolar illness (match/ADA violation) and asking about their childhood, relationship with their parents (or other authority figures), or experience of victimization, all of which are not match/ADA violations, but cited as such in previous discussion.

In terms of studying psychodynamic/insight-oriented psychotherapy... the biggest hurdle is standardizing the treatment. Once your three arms are split, you can easily standardize placebo and drugs (or even manualized algorithm based therapies), but the nature of psychodynamic therapy is to explore and use what the patient brings to the table. The intersection of the personalities of the therapist and the patient mean that no two therapies will be similar in any measurable way. In fact, many studies on manualized therapies are now being called into question because, in retrospect people are realizing that what happens outside of the algorithm (therapist personality, empathy, humor, etc.) are hugely confounding factors, and near impossible to measure. Ultimately, in your study design, you can't just have a group "get therapy", because that group will all be experiencing different things.

 

[Poety]

Hi DS,

I have to disagree with the last part of your statement since I was involved in a clinical study that was actually researching the outcome of insituting a very specific type of therapy to drug abusers to decrease their time to readmissions (which worked by the way).

There was a very specific protocol the PsyD followed and the controls were those that didn't received the therapy at all - so perhaps this type of study can be done with good results? At lesat I've seen it done - maybe the results aren't as valid as I'd like to think I dunno

 

[PublicHealth]

http://www.apa.org/monitor/nov05/neuroscience.html

 

[Poety]

http://www.apa.org/monitor/nov05/neuroscience.html

well this goes right along with what BKN said!

 

[BKN]

In fact, many studies on manualized therapies are now being called into question because, in retrospect people are realizing that what happens outside of the algorithm (therapist personality, empathy, humor, etc.) are hugely confounding factors, and near impossible to measure. Ultimately, in your study design, you can't just have a group "get therapy", because that group will all be experiencing different things.

Sure you can. Without question all studies have individual variations in the therapy received. The usual purpose of statistics is to identify average responses (for example to the average competence of the therapists). The problems with such a study would involve outcome measures, long-term followup, subject compliance, therapy cross-over, etc. But, given enough money and time and talented trialists, it certainly could be done.

You and many others have advanced the idea that therapy can't be measured. That seems to me to be a faith rather than a scientific statement. It's in the same class as the common contention that prayer and belief in God benefit people but can't be measured.

BTW, not relevant, but I say all this as a strong believer in psychotherapy. If I can't have good data, I'll accept personal experience.

 

[PublicHealth]

well this goes right along with what BKN said!

Right! I'm simply trying to infuse some science into this discussion! We're not the only ones kicking around these ideas!

Some more food for thought:

CBT's purported effect on brain in depression:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=14706942&query_hl=1

CBT's purported effect on brain in social phobia:
http://www.ncbi.nlm.nih.gov/entrez/...&dopt=Abstract&list_uids=11982446&query_hl=17

CBT's purported effect on brain in spider phobia:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=12595193&query_hl=6

Behavior therapy's effect on brain in OCD:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=8629886&query_hl=13

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=1514872&query_hl=15

Interpersonal therapy's effect on brain in depression:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11448368&query_hl=8

Review:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=16164763&query_hl=4

 

[nortomaso]

Wow, Public Health, thanks for those thinks. Great articles.

 

[Poety]

That spider phobia one was on a newscast - it works brilliantly!

 

[Doc Samson]

Sure you can. Without question all studies have individual variations in the therapy received. The usual purpose of statistics is to identify average responses (for example to the average competence of the therapists). The problems with such a study would involve outcome measures, long-term followup, subject compliance, therapy cross-over, etc. But, given enough money and time and talented trialists, it certainly could be done.

You and many others have advanced the idea that therapy can't be measured. That seems to me to be a faith rather than a scientific statement. It's in the same class as the common contention that prayer and belief in God benefit people but can't be measured.

BTW, not relevant, but I say all this as a strong believer in psychotherapy. If I can't have good data, I'll accept personal experience.

Can you take a bunch of subjects, put them all in a psychodynamic treatment, and do a whole bunch of scales pre- and post-treatment? Sure. But the newest research on therapy that I've been hearing about is the attempt to measure what makes therapy therapeutic. I just saw a presentation of a massive study comparing CBT, IPT, and dynamic therapy, and the ultimate best predictor of efficacy in each was the relationship between the therapist and the patient. This raises the question of how do you measure "relationship." I know many people infinitely smarter than I who are struggling with this, and thus far don't have any good answers.

 

[Doc Samson]

Hi DS,

I have to disagree with the last part of your statement since I was involved in a clinical study that was actually researching the outcome of insituting a very specific type of therapy to drug abusers to decrease their time to readmissions (which worked by the way).

