Acad Psychiatry 29:332-338, October 2005
doi: 10.1176/appi.ap.29.4.332
© 2005 Academic Psychiatry
How Not to Teach Psychotherapy
Glen O. Gabbard, M.D.
Received March 16, 2005; accepted June 9, 2005. Dr. Gabbard is Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry at Baylor College of Medicine, Houston, Texas. Address correspondence to Dr. Gabbard, Baylor College of Medicine, 6655 Travis, Suite 500, Houston, TX 77030; ggabbard{at}bcm.tmc.edu (E-mail). Copyright © 2005 Academic Psychiatry.
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INTRODUCTION
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For more than one-quarter of a century, I have been trying to teach psychotherapy to psychiatric residents. When I moved from Menninger to Baylor in 2001, I became Director of Psychotherapy Education, and I started to think more systematically about what I’d learned from teaching psychotherapy. Part of my duties at Baylor involves being Director of the Baylor Psychiatry Clinic, where I have weekly case conferences with the PGY-III residents and teach them how to think about psychotherapy and formulation in the outpatients they are seeing. This experience has provided me with a laboratory to experiment with different teaching techniques. At the same time, Bob Hales, M.D., Editor-in-Chief of American Psychiatric Publishing, Inc. (APPI), Books, wanted me to edit the Core Competency in Psychotherapy Series for American Psychiatric Publishing. Since I was writing the text on long-term psychodynamic psychotherapy for that series, I had to think systematically about what works and what does not work in the teaching of psychotherapy.
At some point, I recognized that I had learned as much from what not to do as much as I had from what worked. We all learn by making mistakes. In light of that fact, I would like to share what I’ve learned not to do in this article. I am going to provide you with a list of common mistakes in teaching. I have made many of them myself, so I am in no way exempting my own teaching from this catalog of errors. Rather than telling you what you should do, I am using the "thou shalt not" method designed by Moses when he came down from the mountain with the bronze tablets. Hence, I am going to provide a list of precepts that suggest what not to do.
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Teach Psychotherapy as Though It Is Entirely Isolated From the Rest of Psychiatry
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It is commonplace today to encounter psychiatric residents who claim that they have no interest in psychotherapy and therefore see no point in attending seminars on the subject or arranging to meet with their psychotherapy supervisor for one-to-one instruction. These same residents see no point at all in actually seeing patients in a training clinic to learn psychotherapy. The naive assumption is that there is a psychiatry that exists apart from psychotherapeutic principles. Is it possible to obtain optimal compliance with a psychopharmacology regimen without understanding psychotherapeutic principles? Can you manage a suicidal patient expertly without some understanding of countertransference? Can you provide the best possible inpatient treatment if you know nothing about group dynamics as applied to inpatient staff and patient interactions and have not learned the basic principles of family therapy? One psychiatric resident asked her inpatient supervisor about a psychodynamic formulation of a hospitalized borderline patient. The supervisor responded, without a trace of irony, "Dynamics apply to outpatients, not inpatients."
It is easy to scapegoat biological psychiatrists for generating this attitude about psychotherapy. However, I have often wondered if those who teach psychotherapy are equally guilty. Both psychotherapy supervisors and seminar instructors often convey that psychotherapy operates in a vacuum apart from medication, which is frequently prescribed by someone else, and that principles of neuroscience exist in a parallel universe with psychotherapy but in no way influence how one thinks about the patient while conducting psychotherapy. We now have abundant evidence that psychotherapy changes the brain (1, 2). We also know that for many psychiatric disorders, combining psychotherapy and medication provides superior outcomes than either modality alone (3).
We are even at the point where we are starting to accumulate functional imaging data suggesting differential locations for the effects of pharmacotherapy and psychotherapy in the brain (4). When Goldapple et al. (4) compared the impact of cognitive behavioral therapy (CBT) and paroxetine on depressed patients, they found that psychotherapy altered brain regions that medication did not touch. Therapy worked in a "top down" manner, with decreased metabolic activity in the medial, dorsal and ventral frontal cortices. Paroxetine worked in a "bottom up" way, with decreased activity in the brain stem and subgenual cingulate. Even though most psychiatrists would agree that we cannot make an artificial dichotomy in which psychotherapy treats "psychosocially based" conditions while medication treats "biologically based" conditions, the terms "mind" and "brain" are still used as a form of code to indicate whether one has a psychotherapeutic or psychopharmacologic orientation to psychiatry (5).
