Psychodynamic psychotherapy: a core learning component during psychiatric residency

Vol 11 #6  April 12, 2022

Authors 

Caroline Giroux, MD, FRCPC 1, Hammad Khan, MD, MPH 2, Genise Mcaskill, MD 3,

Alexis Rosvall, MD, MPH 4, Anokh Sohal, DO, MS 5, Emily Weibel, MD 6 

1.Associate Clinical Professor, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. 

2. Psychiatry 4th-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.
3. Psychiatry 3rd-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.
4. Psychiatry 3rd-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.
5. Psychiatry 3rd-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.
6. Psychiatry 3rd-year resident, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA.

Now well over a year into weekly therapy, a patient recently said to me (HK): “It’s wild, isn’t it? It’s wild that we’ve never actually met.”  My generation of therapists have trained during truly unprecedented times. An unfathomable global pandemic, devastating natural disasters, ongoing inter- & intra- national conflicts – the context in which we have trained has brought about both unique challenges and opportunities, particularly in our work as mental health providers.   We have learned that true human connection can form even across the cold buzz of a computer monitor. We have learned that a smile from behind a mask can still foster an inviting degree of warmth. But most of all, we have learned that we are all struggling in our ways – some more and others less, some more acutely and others more chronically.  

As a resident physician, I (HK) have found my training psychodynamic psychotherapy to have been absolutely critical to my professional and personal development over these last few years. During a time when each week felt more unbelievable than the last, recognizing the utility of self-examination and self-reflection felt incredibly grounding and empowering in my work as a therapist. At a time where the world told us that only distance and isolation could keep us safe, psychodynamic psychotherapy reminded us of how powerful connection could be.  

With the world changing before our eyes, we witnessed the impacts of repressed memories, unconscious influences, and patterns of repeated behaviors as they manifested in those for whom we provided care. The pain, the anguish, the suffering that we saw in those seeking our care – these experiences could not be adequately explained by neuroscience models or psychopharmacological theories. At a time when insight and understanding were at a premium, psychodynamic psychotherapy provided us with a framework to understand the challenges we witnessed our patients experiencing.  

As I (HK) enter the late stages of my psychiatry residency training, I am eternally grateful to the patients who have entrusted me with their stories and experiences; the privilege of their trust has allowed me to provide them with care and support during these years while also preparing me for what I hope is decades of being a care provider for my future patients. In addition to my training in the medical model and my training as a psychopharmacologist, I see my training as a psychodynamic psychotherapist as a critical element of who I am as a care provider for both the patients I have met and those I have yet to meet.  

The first time many psychiatrists get any type of therapy training is during residency. And even then, it is often a tool that is neglected until the last 2 years and only given a minimal amount of dedicated learning time. Psychodynamic therapy in particular is an exponentially useful tool in helping psychiatrists understand a unique way of thinking about the dyadic relationship between themselves and the patient they are treating at the time.

Even if a psychiatrist chooses not to participate in psychodynamic therapy after residency, there will still be a beneficial impact on clinical skills when it comes to better understanding the unconscious driving forces that are at play in the patient-physician relationship. With the realization that these different forces exist that are beyond the patient’s understanding, psychiatrists may also consider undergoing their own therapy to better understand how their own background may affect the relationship in ways that were previously unknown. According to one of the co-authors (GM), undergoing individual therapy while in residency can allow one to get in touch with the more repressed dimensions of the self which can lead to improved patient care due to the newfound awareness about what we often subconsciously repress or actively try to bury. 

Psychodynamic psychotherapy training has allowed me (EW) to develop further as a trainee psychiatrist, one that does not heavily rely on medications but also understands the power of therapy in treating symptoms. Learning psychodynamic psychotherapy has taught me that medications are not always the answer, especially in the pediatric population where parents would prefer behavioral modification techniques along with the adult patients that prefer nonpharmacological options due to unwanted medication side effects, interactions with other current home medications, or to minimize additional medications.

There are many therapy modalities introduced during residency training, but psychodynamic psychotherapy has been the one that most of my patients with extensive traumatic experiences naturally transition to in my panel. The opportunity to have weekly visits creates a trusting bond between provider and patient and through this interaction a provider can create a personalized treatment plan to target patient’s distressing symptoms, which changes over time and unlike medications, therapy can change with it. Also, there is much less risk of decompensation when changing therapy techniques compared to changing psychotropic medications.

Therapy gives provider and patient ample time to discuss details of symptoms and how these relate to personal experiences, which is less realistic to accomplish during regular medication management visits. I have also learned through these frequent therapy sessions that when patients are prescribed a medication for a symptom that can be better managed with proper/individualized therapy, most patients prefer to take less medications.