There was a very specific protocol the PsyD followed and the controls were those that didn't received the therapy at all - so perhaps this type of study can be done with good results? At lesat I've seen it done - maybe the results aren't as valid as I'd like to think I dunno

Well, since the cases were all getting to meet with someone, and the controls weren't meeting with anyone at all, maybe just the support and reinforcement of meeting with someone with an apparent interest in their well-being helped the cases stay clean. I've seen many studies that actually use a "sham therapy" (i.e. just meeting with someone and shooting the breeze) to control for this. Again, I think we might all agree that positive relationships help maintain mental health, but what is it about any form of therapy that raises it above just hanging out with your buddies. That is what we need to measure to undoubtedly prove the value of any form of therapy.

 

[Poety]

Excellent points DS. And also, the cases got to meet with me too and the PsyD's in training so they had even MORE of a confounding factor since we had to administer assessments on them. Dual diagnosis patients love attention Im still a clinical research baby so hopefully I'll get the chance to learn more about all this in residency. Were you a researcher in a previous life? Or are you dually trained?

 

[PublicHealth]

Can you take a bunch of subjects, put them all in a psychodynamic treatment, and do a whole bunch of scales pre- and post-treatment? Sure. But the newest research on therapy that I've been hearing about is the attempt to measure what makes therapy therapeutic. I just saw a presentation of a massive study comparing CBT, IPT, and dynamic therapy, and the ultimate best predictor of efficacy in each was the relationship between the therapist and the patient. This raises the question of how do you measure "relationship." I know many people infinitely smarter than I who are struggling with this, and thus far don't have any good answers.

References? Last I heard, "therapeutic alliance" explained less than 10% of the variance in psychotherapy outcome.

 

[PublicHealth]

Again, I think we might all agree that positive relationships help maintain mental health, but what is it about any form of therapy that raises it above just hanging out with your buddies.

Pouring your heart out to a stranger, perhaps? Placebo? Our defenses tend be up around friends. Many patients will tell you that they don't feel comfortable telling their friends about their "emotional stuff." Therapists with a knowledge of psychopathology tend to know what they want to accomplish in therapy (e.g., get patient to express affect, recount traumatic memories, etc.), which purportedly facilitates therapeutic change.

Set the id free, dammit! Repression is evolution's executor.

 

[Poety]

ack, I'm not for the whole re-hashing traumatic experiences - ph you would know this, wasn't there a study done that showed how detrimental it actually is to rehash those experiences? If you don't know it off hand I'll bet you can find it

 

[Doc Samson]

ack, I'm not for the whole re-hashing traumatic experiences - ph you would know this, wasn't there a study done that showed how detrimental it actually is to rehash those experiences? If you don't know it off hand I'll bet you can find it

I think even the most die-hard advocates of psychodynamic therapy would vouch that there are much better treatments for PTSD (where the T is truly significant). I opt for significantly more CBT oriented treatments with these patients. My patients in psychodynamic treatment, for the most part, can't identify a specific trauma, they just know that they aren't functioning the way they'd like. A lot of the work of dynamic therapy is figuring out exactly what may have happened in the course of their development that has led to difficulty today. The patients tend to do the re-hashing all by themselves, playing out the same pattern over and over. Figuring out what it is/where it's coming from is actually a relief.

 

[Doc Samson]

References? Last I heard, "therapeutic alliance" explained less than 10% of the variance in psychotherapy outcome.

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=11986131&query_hl=1

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10028210&query_hl=1

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=15250816&query_hl=1

Some of the data I saw in the presentation is not yet published, but the above links cover the basic thrust of it.

 

[PublicHealth]

My patients in psychodynamic treatment, for the most part, can't identify a specific trauma, they just know that they aren't functioning the way they'd like. A lot of the work of dynamic therapy is figuring out exactly what may have happened in the course of their development that has led to difficulty today.

Repression is a bitch. But consider its evolutionary purpose.

This will get you started:

Nesse, R.M. (1990). The evolutionary function of repression and the ego defenses. Journal of the American Academy of Psychoanalysis 18: 260—286.

The patients tend to do the re-hashing all by themselves, playing out the same pattern over and over. Figuring out what it is/where it's coming from is actually a relief.

Yes, but why is it a relief? Neuroimaging findings that show increased activation in certain brain regions following psychotherapeutic intervention fail to consider the mechanisms underlying therapeutic change. What happens in the course of psychodynamic therapy that makes it effective? Is it the ability to reconceptualize one's "psychic forces?" A modulation of certain neurochemicals? Why is talking about one's problems therapeutic?

 

[PublicHealth]

ack, I'm not for the whole re-hashing traumatic experiences - ph you would know this, wasn't there a study done that showed how detrimental it actually is to rehash those experiences? If you don't know it off hand I'll bet you can find it

I'm not aware of that one article. However, I am aware of a wealth of literature demonstrating the efficacy of exposure therapy in treating PTSD.