A contemporary psychotherapy teacher needs to be conveying to psychiatric residents that psychotherapeutic principles are applied in all settings where psychiatric treatment is delivered. The meanings of medication or electroconvulsive therapy (ECT) to a patient may need to be explored and discussed to maximize compliance. Staff countertransference in an inpatient unit may need to be identified and discussed to improve the effectiveness of hospital treatment. Similarly, formal psychotherapy needs to be understood as part of a comprehensive biopsychosocial treatment plan that may include the use of medication to target symptoms that are not as easily ameliorated by psychotherapy. Understanding of neuroscience principles may also influence how the psychotherapy is conducted. For example, if one understands that much of transference is conveyed in procedural memory, the therapist may look for signs of transference in nonverbal communications observed in the way the patient enters the office and not simply in the patient’s verbal account of how he or she feels about the therapist (6).
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Use "Straw Man" Arguments to Denigrate Psychotherapeutic Approaches That Are Different From Your Own
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The preferred way to exalt your own favorite psychotherapeutic school is to devalue the contributions of other schools. Much of this tendency to criticize alternative models by exaggerating certain features can be accounted for by what Freud (7) described as "the narcissism of minor differences." Freud’s observation lay in two related themes: 1) there is a narcissistic wounding inherent in the perception of even small differences between ourselves and others, and 2) we all have a fundamental need to maintain cohesion within our own community or group by regarding others with contempt who possess essentially minor differences. Hence cognitive therapists may criticize psychodynamic therapists for undervaluing empirical rigor and focusing too much on unconscious mental functioning; dynamic therapists may criticize cognitive therapists for being too superficial and not paying sufficient attention to transference.
We often approach our psychotherapeutic schools as religions that we must fiercely defend by recourse to faith. It is not an accident that "the allegiance effect" emerges as a significant factor in psychotherapy research. In other words, there is a strong relationship between the theoretical orientation of the research investigator and the theoretical orientation of the treatment that emerges as most effective in comparative outcome studies (8). When statistical adjustments are made for the allegiance effect, the outcome differences among therapies often disappear (9). Moreover, meta-analyses generally illustrate that with the exception of some specific disorders, like OCD and phobias, there are few differences in the outcomes of most psychotherapies (9, 10).
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Teach Psychotherapy as a Discipline That Demands Theoretical Purity Rather Than Creative Eclecticism
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This admonition is directly related to the previous concern—namely, we can sound like fanatics when we claim that one approach is far better than another and therefore demand strict adherence to it. We teach and practice in an era of pluralism. There is great value in teaching specific theoretical and technical models of psychotherapy that allow for a coherent understanding of the patient leading to a form of intervention that follows directly from the theory. However, the theoretical model should be one’s slave—not one’s master. The beginning therapist should be taught that all clinical phenomena observed in a patient can rarely be accounted for by a single theory. The patient’s improvement is far more important than theoretical purity. Most patients do not give a damn about theory. They simply want to get over their suffering.
Much of psychotherapy research points out that common factors of therapies are generally more strongly related to outcome than factors specific to each approach (9). Hence a good psychotherapy teacher creates an atmosphere of flexible shifting and borrowing from one model to another when necessary. Areas of convergence between one model and another can be highlighted, when appropriate, to demonstrate to residents how psychotherapeutic approaches tend to have considerable overlap. The identification of schemas by cognitive therapists treating personality disorders (11) and the focus on internal object relations patterns by dynamic therapists (6) have striking similarities. I was pleasantly surprised recently when I was involved in a book signing at the APPI booth at the annual American Psychiatric Association (APA) meeting—Aaron Beck came up to my table and had me sign a book I’d edited on countertransference. I asked him why he was buying the book, and he explained, "Well, I’m having a little trouble with countertransference in treating one of my patients." This anecdote reflects the humility of one of the great thinkers in psychiatry, but it also points to one of the convergences between cognitive and dynamic therapy. Even though in his writing (11) Beck focuses on "emotional reactions" rather than "countertransference," it is clear that we are talking about similar phenomena. There are few absolute truths in psychotherapy, and we must be appropriately humble in what we say we know.
