Graduating resident with little therapy training - help

[yanks26dmb]

Hi guys. Havent posted in a while, but as graduation approaches, feeling some anxiety. My residency training was solid, but therapy was light. Combine with the fact I don't feel like I'm all that great at therapy to begin with, I'm feeling at a loss. I get the sense my patients like working with me, they keep coming back and all that, but I'm fearful I'm destined to be a **** psychiatrist given my poor therapy background. I've been really down on myself lately as graduation approaches. I always thought this would be a period of immense joy and sense of accomplishment, but all I can think of is how much I dont know and how medicore I probably am.

Any thoughts on how to get better at therapy after residency ends? I'll be doing a combination of work - inpatient and a small private practice.

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[Monocles]

OP do you live anywhere near a psychoanalytic institute? Ex: BPSI (boston) where trainees, new grads, and returning attendings can get additional training and hone their skills.

Approved Training Institutes – American Psychoanalytic Association

 

[clausewitz2]

This is somewhat dependent on precisely what therapy modalities you would like to be better at, but for almost any modality you can think of there are organized trainings that you can find relatively swiftly via google. It will cost money/education funds but if you feel your background is very shaky, this would be the place to start.

 

[allantois]

Def ain't cheap to become an analyst as one has to pay for personal analysis

 

[yanks26dmb]

I have no interest in doing psychoanalysis. I'm also not wanting to have therapy only patients. As I'll be largely inpatient with outpatient med management, I would like to be sufficient to make my outpatient appointments more than just medication discussions. I can of course do supportive therapy and some aspects of CBT, I just don't feel great at anything in particular. Even doing MI I feel somewhat useless. I think a psychodynamic slant is most interesting to me, but again, no desire for long-standing psychoanalyst type therapy.

 

[G Sheb]

I'd say the large majority of psychiatrists only dabble with therapy during residency, so you're not really at a disadvantage.
The fact that patients keep coming is a great sign. That's half the battle, and that means you already have some therapy skills, even if you're not aware of that.
That you're also aware of deficiencies in your skill set is another good sign, nothing to feel down about or beat yourself witj.

Most serious therapy training will occur after residency.
You will have ample opportunity to develop those skills. Just look for therapy institutes, depending on what you like. You can get training in CBT, DBT, psychoanalytic/psychodynamic therapy or pretty much any kind of therapy that interests you. Many institutes will offer online training if there's nothing around you.

And finally, you don't need to do a full psychoanalytic training program if you're interested in psychodynamics. You can do 1 to 2 year training in psychodynamic therapy. These tend to be with a much lighter course load, supervision and training requirements.
I would recommend a modern, interpersonal, intersubjective approach. I frankly ran away from classical psychoanalysis like the plague as I find it ridden with prejudices and bulls***.

 

[yanks26dmb]

I would recommend a modern, interpersonal, intersubjective approach. I frankly ran away from classical psychoanalysis like the plague as I find it ridden with prejudices and bulls***.

In regards to that approach - any advice on where to look for this type of training?

 

[G Sheb]

In regards to that approach - any advice on where to look for this type of training?

Probably the White Institute in NYC is the flag bearer of modern psychoanalysis. They pioneered relational psychoanalysis, which is now on the ascendency. They also offer an online training program.
There are also other institutes that specialize in intersubjective psychoanalysis, but I can't attest to the quality.
Otherwise, many centers will have faculty and supervisors with various approaches, so this is very center dependent, and your best bet is to do the research beforehand. American psychoanalysis is more classical than most, but I feel like the classical Freudians are becoming more and more an endangered species.

 

[splik]

You need to find a good supervisor and pay for supervision. That is what will be by far and away most useful to you. You can use the time to discuss difficult cases and develop your case formulation skills and discuss using brief therapeutic interventions.

 

[calvnandhobbs68]

I have no interest in doing psychoanalysis. I'm also not wanting to have therapy only patients. As I'll be largely inpatient with outpatient med management, I would like to be sufficient to make my outpatient appointments more than just medication discussions. I can of course do supportive therapy and some aspects of CBT, I just don't feel great at anything in particular. Even doing MI I feel somewhat useless. I think a psychodynamic slant is most interesting to me, but again, no desire for long-standing psychoanalyst type therapy.

