Questions and answers about talk therapy, also called psychodynamic therapy:
A psychiatric diagnosis alone is a poor and limiting way of understanding a person (see my post on diagnosis). It fosters the fiction we can treat emotional pain as an encapsulated illness, separate from the person having the pain. Most problems that bring people to treatment are woven into the fabric of their lives. It is less about what they have than who they are.
This is a different way of viewing psychiatric disorders—not matching up a patient with a diagnosis, but spending more time understanding the patient as a person.
It is all about understanding the person—and helping them to better understand themselves.
It is rarely helpful to move from a diagnosis to a treatment decision. We should be working to understand the person's underlying psychology.
Please give us an example of this principle in action.
A psychiatry resident and I treated a man who had been in psychiatric treatment for 15 years with little to show for it. He suffered from chronic depression and came asking for medication changes. He said, “I've had psychotherapy before and it doesn't work for me.” But as we talked further, it became clear he had never engaged in meaningful psychotherapy.
He had tried many medications and had other forms of therapy—but not talk therapy. He could not tell us one thing he had learned about himself in these therapies.
But this patient thought he had spent years in therapy. How do we determine whether a person has had a real, robust trial of therapy?
If someone has had meaningful psychotherapy, they will be able to discuss it in a meaningful way. You can ask, “Tell me about your previous therapy. What was your relationship with your therapist like? What did you learn about yourself?” Our patient had no concept that psychotherapy is a relationship. He thought of therapists only as “providers” to dispense techniques.
So we should ask: “I see you have had some psychotherapy. What sorts of things do you remember getting out of therapy?”
Of course. We also invited our patient to tell us how he understood his depression—his own thoughts about what was making him so unhappy and his path through life so difficult. Shockingly, no one had ever asked him this. Not in 15 years! The idea that feelings of sadness and emptiness have meaning—that they are something to reflect on and understand—was alien to him.
He spent eight months in therapy steering around difficult topics, with his doctor repeatedly pointing out how he closed off areas of thought and discussion. Then he opened up. He revealed that in his private thoughts, he was hypercritical. He'd meet someone, home in on a perceived flaw, then condemn them and write them off.
Then it emerged that he viewed himself through the same hypercritical lens. He continually attacked and berated himself. At that point, his doctor was able to say, “If you treat someone badly—if you berate and abuse them—it hurts. That is also true when the person you abuse is yourself. That hurt is what you have been calling depression.” That was the turning point.
But it took eight months. Most psychiatrists don’t have eight months to do weekly therapy.
Who decided that? When did psychiatry become so ready to acquiesce to this—to turn patient care into an assembly line? Psychiatrists may encounter pressure, economic and otherwise, to gear their practices around 15-minute medication checks. That does not make it good care.
People need time to reveal themselves. It doesn't happen on a fixed production schedule—no matter how much insurance companies and academic researchers would have us believe otherwise. Therapist and patient may have the illusion they have completed therapy when real therapy never even started.
How does psychodynamic treatment of panic or other kinds of anxiety disorders work?
A starting point is recognizing that panic is fear. When the frightening thing is external, we call it fear. When it is internal, we may call it an anxiety disorder. In talk therapy, we work to understand what is frightening.
They say sunlight is the best disinfectant. The person does not have to live in terror of something that, in the light of day, is not so terrifying after all. People with panic disorder cannot tell us what is frightening. They do not see the connections between their panic symptoms and the internal events that precede them. We help make those connections.
How is this different from the procedure of eliciting “automatic thoughts” in CBT?
But there are differences. Psychodynamic therapists recognize that self-exploration is genuinely difficult. There are things we look away from. There are layers of experience.
You can ask a person a question and get a perfectly truthful answer. You can ask, “What more comes to mind?” and get a completely different answer that is also true. You can continue this way, each time discovering new layers of experience. But there are obstacles along the way.
Please give us an example of a psychodynamic approach to a patient who has panic attacks.
One of my psychiatry residents treated a patient with panic disorder in brief treatment of about eight weeks. The patient experienced her panic attacks as coming “out of the blue.”
We invited her to notice any thoughts and feelings that preceded the panic attacks and to follow her thoughts wherever they led—without editing or censoring them. Her thoughts ran to dissatisfaction with her husband. And although she complained about him, she never expressed anger. She came to recognize that she was afraid of her own anger. Her panic attacks took the place of anger.
So how was this addressed?
In therapy, she came to understand the different ways she habitually brushed aside angry feelings. She discovered it was okay to pay attention to them. She became familiar with previously-unknown parts of herself. When she no longer experienced angry feelings as dangerous and alien, the panic attacks subsided. And she became more aware of her emotional needs and better able to communicate them, so her marriage improved too.
Here's where it gets interesting: The relationship patterns that played out with her husband also played out in therapy with her therapist. The therapist pointed out the ways she reflexively brushed aside any hint of irritation or annoyance with the therapist. And she began to understand how impossible it was for others to respond to her needs when neither she nor they knew what they were—a recipe for escalating resentment.
People recreate and repeat relationship patterns, which are often invisible to them. Therapy is a relationship, so problematic relationship patterns show up in the therapy relationship too. It takes a skilled therapist to see the patterns while in the midst of them and draw the connections to other areas of the person's life.
Any final thoughts?
If we view ourselves as “providers” whose role is merely to dispense interventions or medications, we cut ourselves off from the things that make this work rich and rewarding—the opportunity to truly know our patients and make a difference in their lives. The work is no longer a calling, it's just a job. That’s bad for the soul—the patient’s, and the doctor’s, too.
This blog entry is a conversation between Daniel Carlat, MD, who is asking the questions, and Jonathan Shedler, PhD, who is answering. Carlat is the publisher of The Carlat Psychiatry Report. A version of this interview originally appeared there.
Shedler, J. (2010). Getting to know me: What’s behind psychoanalysis. Scientific American: Mind, 21, 5, Nov/Dec 2010.