Psychodynamic psychotherapy training has been most vital to my understanding of complex patients with trauma diagnosis that have found themselves feeling helpless by taking numerous medications, failed several medication trials, and continue to have a wide spectrum of symptoms. As  providers we can educate patients about the causes of their symptoms and how these can sometimes be helped through therapy and nonpharmacological options. 

Psychodynamic psychotherapy training has been extremely valuable in my (AS) understanding of my patients’ presentations, beyond the scope of symptomatology and medication management. Embedded within the psychodynamic understanding is developing an awareness of patients’ unconscious conflicts, their attachment styles, their perceptions of relationships, while being cognizant of transference, countertransference, and their defense mechanisms. By delving into the unconscious processes of my patients, I have learned how to understand the narrative of my patients’ lives and not just the symptoms they are presenting with.

Part of the psychodynamic framework requires more frequent and longer visits which leads to a greater therapeutic experience. It is in exploring the developmental aspects of people’s lives that we gain true insight into the nature of their worries, fears, and anxieties. It ultimately provides a much more valuable understanding of the core of their personality, its interplay with the social environment, which influences  many different variables such as adherence to treatment and therapeutic alliance. The nature of psychodynamic psychotherapy also allows for more flexibility with treatment, which contrasts with structured interviews and assessment protocols many of us learn in training. This type of training allows residents to really listen to patients and think beyond certain pathological categories that are important, but at times limiting.  

Psychodynamic psychotherapy training has been perhaps the single most impactful aspect of my psychiatric residency training. Though I (AR) do not necessarily plan to pursue a career in outpatient psychiatry, much less a full-time practice in psychotherapy, the tools and perspective taught in psychodynamic training have become an integral part of my practice and are proving invaluable. Psychodynamic psychotherapy training has taught me to listen deeply, attune to my patients, and view their diagnostic assessments and treatment planning through a broader lens incorporating not only how they present in the moment, but also the totality of their lived experience. 

I (AR) find myself more curious and less judgmental when viewing a patient’s behavior as a manifestation of early developmental experiences and unconscious conflict rather than as solely influenced by current circumstances. For example, one of the more difficult experiences I encountered as a trainee completing her first longitudinal outpatient experience was being “fired” somewhat dramatically by a patient being seen for medication management, toward whom I felt I had offered nothing but kindness and an authentic desire to help. While my immediate reactions to this experience were a confusing mixture of hurt, guilt, inadequacy, anger, and defensiveness, drawing on my psychodynamic training allowed me to better understand my countertransference and continue to cultivate curiosity and empathy toward this patient despite her inflammatory words. The psychodynamic perspective enabled me to better understand that her behavior likely had much more to do with early childhood trauma and previous relationships than it did to anything that happened between us in our appointments. Though this was not a patient in therapy, it was drawing on psychodynamic psychotherapy training that allowed me to see my role in this reenactment and stand by the patient through this experience. She elected to continue care with me and we subsequently developed a deeper therapeutic relationship which facilitated my ability to more effectively evaluate her symptoms and make appropriate medication recommendations. 

Psychodynamic psychotherapy training has also influenced my understanding of how patients make sense of and integrate the destabilizing and frightening experience of having a severe mental illness. An example,  is a young adult patient who I see regularly for treatment refractory psychosis. This first manifested after a major traumatic event during adolescence. Over time, he has developed an elaborate delusion in an effort to make sense of his perceptual disturbances. Though this is a  patient being seen for medication management, psychodynamic psychotherapy training has given me a valuable perspective as to the role that his early trauma and object relations may be playing into the content of this delusion and the treatment resistant nature of his psychosis. Though there are undoubtedly biological drivers of his illness and successful treatment of his symptoms necessitates antipsychotic medications, psychodynamic thinking has enabled me to understand and relate to his experience with more depth, more effectively detect associated symptoms of anxiety and depression, and track the subtle nuances of his improvement. 

Even during relatively brief encounters in crisis settings, I (AR) find myself drawing on psychodynamic techniques to more quickly build rapport with patients, deescalate behaviors, and construct comprehensive patient formulations to guide safety evaluations and treatment planning. At its core, psychodynamic psychotherapy training has cultivated in me greater awareness that there are hidden forces driving behavior in nearly every patient encounter – whether a quick patient message asking for a medication refill or a multi-year therapy relationship. This awareness, curiosity, and desire to more deeply understand patients will continue to have long lasting and powerful implications for my psychiatric practice, regardless of treatment setting. 

The nature of psychodynamic psychotherapy has allowed me (AS) to have a more realistic view of patients while also cultivating more self-awareness in my own therapeutic styles. It has allowed me to adapt and constantly modify my approaches for the needs of our patients.