I mean if you're not looking to do real longitudinal psychotherapy with patients (like if it's not even in the cards for you to see even a few patients weekly for psychotherapy)....you don't have to be particularly great to review CBT techniques or do some "supportive therapy" stuff during 30min followups.

I think you're giving off mixed messages here. Why do you care if you're good at therapy if you're going to be inpatient and outpatient "med management"...if you're already describing your outpatient appointments as "med management" appointments you're not even conceptualizing them as psychotherapy appointments.

If you do want to pick up some patients to do real psychotherapy with, then yeah get some cases in your outpatient private practice you want to see weekly/every other week for a while and pick a modality you want more supervision with. If you want to actually get certified in something, you'd go through the official institute like Beck Institute for CBT (Beck Institute CBT Certified Clinician (BICBT-CC) - Beck Institute) or the equivalent for other psychotherapy approaches, most of them have some official supervision component along with coursework.

Also, adding that you still have what 5 months until graduation? That's absolutely enough time for you to do more CBT or CBT based therapies training. That's 20 weekly sessions, you can probably get at least 12-16 which can be a full course of CBT classically. Talk to your program now, ask for a CBT supervisor for the next 4-5 months, troll around the resident clinic for a few patients in need of a therapist for the next couple weeks and I'm sure you can pick up a couple cases, all paid for by your residency program.

 

[G Sheb]

You need to find a good supervisor and pay for supervision. That is what will be by far and away most useful to you. You can use the time to discuss difficult cases and develop your case formulation skills and discuss using brief therapeutic interventions.

This as well.
Some institutes will have a particular service of offering clinical supervisors. This can do the job equally well, with you doing independent reading on the side. Cause frankly a lot of the courses are a waste of time and money.

 

[tr]

You need to find a good supervisor and pay for supervision. That is what will be by far and away most useful to you. You can use the time to discuss difficult cases and develop your case formulation skills and discuss using brief therapeutic interventions.

I don't know if I agree with this. I think the classical supervision model where the supervisee and supervisor meet separately without the patient isn't very useful, and definitely not for someone who is just starting their therapy training.

This model limits the discussion to whatever the supervisee elects to present, and doesn't give the supervisor a chance to observe what is actually happening in the room. It's like trying to learn horseback riding by meeting with your instructor separately, without the horse, then trying your luck in the saddle solo.

If you can't get directly observed supervision (either by 2 way mirror or, failing that, at least with video) then I really wouldn't bother with this model. I think it's pretty ineffective.

 

[allantois]

I don't know if I agree with this. I think the classical supervision model where the supervisee and supervisor meet separately without the patient isn't very useful, and definitely not for someone who is just starting their therapy training.

This model limits the discussion to whatever the supervisee elects to present, and doesn't give the supervisor a chance to observe what is actually happening in the room. It's like trying to learn horseback riding by meeting with your instructor separately, without the horse, then trying your luck in the saddle solo.

If you can't get directly observed supervision (either by 2 way mirror or, failing that, at least with video) then I really wouldn't bother with this model. I think it's pretty ineffective.

I've worked with master level therapists in training. They would record their sessions (with patient's consent ofc).

 

[tr]

I've worked with master level therapists in training. They would record their sessions (with patient's consent ofc).

Yes, we had video recorded sessions in residency as well. I think most training programs now require this, at least for a small number of sessions. They were minimally helpful IME, as we never went through the full length of the video with the supervisor, but just watched selected snippets.

Two way mirror observation with supervisor keeping notes to review afterwards was more effective.

Small group based workshop with other trainees, swapping between patient and therapist roles, was the most effective IME.

 

[Mad Jack]

Therapeutic alliance is more important than skill in any particular modality. Pick something you feel you can learn to do well and obtain further training in it through the avenues others have noted. Just using the basic principles of CBT and supportive therapy in day-to-day interactions with patients can make a profound difference if your therapeutic alliance is strong.

 

[WisNeuro]

Yes, we had video recorded sessions in residency as well. I think most training programs now require this, at least for a small number of sessions. They were minimally helpful IME, as we never went through the full length of the video with the supervisor, but just watched selected snippets.

