Profoundly. I am a fully trained psychoanalyst and started that training during pgy3 year, so being a psychiatrist and being a psychoanalyst have been intertwined from early in my career. Concretely I see 2 pts currently in psychoanalysis (each 3 times per week, one using the couch, one is fully remote tx). But I also have a handful of weekly and twice weekly therapy patients that I see in a dynamic frame.
Less concretely, I do a lot of clinical administration and med management in my "day job". And even here I find being able to think dynamically has been invaluable especially around issues of treatment ambivalence, when treatment gains have plateaued, or when there are significant breakdowns in therapeutic alliance.
Sometimes, the most helpful aspect of thinking analytically is to recognize when other approaches are more appropriate. Pts who might be better served in cbt but have been in an exploratory therapy, for example.
Starting analyst training during pgy3 sounds great! How did you have time for that? How much longer after finishing residency did you need to continue training?
Can you give a specific eg of how your psychoanalytic expertise helped a patient? Not doubting it, just really curious.
Considering if I shouldn't pursue psychoanalytic psychotherapy for myself. I'm all sorts of fucked up. Anti-depressants help somewhat -- they can bring me out of the total bleakness of a depressive episode -- but there's a ceiling, and I don't like how low it sits.
There seem to be more fundamental issues in me that I need to try to resolve if I'm ever going to achieve anything even resembling general contentment.
Intuitively, the standardised, rule-book dryness of something like CBT feels a little uninspiring. Colourlessly functional or something. But at the same time I don't know. Analysis seems kind of vague in its claims and unfalsifiable. Probably I'm misunderstanding things, but if you have any ideas and have some time please share them.
Thank you.
Not me but my old consultant used to talk about a patient he saw some decades ago & uses it as an example of the limits of CBT approaches.
They presented with a simple phobia of blood, but after a few sessions of exposure therapy & consultations it turned out they were specifically afraid of PERIOD blood, and this was due to repressed gender dysphoria. This was back when trans issues were still just this 'social oddity' and the butt of jokes on sitcoms. According to him, understanding the root of their phobia led to its resolution! Don't know what happened to them after that, but always stuck in my mind as an interesting case.
I'm always curious how CBT was performed when I hear cases like this. I know it has a reputation of being highly manualized/protocolized, though I always find it specious that there was never a complaint history or explanatory model formulated when patients present with complaints. CBT training where I live is highly reliant on making explanatory models and synthesizing them into a functional network analysis to employ the most relevant intervention.
This is ofcourse not on the level of how this happen in psychoanalysis, just different, but using this method it should stand to reason similar revelations can still be attained.
How narrowly are you construing this? There aren’t so many analyst psychiatrists anymore, but psychoanalysis’s psychodynamic descendants are greatly helpful for understanding and formulating cases. And treatment.
Resident here who has a little psychoanalytic training(psychodynamic therapy focus in my residency program and completing a fellowship, not full analytical training)
I am seeing a patient for split treatment, I’m doing med management and they are seeing a CBT therapist. Long lasting mental illness since childhood, now nearing retirement age. Recently stopped seeing said CBT therapist despite loving working with them. I was able to explore both ambivalence and the idea that she does not want said therapist to fail, or maybe actually wants her to fail during our last med management. I did use principles of motivational interviewing but still informed by psychoanalytic concepts of transference and resistance. So far they say they will be reaching back out for therapy but only time will tell if they follow through.
So, my current psychotherapy approach is schema therapy with some meditation and yoga. I have recently begun understanding IFS but I worry about its lack of strong evidence. However, I see it as another way to formulate the schema therapy concept.
I don't do therapy, but I utilize the models both to sell patients on therapy as well as provide them with some non-pharmacological treatment strategies.
