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Key points
- It rarely helps to move from a psychiatric diagnosis to treatment without understanding the psychological context of a patient's symptoms.
- Some people think they have been in therapy when in fact they have never engaged in a meaningful psychotherapy process.
- Therapists who see themselves as “providers” who only dispense interventions or medications cut themselves off from meaningful work.
In this interview with Daniel Carlat for The Carlat Psychiatry Report, I discuss psychodynamic therapy and how it differs from routine psychiatric care. Which would you want for yourself or a loved one?
Daniel Carlat: For most psychiatrists, evaluating a patient involves coming up with a DSM diagnosis and finding a medication appropriate for that diagnosis. How is the psychotherapeutic approach different?
Jonathan Shedler: For most patients, DSM diagnostic categories are a poor and extraordinarily limiting way of understanding emotional suffering (read my post about this). First, most patients don't come to us packaged in clear-cut diagnostic categories. Second, DSM assumes it is useful to view emotional suffering as a “disease,” like influenza or diabetes or ringworm. It fosters the fiction that you can treat emotional pain as an encapsulated illness that is separable from the person experiencing the pain. But most of the problems that bring people to treatment are woven into the fabric of their lives. It is less a question of what the patient “has” than who they are—their way of being in the world.
DC: So 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.
Shedler: Yes. It is rarely helpful to move from a psychiatric diagnosis to a treatment decision—as many practitioners are now trained to do—without understanding the meaning of the person’s difficulties and their larger psychological context. It would be more helpful to think of depression, for example, not as a disease but as the emotional equivalent of fever. Fever is a nonspecific response to a wide range of underlying conditions, from the common cold to Ebola. Diagnosis does not end with taking a patient’s temperature. Depression is likewise a nonspecific response to a wide range of underlying difficulties. To help our patients, we need to treat the causes of the "fever."
DC: Can you give us an example of this principle in action?
Shedler: A psychiatric resident and I treated a patient in his thirties who had been in psychiatric treatment for 15 years with little if any benefit. He suffered from chronic depression and came in asking for medication changes. We met with the patient and asked about what was going on in his life, the trajectory that had gotten him where he was, and his thoughts about what might help him to feel better. He said, “I have had psychotherapy before, it doesn't work for me.” But as we talked further, it became clear that he had never engaged in a meaningful psychotherapy process.
He had been on one medication after another, and he had been through an alphabet soup of brief “evidence-based” psychotherapies (“alphabet soup” because the therapies are all known by three- or four-letter acronyms). But he couldn’t say anything about what he learned about himself in any of these therapies, nor could he say anything meaningful about his relationship with any therapist.
DC: But this patient thought he had spent years in therapy. So, as psychiatrists, how do we determine whether a person has had a real robust trial of therapy?
Shedler: If a person has had meaningful therapy, he will be able to discuss it in a meaningful way. You can ask the patient, “Tell me about your previous therapy. What was the relationship with your therapist like? What did you learn about yourself?” In this particular case, what was striking was that this intelligent patient had no concept that psychotherapy involved a relationship. He viewed therapists merely as “providers” who dispense various techniques and interventions.
DC: So we should ask: “I see you have had some psychotherapy. What sorts of things do you remember getting out of therapy?”
Shedler: Certainly. We also invited the patient to tell us how he understood his depression—his own view about what was making him so unhappy and making his path through life so painful. Shockingly, no one had ever asked him this. The idea that his depression, his sadness and emptiness, could have meaning, that it was something to reflect on and potentially understand, was completely alien.
He spent about nine months in therapy making small talk and steering around emotionally meaningful topics. After nine months of work—with the doctor repeatedly pointing out how the patient closed off certain areas of thought and discussion—he began to open up. He revealed that in his private thoughts, he was hypercritical of almost everyone. He'd meet someone, home in on a perceived flaw, then condemn them and write them off.
What next emerged was that he viewed himself through the same lenses. He was constantly condemning and attacking himself. At that point, we could redefine his “depression” in a way that made it possible to do some psychological work. We were able to say, “If you treat someone badly—if you berate and abuse them—it hurts. That is also true when the person you mistreat is yourself. The resulting hurt is what you have been calling ‘depression.’” That was the turning point in his treatment.
DC: But it took nine months. Most psychiatrists don’t have nine months to do weekly therapy.