Two way mirror observation with supervisor keeping notes to review afterwards was more effective.

Small group based workshop with other trainees, swapping between patient and therapist roles, was the most effective IME.

I would agree. During my training, and my supervision of others, I have experienced audiotaping, videotaping, two-way mirror, and no recording at all. The mirror system was by far the most rich and efficient setup.

 

[WisNeuro]

Therapeutic alliance is more important than skill in any particular modality. Pick something you feel you can learn to do well and obtain further training in it through the avenues others have noted. Just using the basic principles of CBT and supportive therapy in day-to-day interactions with patients can make a profound difference if your therapeutic alliance is strong.

Multiple threads about this debate. The Wampold stuff is very flawed, and can't really state this across the board. Common factors definitely important, but we do see sizable differences in certain disorders/treatments that are very likely due to the active treatment mechanisms independently.

 

[Mad Jack]

Multiple threads about this debate. The Wampold stuff is very flawed, and can't really state this across the board. Common factors definitely important, but we do see sizable differences in certain disorders/treatments that are very likely due to the active treatment mechanisms independently.

I should not have generalized so much, fair. If you're working with OCD, you best know some ERP, for instance. For your garden variety depression, anxiety, and the like that you aren't seeing as therapy-only patients though? Probably not going to make much difference what you're doing when you are primarily managing meds, as long as you are decent at what you do and you aren't engaging in anything super off the wall.

 

[WisNeuro]

I should not have generalized so much, fair. If you're working with OCD, you best know some ERP, for instance. For your garden variety depression, anxiety, and the like that you aren't seeing as therapy-only patients though? Probably not going to make much difference what you're doing when you are primarily managing meds, as long as you are decent at what you do and you aren't engaging in anything super off the wall.

If you're not actually doing targeted therapy, doesn't really matter, I'd just suggest getting good at MI and some very basic CBT principles as that's probably your biggest ROI for the time you have.

 

[smalltownpsych]

A lot of what I teach supervisees is how a lot of what we do is counterintuitive. A good supervisor can help you develop this skill set and it does help to have some direct observations or recorded sessions. Everyone else in the patient‘s life is going to be enacting patterns that the patient is pulling for. Don’t try to make them feel better or behave better or give them advice about their life and relationships. Part of why patients are enjoying you is because you are already not trying to “help“ them with the emotional and interpersonal and are listening to them with a non-judgemental stance. If you start trying to do “therapy” without guidance, then patients will quickly figure that out and not be so quick to come back. 😁

 

[SmallBird]

I should not have generalized so much, fair. If you're working with OCD, you best know some ERP, for instance. For your garden variety depression, anxiety, and the like that you aren't seeing as therapy-only patients though? Probably not going to make much difference what you're doing when you are primarily managing meds, as long as you are decent at what you do and you aren't engaging in anything super off the wall.

The other thing to consider when considering comparing treatment options is effect sizes, which give insight beyond the % of people who are likely to respond to a treatment but also how much they will improve. The effect size for behavioral activation for example is around 0.8 and for SSRIs is more like 0.3 - 0.4, and yet the conventional wisdom is that meds and therapy are approximately equal. Practically, I find that I can help a patient immensely by having some knowledge of how to use values identification to then work on goal setting and activity logs in instances where it is clear that they are doing very little with their day, and I have a hard time believing that a dynamic approach would be as impactful even if our relationship was strong in both cases.

 

[Geraltofrivia]

You should read this excellent book: "Psychoanalytic Diagnosis" by Nancy McWilliams, found here Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process: 9781462543694: Medicine & Health Science Books @ Amazon.com . This book will teach you the basics of Psychodynamic Psychotherapy, which in my opinion is an excellent therapeutic technique to learn. You can find supervision by calling psychiatrists /PsyDs in your area and ask if they know anything about Psychodynamic Psychotherapy. I am a recent graduate but my program heavily emphasized this treatment and I think it works so that's all I can say lol

 

[clausewitz2]

If you're not actually doing targeted therapy, doesn't really matter, I'd just suggest getting good at MI and some very basic CBT principles as that's probably your biggest ROI for the time you have.