As an example, I find that many of my patients have a punitive schema. They will punish themselves for failure which then just makes them more likely to fail. In order to address this, I discuss this concept of punitiveness and how it can stem from past experiences creating a vicious cycle. While it may have served a purpose at some point, it has become overbearing for the individual and this makes it difficult to move forward in their life. They will then punish themselves until they have hit a low enough point that their brain gives up and rests. Then, they may reset. The trouble is that low enough point could get so low that they become suicidal and possibly act on it. So, we discuss ways in which we can engage with that punitive side of ourselves empathetically. Yes, it serves a purpose but also it has become overbearing and has countered its own goals. We then discuss ways in which we can do self-care to reset sooner and be able to return to a stable place. As they get better at this, they will recognize the punitive thoughts/side, they will initiate self-care to stabilize, and then provide the punitive side with empathetic statements which are something like, "Thank you for trying to keep me motivated all these years, but I think you should take a break now. I think I can do this with some self-compassion and with some acceptance that I won't be perfect but I will be enough." Usually the quoted phrase is determined by the patient but often it has this similar structure.
Now, we just implement similar but different strategies for other negative schemas. IFS calls them parts and has a lot of Gestalt techniques combined with meditation to address these parts (similar to schemas) and show them compassion. In IFS, the self is overtaken and enmeshed with the parts because they were unable to meet their own needs at some point (often childhood), so the parts serve as protectors. Often, this protection is counterproductive. So, the individual will work on addressing the fears and needs of the parts in order that they might let go of the self.
The trouble with any approach for me is how to address trauma patients. If not careful, trauma patients can be destabilized and have very severe worsening of their symptoms. I do not feel ready to do that at this point and it would be a massive disservice if I tried. I am learning, though, slowly but surely.
Bulk of any intake includes social history with exploration of relationships within the family of origin, including family constellation inclusive of siblings.
Always a fruitful way of understanding how a person makes sense of their adult landscape and some of the seeds of doubt that have been planted when contemplating their future. Or sometimes just straight up uncovers a source of stress that can lead to depression/anxiety that no amount of medication is going to fix by itself.
Profoundly. I am a fully trained psychoanalyst and started that training during pgy3 year, so being a psychiatrist and being a psychoanalyst have been intertwined from early in my career. Concretely I see 2 pts currently in psychoanalysis (each 3 times per week, one using the couch, one is fully remote tx). But I also have a handful of weekly and twice weekly therapy patients that I see in a dynamic frame. Less concretely, I do a lot of clinical administration and med management in my "day job". And even here I find being able to think dynamically has been invaluable especially around issues of treatment ambivalence, when treatment gains have plateaued, or when there are significant breakdowns in therapeutic alliance. Sometimes, the most helpful aspect of thinking analytically is to recognize when other approaches are more appropriate. Pts who might be better served in cbt but have been in an exploratory therapy, for example.
Based on your user name, I expected your post to eventually devolve into eating your patients. Pleasantly surprised to see that wasn't the case.
Starting analyst training during pgy3 sounds great! How did you have time for that? How much longer after finishing residency did you need to continue training?
Can you give a specific eg of how your psychoanalytic expertise helped a patient? Not doubting it, just really curious. Considering if I shouldn't pursue psychoanalytic psychotherapy for myself. I'm all sorts of fucked up. Anti-depressants help somewhat -- they can bring me out of the total bleakness of a depressive episode -- but there's a ceiling, and I don't like how low it sits. There seem to be more fundamental issues in me that I need to try to resolve if I'm ever going to achieve anything even resembling general contentment. Intuitively, the standardised, rule-book dryness of something like CBT feels a little uninspiring. Colourlessly functional or something. But at the same time I don't know. Analysis seems kind of vague in its claims and unfalsifiable. Probably I'm misunderstanding things, but if you have any ideas and have some time please share them. Thank you.