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Assign Nonpsychiatrist Faculty to Teach Psychotherapy to Residents
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Despite the repeated efforts of the residency review committee (RRC) to underscore that psychotherapy is part of the standard therapeutic armamentarium of psychiatrists, powerful forces oppose this message. In mental health clinics throughout the United States, psychotherapy is conducted by nonpsychiatrist mental health professionals, while medication management is relegated to psychiatrists in 15- or 20-minute appointment times. Residency training programs may collude with this artificial dichotomy by asking social workers and psychologists to teach psychotherapy seminars to residents and supervise their psychotherapy. The message conveyed is that psychotherapy is not a core part of who we are and what we do. I am not suggesting that social workers and psychologists are inept at teaching psychotherapy. Many are both superb therapists and outstanding teachers. What I am saying is that residents are constantly internalizing role models and consolidating a professional identity based on those models. Children become what their parents do more than what their parents say. The same can be said of psychiatric residency training. If their professional role models treat psychotherapy as a marginal endeavor taught by allied professionals, residents will assume that psychiatrists are not really psychotherapists. I realize that in some areas of the country, the only faculty members qualified to teach certain types of psychotherapy are nonpsychiatrists. That is a problem that the American Association of Directors of Psychiatric Residency Training (AADPRT) and other organizations are trying to address by emphasizing a set of core competencies in psychiatric education.
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Do Not Illustrate Theory With Clinical Examples
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There is a long tradition in the teaching of psychoanalytic psychotherapy to obfuscate straightforward clinical principles by excessive use of jargon. While a certain degree of jargon is unavoidable in the building of theoretical models, a good teacher owes it to the students to show how the theory or model is applied by illustrating the basic concept with clinical material. Unfortunately, most students are reluctant to say they do not understand what a particular theoretical construct means, so instructors are often not challenged to clarify what they are talking about when they use obscure jargon or arcane theoretical constructs. Teachers must therefore be proactive in providing clear applications of their models to a psychotherapy process that makes the meaning and application clear to all students without having anyone feel humiliated by asking questions that reveal their ignorance.
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Never Let Them See You Sweat
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Even under the best of circumstances, the practice of psychotherapy is accompanied by a good deal of uncertainty and extended periods where the therapist is uncomfortable because the clinical data do not fall into some obvious formulation (12). Unfortunately, some psychotherapy instructors think it will impress their students if they act like they know exactly how to deal with every clinical situation that arises. Hence they assume an air of confidence as though psychotherapy is a simple technique that can be mastered by experience. In reality, you do not learn a body of knowledge and simply apply it to patients. You treat patients to learn therapy, and it is a lifelong process. Teachers who acknowledge their own struggles and uncertainty prepare their residents for the realities of psychotherapeutic practice. I find one of the hardest things to teach is that it is okay to say, "I do not know" when a patient asks a therapist a question.
The practice of psychotherapy is most usefully taught as a series of hypotheses that are repeatedly tested and that are altered again and again as one observes the patient’s response to trial interventions. In providing this type of modeling for the student, instructors also are cautioning the young therapist against the common mistake of rigidly applying a formula to the clinical material when the patient does not feel that it fits and reluctantly complies to please the therapist. An underlying theme here is that psychotherapy must always be a collaboration between therapist and patient, where the two work together to see which models of understanding are most useful.
I once attended a case conference where an anxious resident was presenting a case to a distinguished visiting professor. The resident commented that the patient came into the session and said she needed to have her brakes checked before she drove home. The visiting professor interrupted the presenter and said with sweeping authority, "She’s afraid that she’s going to kill her husband." Many of the residents reacted with awe at the omniscience of the consultant and wished that they would someday be able to read minds as well as he could. The visiting professor could just as easily have stated his opinion as a hypothesis that he would want to investigate with further material from the patient. Instead, he chose to express himself with what could only be termed as "absolute certainty."