I'd argue if you are totally unfamiliar with the principles of E/RP it is really easy to unintentionally sabotage someone with OCD as a psychiatrist, but avoiding making things worse requires a lot less knowledge and training than actively doing exposure work.

 

[WisNeuro]

I'd argue if you are totally unfamiliar with the principles of E/RP it is really easy to unintentionally sabotage someone with OCD as a psychiatrist, but avoiding making things worse requires a lot less knowledge and training than actively doing exposure work.

I would definitely agree. There are a lot of people out there doing very bad CBT based work for manualized therapy. Many people assume that they can do it competently after reading a book or taking a workshop, with no supervision. Bad therapy for anxiety disorders is far worse than no therapy at all.

 

[forchinet121]

I'd argue if you are totally unfamiliar with the principles of E/RP it is really easy to unintentionally sabotage someone with OCD as a psychiatrist, but avoiding making things worse requires a lot less knowledge and training than actively doing exposure work.

How would a psychiatrist make OCD worse?

 

[WisNeuro]

How would a psychiatrist make OCD worse?

By mismanaging exposure targets, reinforcing obsessions and compulsions, rather than habituating.

 

[forchinet121]

By mismanaging exposure targets, reinforcing obsessions and compulsions, rather than habituating.

Can you give an example of what you mean

 

[WisNeuro]

Can you give an example of what you mean

At a very basic level, going too far, too fast. If you set someone up to fail in an exposure, you will likely have the opposite effect. Another issue is not having the patient go far enough in an exposure, not allowing enough time for the habituation, thereby reinforcing the avoidance strategies that they use. Choosing the wrong form of exposure depending on the target. Providing reassurance, etc, etc. There are many pitfalls in exposure, and other treatments, that will either hinder positive outcomes, or reinforce negative outcomes.

 

[clausewitz2]

. Another issue is not having the patient go far enough in an exposure, not allowing enough time for the habituation, thereby reinforcing the avoidance strategies that they use.

There is a body of more recent literature for OCD that argues that habituation is not the mechanism by which E/RP works, but rather, actively learning a different set of conditioned responses that does not involve compulsing. This is partly motivated by the mounting evidence that reduction in SUDS within session is not actually necessary for E/RP to be effective, so long as you are actually provoking real significant distress with the exposure and successfully preventing compulsions.

EDIT: as physicians it is super easy for us to get drawn into reassurance even if not doing therapy.

 

[SmallBird]

You should read this excellent book: "Psychoanalytic Diagnosis" by Nancy McWilliams, found here Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process: 9781462543694: Medicine & Health Science Books @ Amazon.com . This book will teach you the basics of Psychodynamic Psychotherapy, which in my opinion is an excellent therapeutic technique to learn. You can find supervision by calling psychiatrists /PsyDs in your area and ask if they know anything about Psychodynamic Psychotherapy. I am a recent graduate but my program heavily emphasized this treatment and I think it works so that's all I can say lol

This book is absurdly fantastic. I have read it and bought it for multiple people and have also heard her speak and awkwardly met her a few times and blushed a lot. My application is less about doing therapy but more about having a framework for understanding the common clinical challenges I face even as an inpatient psychiatrist. It is the most helpful lens for understanding things like patients who refuse meds, self-sabotage, try and undermine treatment, over-invest in illness identities. I honestly believe that applying the understanding that began with book is the reason I am a 'good' inpatient psychiatrist. It is also a big part of why it takes a little longer to get done with my case load and why I don't think I will quickly be replaced by someone with less training.

 

[WisNeuro]

There is a body of more recent literature for OCD that argues that habituation is not the mechanism by which E/RP works, but rather, actively learning a different set of conditioned responses that does not involve compulsing. This is partly motivated by the mounting evidence that reduction in SUDS within session is not actually necessary for E/RP to be effective, so long as you are actually provoking real significant distress with the exposure and successfully preventing compulsions.

EDIT: as physicians it is super easy for us to get drawn into reassurance even if not doing therapy.

I'll have to check that out. Admittedly, I am removed from the OCD lit, much more up to date on the PTSD end of things.