The supervision provided when consulting my psychodynamic cases has also been a source of great insight into my therapeutic style, which has been extremely valuable to me as a trainee. Given that the nature of psychiatric illness is in most cases rarely short term, I believe that the longitudinal nature of psychodynamic therapy allows residents to gain more realistic time-courses of psychiatric disorders. The ability to think in this longitudinal framework is also beneficial for our non-therapy patients. Being cognizant of different factors of a patient’s personality make up has been very useful for patients that I see  for medication management. Having the ability to utilize these frameworks has allowed me to develop better rapport and more successful outcomes with patients undergoing medication management 

Ultimately, I (AS) believe that the art of psychodynamic psychotherapy is something that needs to be practiced and utilized by all residents as a means to cultivate more adaptability, empathy, and create better frameworks for our patients. In the end, this leads to better outcomes and more fruitful learning environments for trainees. 

The therapeutic relationships that we form with our patients allows us to talk about, well, anything. Whether it is addressing the tragic loss of George Floyd in Minneapolis in May 2020 and the subsequent nationwide protests highlighting racial tensions or exploring the unique pain of losing loved ones during the ongoing COVID-19 pandemic, we – as therapists – work to facilitate the understanding of emotions and processes that feel incredibly unique to the times during which we live.  

Yet exposure to psychodynamic therapy during residency training served as a constant reminder that exploring these intrapsychic processes yielded lessons that are by no means new. As a trainee living through and providing care during what appears to be unprecedented times, training in psychodynamic therapy highlighted how exploring internal conflict and appreciating the centrality of the therapeutic relationship can be truly timeless. This framework allowed us, psychiatric residents, to appreciate the shared experience of the human condition.   

One can certainly read about the value of psychodynamic psychotherapy teaching through didactic materials or articles in the scientific literature such as the reference [1] proposed by one of the co-authors (GM). But the surest way to be convinced about its importance and committed to incorporate it in patient encounters whenever indicated is via direct experience, which the authors aimed to share in this article. 

As an attending (CG) who has been in practice for 16 years and a trauma psychiatrist who has been working for over seven years with third-year residents (five of whom are contributing to this article), I have had ample opportunities to witness and experience the value of teaching and learning about psychodynamic therapy. I therefore invited residents to share their views from their direct experience on such a core element of their training. 

In summary, because medications are not always the sole answer, because psychodynamic psychotherapy allows a more in-depth exploration of issues due to higher frequency and longer duration of sessions, we want to emphasize the necessity of that experiential aspect of all residency trainings in psychiatry. I find the case examples described above quite compelling and highlight the importance of developing and applying a psychodynamic lens during various clinical encounters. Additionally, supervision deepens the insights and adds to the understanding of the patient by deconstructing sub-therapeutic phenomena such as transference and countertransference.

But as a resident (GM) remarked, though there are many benefits to teaching psychodynamic therapy in residency, there are drawbacks to the way it is taught to residents. It often seems like an afterthought, or at least not as necessary as other aspects of psychiatry because of its relegation to the later years of residency. However, from day one of residency we are meant to have deep, personal conversations with patients. Often learning from patients about life events they have never told to another soul. Therapy, especially psychodynamic therapy which hones in on the said and unsaid things in the relationship between two people should be at the forefront of our education. It could lessen significant amounts of confusion in the concepts of transference which are often referenced in passing but when deeper explanations are sought, the learner is often left wanting more. Residents are always trying to find diverse ways to connect or relate to patients better and learning psychodynamic therapy is often a significant part of that. 

In conclusion, a psychodynamic approach helps us and the patients who share a life story connect the dots of their narrative. It allows us to help the patient look back at their past experiences and learn how they shaped their self-concept, their attachment, their relationships and their coping styles.  And the majority of our patients have suffered some degree of developmental trauma, hence the relevance of exploration of past dynamics. It also invites our own self-reflection that leads to insights we should sooner or later put to the service of our patients, breaking their sense of aloneness and making them “feel felt”. This is an invitation to scuba-dive into one’s life to understand the underlying mechanisms of disease and other forms of suffering as opposed to surfing by going through the motions of busy existence or putting out fires. Psychodynamic therapy renders justice to the beautiful, mysterious, ever-evolving complexity of our brains and our lives. It fosters self-understanding and personal growth, the soil in which healing and empowerment can occur. 

Reference: 

1. Adam M. Brenner (2006) The Role of Personal Psychodynamic Psychotherapy in Becoming a Competent Psychiatrist, Harvard Review of Psychiatry, 14:5, 268-272, DOI: 10.1080/10673220600968670