A corollary of the previous commandment is to avoid showing examples of how you actually work with patients so you can continue the mystification process. Residents can then idealize you and assume that you know exactly what to do in all situations. If you have the courage to show your own work, residents will then see that you also are faced with a variety of dilemmas, as they are, and that you do not always know if your intervention is going to be the most useful one. Many psychotherapy teachers rely on the excuse that they cannot possibly share their own work due to confidentiality. While this is a convenient cop-out, one can easily present former cases long terminated, where the identity of the patient is not at all apparent, and disguise can be introduced as well (13). It is most helpful if the instructor also supplies how he or she thought about the particular dilemmas faced with the case being presented. To a large extent, we teach ways of thinking to residents when we teach them psychotherapy.
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Teach Professional Boundary Issues and Ethics as Rigid Rules Isolated From Clinical Struggles
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Professional boundaries present a set of dual dangers. On the one hand, boundaries can be ignored to the point where the psychiatric resident conducting psychotherapy becomes more like a friend, parent, or lover to the patient than a professional. On the other hand, they can be rigidly applied in such a way that the therapist is too aloof and remote to connect with the patient. There is a broad middle ground between these extremes, but boundary management has to be construed flexibly and tailored to the individual patient’s needs (14).
A third-year female psychiatric resident was asked by a male patient if he could have a hug. She responded that it was against the rules. He asked, "What rules?" She replied, "The Clinic rules." He replied, "Does that mean you could hug me if we had therapy somewhere else?" She replied, "No. We cannot hug no matter where the therapy takes place. There are ethics rules that prevent me from hugging patients." The patient then asked, "Why does the profession have these rules? A hug would make me feel a lot better." She replied, "It is not professional." The patient then asked, "Isn’t my feeling better more important than being professional?"
In this somewhat comical exchange, the problem with teaching ethics as a set of rules becomes apparent. Boundaries and ethics must be taught in the context of psychotherapeutic dilemmas that involve such concepts as transference, countertransference, resistance, therapeutic alliance, and the overall philosophy of what therapy is and what it is not. I teach my residents that sometimes the best response to an interrogation like the one recounted above is to simply say, "I’m not comfortable with that." But in the classroom, there needs to be an overarching framework involving the concept of fiduciary relationships and the principle of putting the patient’s needs first that must be incorporated into various situations in psychotherapy that create considerable anxiety in both partners of the dyad. As Joshua Reynolds (15) said a long time ago, "Could we teach taste or genius by rules, they would no longer be taste and genius."
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Ignore All Psychotherapy Research
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A long-standing problem in the field of psychotherapy has been a chasm between psychotherapy researchers and practitioners. Psychotherapists tend to view psychotherapy research as investigating oversimplified issues in a way that does not reflect the complexity encountered in the clinical setting. When findings are gleaned from psychotherapy research, the most common response is, "Well, I already knew that!" This denigration of psychotherapy research is also a form of resistance to changing one’s approach based on new data. As Piper (9) points out, many researchers write with a target audience of other researchers in mind. Moreover, conclusions are often couched in qualifications and limitations that fail to inspire confidence in clinicians and teachers of psychotherapy. Some research may be critically important in that it directs psychotherapists to a more effective treatment. For example, there is an extensive literature on exposure and response prevention for obsessive-compulsive disorder (6). On the other hand, no cases in the literature have ever reported a successful treatment of obsessive compulsive disorder (OCD) symptoms with psychodynamic psychotherapy alone. Nevertheless, it is still commonplace to see cases of OCD treated for years with dynamic therapy without any symptomatic improvement because the practitioner has failed to read the literature on the subject.