Here's a review from some experts in this area:
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=16242154&query_hl=5

 

[Doc Samson]

Repression is a bitch. But consider its evolutionary purpose.

This will get you started:

Nesse, R.M. (1990). The evolutionary function of repression and the ego defenses. Journal of the American Academy of Psychoanalysis 18: 260—286.



Yes, but why is it a relief? Neuroimaging findings that show increased activation in certain brain regions following psychotherapeutic intervention fail to consider the mechanisms underlying therapeutic change. What happens in the course of psychodynamic therapy that makes it effective? Is it the ability to reconceptualize one's "psychic forces?" A modulation of certain neurochemicals? Why is talking about one's problems therapeutic?

That's where we start getting into the proof vs. faith debate. No-one (as yet) knows why it helps, but a century's worth of experience seems to show that it does. I can't prove what about dynamic therapy makes it effective (any more than you can prove what makes any therapy effective), but I know that it is. The difference in functioning of my patients, and the relief of their distress is good enough reason for me to keep going.

In purely experiential terms, I have heard my patients tell me things along the lines of "I could never figure out whay I kept (getting fired/dating losers/fighting with spouse/etc). I thought I was just totally f-ed up. It's such a relief to finally figure out where this is coming from." Connecting pathological behavior to developmental experience, rather than some in-born error of psyche is comforting (I think) because it offers hope for change.

 

[BKN]

Can you take a bunch of subjects, put them all in a psychodynamic treatment, and do a whole bunch of scales pre- and post-treatment? Sure. But the newest research on therapy that I've been hearing about is the attempt to measure what makes therapy therapeutic. I just saw a presentation of a massive study comparing CBT, IPT, and dynamic therapy, and the ultimate best predictor of efficacy in each was the relationship between the therapist and the patient. This raises the question of how do you measure "relationship." I know many people infinitely smarter than I who are struggling with this, and thus far don't have any good answers.

You guys are doing great in this thread. I'm going to butt out. But one further comment about this particular post. I was saying that you could compare psychotherapy to drugs to placebo successfully. I also believe that the same sort of trials can be done within different types of therapy. You are suggesting that they cross over between therapists. I'm sure thats true and to the extent that therapies are misclassified they tend to make the groups look more similar (unidirectional bias towards no effect). The consequence is that the sample size requirements inflate as the square of proportion misclassifed. If anyone cares there's a good discussion in fleiss's biostat book from the 80's. (the one on continuous variables, not the one on proportions).

 

[Poety]

Repression is a bitch. But consider its evolutionary purpose.

This will get you started:

Nesse, R.M. (1990). The evolutionary function of repression and the ego defenses. Journal of the American Academy of Psychoanalysis 18: 260—286.



Yes, but why is it a relief? Neuroimaging findings that show increased activation in certain brain regions following psychotherapeutic intervention fail to consider the mechanisms underlying therapeutic change. What happens in the course of psychodynamic therapy that makes it effective? Is it the ability to reconceptualize one's "psychic forces?" A modulation of certain neurochemicals? Why is talking about one's problems therapeutic?

I'm in the airport PH so I can't look up that reference - whats it essentially say? There is a reason we repress? If so, then thats what I'm talking about. There is nothing wrong with repressing things and learning to deal and build a better behavior AROUND what is repressed - I know some people think that you have to hash it out, have the breakdown, face the fears, and then move forward - and I think for some this is very beneficial - but to force this in a therapy is wrong - and I would seriously want to know I have consent for a patient to undergo such stress provoking therapy at all.

This is just my whole thought on this idea - any psychs out there care to chime in? OPD? SAZI? DS?

 

[Anasazi23]

I try to stay out of psychodynamic discussions.
The truth is that the more exposure I have to it, and the more opportunity I have to practice it in my outpatient setting, the more valuable I see it becoming in my arsenal of psychiatric tools. My thoughts and feeling regarding this mode of therapy and more importantly, my way of thinking about patients continues to adapt.

There are so-called mature and immature defense mechanisms. Defenses serve a purpose, even if they are at times, maladaptive. The sophistication level of the defense, along with the inherent 'assets' of the patient (such as intelligence) make a large difference in that person's adaptation to a stressor.

Denial, for example, can be a useful short-term defense, usually for people of lower intelligence. The problem is that it is often extended beyond its usefulness, and becomes maladaptive and sometimes bizarre.

Repression is a more mature defense than denial, but perhaps not quite as mature as intellectualization or sublimation, for example...depending on the circumstance. Indeed, repression is a commonly used defense, particularly when the traumatic event or life stressor occurred some time ago. Some studies, such as international investigations on debriefing after disasters (such as the recent tsunami) have been shown to increase psychopathology i.e. anxiety and depressive states. In this sense, the repression was adaptive. Should events later in life cause these ideas and feeling to resurface, however, psychopathology may again resurface, or likewise, surface for the first time.