Shedler: Who decided that? When did psychiatrists become so ready to acquiesce to this? This is one problem with a “diagnose and prescribe” approach to treatment: We never learn who our patients are or what they need. It is also a problem with brief, manualized psychotherapy (see my post about this). Many patients require time to reveal themselves to us, and for that matter, to reveal certain things to themselves. So therapist and patient may have the illusion that they have completed therapy when real therapy never even started. Psychiatrists may encounter pressure—economic and otherwise—to gear their practices around 15-minute medication checks, but that doesn’t mean it is good care.
DC: What do you think about CBT techniques that are used for anxiety disorders? Psychotherapy for panic disorders tends to be a manual, menu-driven approach, and sometimes it is said to only take a couple of sessions to work.
Shedler: There is a lot of research on this. If we are talking about a psychologically healthy person with good relationships, good attachments, who is functioning well in other domains, then we can treat an encapsulated symptom of, say, panic attacks relatively quickly. But that is not how most patients come packaged. We know clinically and empirically that most patients meet criteria for multiple diagnoses, and their symptoms are rooted in their psychological makeup or personality. Brief, manualized treatments are effective for a small subset of high-functioning patients with uncomplicated panic disorder. Research shows that brief psychodynamic therapy is effective for panic disorder.
DC: How does psychodynamic treatment of panic or other kind of anxiety disorder work?
Shedler: A starting point is the recognition that panic is fear. The person is afraid of something. When what is frightening is external and obvious, we call it fear. When what is frightening is internal and not obvious, we may call it panic disorder. But the experience of panic is not without psychological meaning. It does not occur in a psychological vacuum. Therapy involves exploring the patient’s inner experience to make explicit what is frightening and bring it into the light of day. They say sunlight is the best disinfectant. The patient doesn’t have to go through life being terrified of something that, seen in the light of day, is not so terrifying after all. Patients with panic disorder cannot initially tell us what is frightening. They don’t know. So we help them explore their inner world and put words to their fear.
DC: How is this different from the procedure of eliciting “automatic thoughts” in CBT?
Shedler: This is an area where there is some convergence between psychodynamic and cognitive approaches. Remember that Aaron Beck, the father of cognitive therapy, was a psychoanalyst. Cognitive therapists speak of automatic thoughts, psychodynamic therapists speak of following the patient’s chain of associations. In both cases, the intent is to help the patient attend to areas of mental life that otherwise escape notice.
The difference is that in psychodynamic therapy, there is a recognition that it may take a lot of work before a person can put words to certain aspects of inner experience. You can ask a person a question and get a perfectly truthful answer. You can pursue the question further by asking, “What more comes to mind?” and get a completely different answer that is also true. And you can continue in this manner, each time discovering additional layers of meaning.
DC: Please give us an example of a psychodynamic approach to a patient who has panic.
Shedler: One of my psychiatry residents successfully treated a patient with panic disorder in a brief treatment of less than 12 weeks. The patient was an otherwise high-functioning person. She experienced her panic attacks as arising “out of the blue.” We invited her to speak freely, without editing or censoring her thoughts, and to follow them wherever they led. Her thoughts consistently ran to dissatisfactions with her husband. And although she complained about him, she never expressed anger. We came to recognize that she was afraid of her own anger. You could say she had an “affect phobia.” Panic attacks took the place of anger.
DC: So how was this addressed?
Shedler: Over the course of therapy, she began to recognize her anger, and also recognize the various things she did to ward it off. She began to recognize that it was okay to attend to it and put it into words. It was not so dangerous after all; it did not destroy her, or her husband, or her doctor. She became more comfortable with this part of herself. When she no longer experienced her anger as intolerable and alien, she began to better understand her emotional needs and better communicate them to others, including her husband.
Things changed internally and externally. Internally, she gained access to areas of emotional life that were previously alien. Externally, she could better meet her needs when she allowed herself to recognize and express them. The psychological themes underlying her panic also played out in the therapy relationship. She reflexively warded of feelings of anger and irritation toward her doctor and the therapy, and her doctor helped her recognize this. So there was a reverberation or interplay between the relationship patterns with her husband and the relationship patterns that emerged in the therapy relationship. That is what we mean by the term transference.
DC: Interesting. Any final thoughts?
Shedler: 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 create meaningful relationships, to truly know our patients, to make a difference in their lives. The work is no longer a calling, it’s just a job. I think that’s bad for the soul—the patient’s, and the doctor’s too.
© 2013 by Jonathan Shedler, PhD
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