Research has also shown that patients who have a history of satisfying interpersonal relationships do better in insight-oriented therapies, while patients who do poorly in their relationships fare better with supportive therapy, a finding found in both individual and group therapy (9, 16, 17). A brief reading of abstracts in the psychotherapy research literature might well go a long way to avoid mistakes, and instructors can model the approach of integrating research findings with clinical practice by teaching the value of research for the psychotherapist.
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Worship at the Altar of Evidence-Based Therapies
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One can also err in the opposite direction by relying too heavily on research. My writing (18, 19) should amply demonstrate that I am pro-psychotherapy research and, in fact, have spent much of my career engaged in psychotherapy research. Nevertheless, a disconcerting trend has developed in recent years to equate evidence-based therapy with the final truth and the only truth.
Randomized controlled trials provide valuable data, but they have to be supplemented in teaching. A design that is ideal for psychopharmacology research has limits when applied to psychotherapy. In brief, psychotherapists are not the same as pills. They are larger than pills. Their effectiveness does not expire in 1 year. They vary in gender, culture, and age. They have different personalities.
Psychotherapy researchers have demonstrated that the therapeutic relationship, particularly when the therapist is experienced and flexible in responsiveness, accounts for most of the outcome variance (20, 21). Technique accounts for only 12–15% of the variance across different kinds of therapies (20). Moreover, the results from efficacy studies may not apply to the typical patient seen in practice, where comorbidity is pervasive and the exclusion criteria used in randomized controlled trials (RCTs) cannot be applied (22).
Barlow (23) has suggested that we might wish to distinguish psychological treatments that are specific to a disorder from generic psychotherapy for problems in living. Unfortunately, patients do not know about this distinction, and the problems of living are inextricably intermingled with specific disorders. Depression, for example, notoriously creates problems of living in the domains of social relationships, work and quality of life (24). Moreover, improvement in symptoms is not the only goal of psychotherapy. Patients also learn fundamental truths about what it is to be human—the inevitability of conflict in relationships, the inability to control external events, the fact that love is inextricably tied to hate, and the essential task of mourning that accompanies each developmental phase of adult life.
We also must face a simple fact of psychotherapeutic practice—many fundamental principles of good technique cannot be subjected to the methodology of randomized controlled design. We know, for example, that it is generally a problem if you are saying "I love you" to a patient, and we teach our residents not to say it. But if one submitted a proposal to randomly assign patients to one treatment where the therapist professed love and another where the therapist remained mum on the subject, funding would be unlikely.
The knowledge based on evidence-based therapies is limited by what research is funded. When research is asymmetrical, with only some treatments receiving rigorous testing, conclusions must be tentative. Absence of evidence is not evidence of absence. We have limited research on long-term dynamic therapy. Few funding sources are available. The cost would be prohibitive, and random assignment would be highly problematic since few who seek out the treatment want a waiting list or short-term alternative.
Westen et al. (25) point out that randomized controlled trials are valid for some disorders and some treatments but not for others. They also stress that meta-analytic studies support a more nuanced view of treatment efficacy than that implied by a dichotomous judgment of supported versus unsupported. Finally, observational studies are necessary for longer treatments, and the findings supplement RCTs. Recent discussions in the New England Journal of Medicine (26, 27) noted that observational studies do not tend to overestimate the magnitude of treatment effects compared with RCTs.
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Protect Residents From the "Dirty Business" of Patient Fees
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Few problems in psychotherapy training are more formidable than instilling the notion in one’s residents that they are worth the fee they charge. They far prefer to have the business office handle the unpleasant tasks of setting and collecting payment. The resident’s favorite mode of avoiding aggression, anger, and negative transference is to collude with the patient in never discussing the fee.
A PGY-III resident brought me a poignant example of struggles with the fee that led to an eye-opening educational experience for her. She was seeing an aging stripper who said that she could barely afford the low fee offered at the Baylor Psychiatry Clinic, so she was offering a somewhat lowered fee to make the therapy affordable for the patient. The patient talked at length about conflicts with her mother. The resident noted that the patient seemed to barely get started by the end of the 50-minute hour, so she offered her the possibility of continuing for a double session of 100 minutes. I asked the resident if she were charging her for the second session. She said that the patient could not afford it and told her that she would have to resort to prostitution, as many of her colleagues at the strip club did, to find the financial resources necessary to pay twice as much. The resident felt that she would be forcing her patient into prostitution if she insisted on doubling the fee, so she capitulated. I asked her if she could see any problem with providing free therapy. The resident responded that doubling the price seemed like selling therapy for personal profit rather than offering treatment out of genuine concern for the patient. She argued that charity care is part of medicine’s tradition.