 

[notamindreader]

Hi guys. Havent posted in a while, but as graduation approaches, feeling some anxiety. My residency training was solid, but therapy was light. Combine with the fact I don't feel like I'm all that great at therapy to begin with, I'm feeling at a loss. I get the sense my patients like working with me, they keep coming back and all that, but I'm fearful I'm destined to be a **** psychiatrist given my poor therapy background. I've been really down on myself lately as graduation approaches. I always thought this would be a period of immense joy and sense of accomplishment, but all I can think of is how much I dont know and how medicore I probably am.

Any thoughts on how to get better at therapy after residency ends? I'll be doing a combination of work - inpatient and a small private practice.

I think these are very normal worries and a healthy sign to have the awareness that we do not finish residency training knowing everything. I agree with many of the points noted above, particularly the supervision piece. I believe that our counter-transference is more easily unearthed and understood in a relational capacity by working with a supervisor, or better yet, with your own psychotherapist. I strongly encourage trainees and colleagues to pursue their own psychotherapy - it has unquestionably made me a better therapist by really understanding the therapeutic experience from both sides.
I would also recommend a 1 or 2 year psychodynamic/psychoanalytic psychotherapy training (not necessarily to pursue psychoanalysis) as these programs often help develop a good scaffolding around the therapeutic frame. If you are pursuing private practice this is even more essential as even small patient-clinician issues or tensions may create big emotions for both you and your patients, i.e. you or the patient showing up a few minutes late to the visit; negotiating your hourly fees; outreaching to some patients after hours

 

[tr]

Can you give an example of what you mean

I will give a very concrete example.

I had a patient who was obsessed with the (unfounded) fear that they might be a child molester. One of their compulsions was to repeatedly shift their sleeping child farther away from them, which would provide a temporary sense of safety/relief. They were seeing an otherwise well trained therapist who had little experience in OCD. The therapist was actively encouraging the patient to persist in the shifting behavior, viewing it as a 'coping mechanism' rather than recognizing it as a compulsive behavior that needed to be resisted. This reinforced the compulsion rather than eliminating it.

I have also had several OCD patients with compulsions to confess, whose therapists encouraged the confessing in the mistaken belief that they were providing effective supportive psychotherapy. Actually what they were doing was turning the whole therapy session into a big self-reinforcing compulsion loop.

OCD in particular is easy to mess up by just being a nice supportive person. I echo @smalltownpsych up above who notes that effective psychotherapy is often about suppressing your intuitive 'nice-person' reactions and replacing them with more considered, targeted, but often difficult and unintuitive responses.

 

[clausewitz2]

I will give a very concrete example.

I had a patient who was obsessed with the (unfounded) fear that they might be a child molester. One of their compulsions was to repeatedly shift their sleeping child farther away from them, which would provide a temporary sense of safety/relief. They were seeing an otherwise well trained therapist who had little experience in OCD. The therapist was actively encouraging the patient to persist in the shifting behavior, viewing it as a 'coping mechanism' rather than recognizing it as a compulsive behavior that needed to be resisted. This reinforced the compulsion rather than eliminating it.

I have also had several OCD patients with compulsions to confess, whose therapists encouraged the confessing in the mistaken belief that they were providing effective supportive psychotherapy. Actually what they were doing was turning the whole therapy session into a big self-reinforcing compulsion loop.

OCD in particular is easy to mess up by just being a nice supportive person. I echo @smalltownpsych up above who notes that effective psychotherapy is often about suppressing your intuitive 'nice-person' reactions and replacing them with more considered, targeted, but often difficult and unintuitive responses.

I would sum up the most common countertransference to people with real-deal OCD as "there, there, dear". This is most certainly an enactment/the behavioral schema they habitually provoke in people they encounter. You most definitely cannot use your nice-person reaction because ideally confessions of worries about being a child molester should be met with something equivalent to a shrug and "I don't know, maybe you are. That's always possible."

 

[WisNeuro]

I would sum up the most common countertransference to people with real-deal OCD as "there, there, dear". This is most certainly an enactment/the behavioral schema they habitually provoke in people they encounter. You most definitely cannot use your nice-person reaction because ideally confessions of worries about being a child molester should be met with something equivalent to a shrug and "I don't know, maybe you are. That's always possible."

