Shirah Vollmer MD

The Musings of Dr. Vollmer

Teaching Psychotherapy: Tryin’ Again!

Posted by Dr. Vollmer on June 6, 2013

Well, I considered hanging up my hat on the teaching front. The world of psychiatry was tilting far towards algorithms, away from the individual relationship with patients. My world in my office, I could manage the way I saw fit, but the world of the new psychiatry trainees was concerning me. How would they learn how to talk and, perhaps more importantly, how to listen. Then, without any warning, there was a query. The residents were looking for someone to answer the following questions.
How do you structure an initial session?
How do you decide or explain goals of therapy?
How do you evaluate if a patient is appropriate or not for psychodynamic therapy?
How do you set the frame properly? (ending on time, minimizing time spend talking outside of sessions, other boundary issues, etc).
Wow. I am back in business. They were asking questions which lit the fire in my belly. I dragged out my book “Becoming A Psychotherapist” by Rosemary Balsam MD and her husband Alan Balsam MD. I am going to bring chapters and we are going to have a discussion about  how one, as a psychiatrist, learns to become a psychotherapist. Maybe the psychiatric world is ready for another pivot; only this time a pivot back towards the individuality of the patient. I can hope.
So, how do you structure an initial session? I think that question is going to be how do I structure an initial session.  I am going to talk about listening with a mental outline. Is the patient mentioning their childhood? Why now are they coming in for treatment? Whose recommendation did they take to get here? It is not that I am going to ask these questions, but I am going to be curious if the opening remarks address these issues. I am interested in what the patient says and what he does not say, as well as how he says things, including the nature of his presentation. The goals are co-created, discussed in an ongoing way about what makes sense to focus on. The appropriateness for therapy depends on the psychiatrist’s assessment of the patient’s mental state and mental capacities. The frame is constantly negotiated depending on the needs of the individual. I project we will have a rich discussion. Stay tuned.


11 Responses to “Teaching Psychotherapy: Tryin’ Again!”

  1. Jon said

    There are good reasons for the seemly quixotic desires to no longer tilt toward windmil… I mean “algorithms, away from the individual relationship with patients.” While algorithms have their place, the place of primary import is the patient and their story. Fortunately, the residents understand that this is reality of practice. They may eventually be beaten down into become more “efficient,” but their desire to understand how to be an effective psychotherapist speaks volumes. I wish them and you the best of luck in these next episodes of a grand adventure. Dream that impossible dream. It may still come at least partially true.

  2. Shelly said

    It must bring you great relief to know that not everything can be answered by computers and pre-written teaching curriculums that the residents’ learning manuals already in place contain. You are validated and are needed on the teaching staff and will shape the new recruits into functional psychiatrists. As you say, “there’s hope!”

    • Yes, there is hope. This movement is resident driven which is really inspiring, but at the same time, the residents are transient and as such, this could be fleeting. We will see. Thanks.

  3. Ashana M said

    When I meet with parents about their children, I always feel that it’s really much the same as structuring a reference interview, and I tend to imagine the reference interview as also being much the same as an intake or initial therapy session. Between the words being said, what you are really listening for is the client’s own understanding of the problem, his or or her own goals for the outcome, the available time-frame, the depth or breadth of resolution desired, and the preferred working method. Most people know very well what they want to accomplish (the research indicates this very clearly), and they often have an idea of how they would prefer to do it, but it’s sometimes so hard to hear. I think it’s also hard as “experts” to let go of control as much as we need to and allow clients to make choices about the process that will get them where they want to go–instead of where we think they should go.

    • Hi Ashana,
      Your comment reminds me of Wilfred Bion’s famous quote where he says that “you should start every session without memory or desire.” As you suggest, allowing the patient the space to contemplate their journey is a major job of the therapist. Imposing one’s own goals on the process robs the patient of their job as captain of their own ship. Respecting this space is critical to promoting growth and development. Thanks.

      • Ashana M said

        You have to know what the destination is supposed to be in order to help someone else get there.

        • Jon said

          With all due respect Ashana, why? Understanding that someone is going about something improperly does not mean one must understand the end-goal of that process. I do not need to know where a driver is driving in order to know that that driver and his passenger should be wearing seatbelts.

          • I agree with both of you. If we consider the destination to be a life which is lived with a minimum of defensiveness to new ideas, with a flexibility of thought, then the patient/practitioner dyad does have a goal. On the other hand, the specifics of that goal, career choice, partner choice, play choices, are not in the mind of the therapist, but will hopefully be positive “fall out” from the work of decreasing defensiveness.

            • Ashana M said

              Some people have the destination you lay out as a goal. Some people wish to avoid responsibility for their lives. Some people would like to find a better box to lock their feelings in. Some people are looking for more comfortable ways not to change.

              I know I had clear goals for my own psychotherapy, although I don’t know if I was able to articulate them: to be able to live with what I know. I ran through a lot of therapists who could not help me get there. They wasted my time and theirs. But I never went where they would have preferred I had gone. I don’t think any of us ever do.

          • Ashana M said

            Because a client who has no interest in safety will not wear a seatbelt no matter what you say. You are just wasting everyone’s time. You are better off trying to ascertain what the client is trying to accomplish from the outset.

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