Shortly thereafter, the patient arrived at a session and announced that she had just paid for a $900 Botox treatment on her face. The resident told me she felt like the "biggest sucker in the world" and suddenly became aware of how she had colluded with the patient in devaluing the therapy. As we processed what happened, the resident did an impressive job of examining her countertransference. She noted certain similarities between the patient’s relationship with her mother and the resident’s relationship with her own mother. She noted that she was overidentified with her patient and was trying to undo the damage done by her own mother by rescuing the patient. She was also avoiding the role of the "bad mother" in the transference by indulging the patient’s wish to get something for nothing, a common countertransference I have elsewhere labeled "disidentification with the aggressor" (28). This vignette also nicely illustrates a point raised above: the need to consider professional boundary issues in the context of clinical struggles in the therapy.
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Treat Countertransference as a Sign of Pathology or Egregious Error
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Residents have all kinds of emotional reactions to their patients. These countertransference phenomena are a gold mine of information about what the patient may induce in others. If the teacher or supervisor conveys that countertransference is an aberration that reflects inexperience or therapist psychopathology, the astute trainee will shut down and simply keep all emotional reactions private. A sure way to accomplish this avoidance is to tell residents who have feelings about their patients that they should be in therapy to work those feelings out. This approach will assure that you never hear about them again.
A male psychiatric resident told his supervisor that he found himself attracted to his female patient and wondered if there was something wrong with that. His supervisor looked alarmed and lectured him on the need to maintain professional boundaries. He also asked the resident if he thought he should refer the patient to a female therapist. The resident was mortified and came to see me. He wondered if he should be in another specialty. He felt he had transgressed professional boundaries and was at risk for committing an egregious boundary violation. I assured him that most of us deal with feelings of attraction to patients on a regular basis and use that information to guide us in our understanding of the patient. He was relieved, but he asked me if it was possible to change supervisors.
We now recognize psychotherapy as a two-person enterprise. There are two subjectivities in the room, each mutually influencing each other. Countertransference is a therapeutic tool that allows unique access to the inner world of the patient (29). One of the central goals of psychotherapy training should be to promote curiosity and reflectiveness about oneself in the resident. We learn about ourselves as we treat the patient. We must not view the patient as a specimen on the other end of a microscope who is being observed by a detached scientist. Therapists themselves are always influencing the field of observation and subjectively interpreting whatever they see. A personal experience in therapy is of great value in the development of a therapist. How one brings this up with residents is a matter of tact and timing.
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Concluding Comments
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We teachers are attempting an impossible task: to help students navigate a complex human interaction with a myriad of conflicting goals and make the optimal choice from an array of interventions while a host of important variables shift from moment to moment. There is much about psychotherapy that cannot be taught in a classroom or in supervision. There is no substitute for the hands-on experience of rolling up one’s sleeves, making occasional errors, and monitoring the consequences of one’s interventions. Years ago I was inspired by Donald Hall’s book, Life Work (30), which he wrote in his 65th year after being told he had liver cancer. He quoted Henry Moore, the great sculptor, as telling him a bit of wisdom that applies to our efforts as educators, "The secret of life is to have a task, something you devote your entire life to, something you bring everything to, every minute of the day for your whole life. And the most important thing is—it must be something you cannot possibly do!"
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J. J. Hunter, R. G. Maunder, and M. Gupta
Teaching Consultation-Liaison Psychotherapy: Assessment of Adaptation to Medical and Surgical Illness
Acad Psychiatry,
October 1, 2007;
31(5):
367 - 374.
[Abstract]
[Full Text]
[PDF]
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INTRODUCTION
Teach Psychotherapy as Though...