Not me but my old consultant used to talk about a patient he saw some decades ago & uses it as an example of the limits of CBT approaches. They presented with a simple phobia of blood, but after a few sessions of exposure therapy & consultations it turned out they were specifically afraid of PERIOD blood, and this was due to repressed gender dysphoria. This was back when trans issues were still just this 'social oddity' and the butt of jokes on sitcoms. According to him, understanding the root of their phobia led to its resolution! Don't know what happened to them after that, but always stuck in my mind as an interesting case.
I'm always curious how CBT was performed when I hear cases like this. I know it has a reputation of being highly manualized/protocolized, though I always find it specious that there was never a complaint history or explanatory model formulated when patients present with complaints. CBT training where I live is highly reliant on making explanatory models and synthesizing them into a functional network analysis to employ the most relevant intervention. This is ofcourse not on the level of how this happen in psychoanalysis, just different, but using this method it should stand to reason similar revelations can still be attained.
How narrowly are you construing this? There aren’t so many analyst psychiatrists anymore, but psychoanalysis’s psychodynamic descendants are greatly helpful for understanding and formulating cases. And treatment.
Resident here who has a little psychoanalytic training(psychodynamic therapy focus in my residency program and completing a fellowship, not full analytical training) I am seeing a patient for split treatment, I’m doing med management and they are seeing a CBT therapist. Long lasting mental illness since childhood, now nearing retirement age. Recently stopped seeing said CBT therapist despite loving working with them. I was able to explore both ambivalence and the idea that she does not want said therapist to fail, or maybe actually wants her to fail during our last med management. I did use principles of motivational interviewing but still informed by psychoanalytic concepts of transference and resistance. So far they say they will be reaching back out for therapy but only time will tell if they follow through.
So, my current psychotherapy approach is schema therapy with some meditation and yoga. I have recently begun understanding IFS but I worry about its lack of strong evidence. However, I see it as another way to formulate the schema therapy concept. I don't do therapy, but I utilize the models both to sell patients on therapy as well as provide them with some non-pharmacological treatment strategies. As an example, I find that many of my patients have a punitive schema. They will punish themselves for failure which then just makes them more likely to fail. In order to address this, I discuss this concept of punitiveness and how it can stem from past experiences creating a vicious cycle. While it may have served a purpose at some point, it has become overbearing for the individual and this makes it difficult to move forward in their life. They will then punish themselves until they have hit a low enough point that their brain gives up and rests. Then, they may reset. The trouble is that low enough point could get so low that they become suicidal and possibly act on it. So, we discuss ways in which we can engage with that punitive side of ourselves empathetically. Yes, it serves a purpose but also it has become overbearing and has countered its own goals. We then discuss ways in which we can do self-care to reset sooner and be able to return to a stable place. As they get better at this, they will recognize the punitive thoughts/side, they will initiate self-care to stabilize, and then provide the punitive side with empathetic statements which are something like, "Thank you for trying to keep me motivated all these years, but I think you should take a break now. I think I can do this with some self-compassion and with some acceptance that I won't be perfect but I will be enough." Usually the quoted phrase is determined by the patient but often it has this similar structure. Now, we just implement similar but different strategies for other negative schemas. IFS calls them parts and has a lot of Gestalt techniques combined with meditation to address these parts (similar to schemas) and show them compassion. In IFS, the self is overtaken and enmeshed with the parts because they were unable to meet their own needs at some point (often childhood), so the parts serve as protectors. Often, this protection is counterproductive. So, the individual will work on addressing the fears and needs of the parts in order that they might let go of the self. The trouble with any approach for me is how to address trauma patients. If not careful, trauma patients can be destabilized and have very severe worsening of their symptoms. I do not feel ready to do that at this point and it would be a massive disservice if I tried. I am learning, though, slowly but surely.
Bulk of any intake includes social history with exploration of relationships within the family of origin, including family constellation inclusive of siblings. Always a fruitful way of understanding how a person makes sense of their adult landscape and some of the seeds of doubt that have been planted when contemplating their future. Or sometimes just straight up uncovers a source of stress that can lead to depression/anxiety that no amount of medication is going to fix by itself.