It is impossible to tell for which person repression will serve as a lifelong adaptive defense vs. those for which lifestyle patterns change subconsciously or maladaptively later. As such, they are not easily quantified. The concept is more existential than that. There will always be patients who experience life stressors of varying degress. Our job is to be there and treat the resurfacing of repressions and the like the best way we can.

At least that's how I understand it at this point. I think learning psychodynamics is a lifelong process. To close your mind to it prematurely is to do yourself a disservice.

 

[Doc Samson]

I think learning psychodynamics is a lifelong process. To close your mind to it prematurely is to do yourself a disservice.

Amen my brother!

 

[Poety]

I try to stay out of psychodynamic discussions.
The truth is that the more exposure I have to it, and the more opportunity I have to practice it in my outpatient setting, the more valuable I see it becoming in my arsenal of psychiatric tools. My thoughts and feeling regarding this mode of therapy and more importantly, my way of thinking about patients continues to adapt.

There are so-called mature and immature defense mechanisms. Defenses serve a purpose, even if they are at times, maladaptive. The sophistication level of the defense, along with the inherent 'assets' of the patient (such as intelligence) make a large difference in that person's adaptation to a stressor.

Denial, for example, can be a useful short-term defense, usually for people of lower intelligence. The problem is that it is often extended beyond its usefulness, and becomes maladaptive and sometimes bizarre.

Repression is a more mature defense than denial, but perhaps not quite as mature as intellectualization or sublimation, for example...depending on the circumstance. Indeed, repression is a commonly used defense, particularly when the traumatic event or life stressor occurred some time ago. Some studies, such as international investigations on debriefing after disasters (such as the recent tsunami) have been shown to increase psychopathology i.e. anxiety and depressive states. In this sense, the repression was adaptive. Should events later in life cause these ideas and feeling to resurface, however, psychopathology may again resurface, or likewise, surface for the first time.

It is impossible to tell for which person repression will serve as a lifelong adaptive defense vs. those for which lifestyle patterns change subconsciously or maladaptively later. As such, they are not easily quantified. The concept is more existential than that. There will always be patients who experience life stressors of varying degress. Our job is to be there and treat the resurfacing of repressions and the like the best way we can.

At least that's how I understand it at this point. I think learning psychodynamics is a lifelong process. To close your mind to it prematurely is to do yourself a disservice.

Thanks Sazi! Wonderful post as usual

And speaking of which, I had a great convo with a faculty member today about these forums - he thinks they're actually frightening because there is too much anonimity and it allows for people to behave in ways that there are no consequences, we talked (and went over time without knowing it!) about how consequences to specific behaviors are essential in keeping society in check, and how when we lose the consequences, we learn that we can get away with behaviors and keep pushing the line even further and further.. which brings us to teh dateline nbc thread ofcourse but i just wanted to throw that in here

 

[PublicHealth]

And speaking of which, I had a great convo with a faculty member today about these forums - he thinks they're actually frightening because there is too much anonimity and it allows for people to behave in ways that there are no consequences, we talked (and went over time without knowing it!) about how consequences to specific behaviors are essential in keeping society in check, and how when we lose the consequences, we learn that we can get away with behaviors and keep pushing the line even further and further.. which brings us to teh dateline nbc thread ofcourse but i just wanted to throw that in here

Set the id free!

 

[Anasazi23]

Thanks Sazi! Wonderful post as usual

And speaking of which, I had a great convo with a faculty member today about these forums - he thinks they're actually frightening because there is too much anonimity and it allows for people to behave in ways that there are no consequences, we talked (and went over time without knowing it!) about how consequences to specific behaviors are essential in keeping society in check, and how when we lose the consequences, we learn that we can get away with behaviors and keep pushing the line even further and further.. which brings us to teh dateline nbc thread ofcourse but i just wanted to throw that in here

Thanks for the kind words, Poety.

So, posting on SDN will cause you to become a child molester?

Sounds reasonable.

Sounds like another faculty member who's ego is too inflated to deal with the fact that the anarchy-stricken internet allows people to express their views without his imposed rules and punishment system.

Too bad.

 

[Poety]

Norto - are you replying to yourself again? J/K

DS: I think you made some really good points - and I think that it actually can (and has) been proven that therapy works - however, perhaps Norto are you talking about just psychoanalysis?

At one of the residency's I've applied to they use the Missouri Modules for therapy training - with the thought being that Psychoanalysis is outdated and no where near as efficient for treating patients now a days. The PD explained that in real practice, no one has the time nor the money to actually partake in true psychoanalysis anymore.

I'm copying this to the psychoanalysis debate board. Thoughts?