My favorite, when treating panic disorder, when someone is at or near panic asks "am I having a heart attack?," and just replying, "I guess we'll find out soon."

 

[meringue]

Hi guys. Havent posted in a while, but as graduation approaches, feeling some anxiety. My residency training was solid, but therapy was light. Combine with the fact I don't feel like I'm all that great at therapy to begin with, I'm feeling at a loss. I get the sense my patients like working with me, they keep coming back and all that, but I'm fearful I'm destined to be a **** psychiatrist given my poor therapy background. I've been really down on myself lately as graduation approaches. I always thought this would be a period of immense joy and sense of accomplishment, but all I can think of is how much I dont know and how medicore I probably am.

Any thoughts on how to get better at therapy after residency ends? I'll be doing a combination of work - inpatient and a small private practice.

Hi, yanks. I'm just curious what you mean when your therapy was light. What was the structure of your training program like oriented around therapy? I'm just generally interested to see how therapy is taught in various programs, as I feel that my program has a lot of therapy training, but am interested to see how this might translate concretely (e.g. supervision hours a week for therapy, caseload for therapy [45 minute weekly patients] and for how many years). Thank you!

 

[tr]

My favorite, when treating panic disorder, when someone is at or near panic asks "am I having a heart attack?," and just replying, "I guess we'll find out soon."

Good Lord, you two have nerves of steel. I don't think I'm quite there yet. I'd usually do a guided 'Examine the Evidence ' or maybe 'Feared Fantasy' in those situations.

 

[WisNeuro]

Good Lord, you two have nerves of steel. I don't think I'm quite there yet. I'd usually do a guided 'Examine the Evidence ' or maybe 'Feared Fantasy' in those situations.

This was usually in younger people (<40), who had minimal or no CV risk factors, and had already been to the ED with a panic attack and worked up. So, the chances were pretty low of an actual HA. I did have a couple patients who were post MI who developed some panic and certain avoidance behaviors that I was a little more nuanced with in responding to that specific common panic fear.

 

[Desired Member]

I don't know if I agree with this. I think the classical supervision model where the supervisee and supervisor meet separately without the patient isn't very useful, and definitely not for someone who is just starting their therapy training.

This model limits the discussion to whatever the supervisee elects to present, and doesn't give the supervisor a chance to observe what is actually happening in the room. It's like trying to learn horseback riding by meeting with your instructor separately, without the horse, then trying your luck in the saddle solo.

If you can't get directly observed supervision (either by 2 way mirror or, failing that, at least with video) then I really wouldn't bother with this model. I think it's pretty ineffective.

This is how therapy "training" was done in my program and it felt nearly useless

 

[ObsequiousAplomb]

Hi, yanks. I'm just curious what you mean when your therapy was light. What was the structure of your training program like oriented around therapy? I'm just generally interested to see how therapy is taught in various programs, as I feel that my program has a lot of therapy training, but am interested to see how this might translate concretely (e.g. supervision hours a week for therapy, caseload for therapy [45 minute weekly patients] and for how many years). Thank you!

Not Yanks, but answering the part where you asked about other programs.

At my peak I had 12 hours a week of therapy and had one supervision hour for every 2 clinical hours of therapy. Since I had a number of CBT cases and dynamic patients who remitted I averaged closer to 8 hours a week of therapy cases PGY-3 and 6 hours PGY-4. Overall around 30 cases of therapy.

5 of them were for two full years and 3 of those continued beyond residency to private practice while the other 2 were in remission by the latter half of PGY-4 and discharged from the clinic.

 

[Geraltofrivia]

This book is absurdly fantastic. I have read it and bought it for multiple people and have also heard her speak and awkwardly met her a few times and blushed a lot. My application is less about doing therapy but more about having a framework for understanding the common clinical challenges I face even as an inpatient psychiatrist. It is the most helpful lens for understanding things like patients who refuse meds, self-sabotage, try and undermine treatment, over-invest in illness identities. I honestly believe that applying the understanding that began with book is the reason I am a 'good' inpatient psychiatrist. It is also a big part of why it takes a little longer to get done with my case load and why I don't think I will quickly be replaced by someone with less training.

Totally agreed. I might have to leaf through it again