#5 On Psychotherapy Training

The Problem

For the past 11 years I have been blogging about serious psychotherapy, especially about “attachment to your therapist.” Far too often I have been saddened to hear about patients abandoned by their therapists or harshly discharged by clinic administrators when they dared to disclose intense feelings that should be the focus of discussion in their treatment.

In a case where I consulted personally, the therapist had a sophisticated understanding of attachment issues and encouraged her patient, who had a history of early life neglect, to form a deeper attachment to her, which he did. After some months of intensive sessions, as the attachment was evolving, she dropped him, declaring that he needed a psychoanalyst instead. He was devastated with sadness and anger, feeling lured into a connection, then abandoned. Not surprisingly the referral did not work.

How can such experiences of rejection and abandonment be prevented? Better licensing and credentialing seem exceedingly difficult to achieve. Even strong laws and the easy availability of malpractice suits don’t seem to be effective. If not that, then the other possible solution is better education of clients and training of therapists. It is time to take a fresh look at training. Here are the issues as I see them:

Training is the Answer but How?

For psychiatrists, who used to be the bulk of psychotherapists, training has been eroded by psychopharmacology, perhaps due to the erroneous belief that psychotherapy is not “scientific.” There is still enthusiasm for therapy among psychiatrists. 76% of psychiatric trainees planned to practice psychotherapy, while fully 46%, realized that their training was inadequate and expected to pursue additional learning.

Patients only know to expect a competent therapist who can help them with the problems they bring. They have no way of knowing that what they get depends heavily on the history and whims of the academic department where they got their training.

Training is stuck in tradition. Almost all programs identify themselves with one school or orientation whose theories and explanations don’t make sense in the terms that belong to other schools. From the beginning of our field, no theory was more valid than another. As in the Middle Ages, when Ptolemy’s theory was as good as that of Copernicus, there has been no scientific consensus about how therapy works and the choice of one school over another has been based on personal preference.

Times have changed. In the 21st. Century, science has begun to give us clarity about the universal infrastructure that underlies all therapies. Single school training is limiting and inefficient, discouraging use of a range of techniques and narrowing the options for a given patient. Therapists either remain limited, or have to learn an entirely different theory and set of practices to treat patients who don’t fit with their original training. This has to change.

A significant number of thinkers have embraced psychotherapy integration, but many, if not most, of them still don’t believe that the theories behind various therapies can ever be reconciled. I am doubtful that we will get far in trying to convince older teachers and academics, who have invested a career in one school, that they should be more open. They are happy with what they have known, practiced, and taught. Why should they change now?

An Answer for Today

That is what has led me to the belief that teaching younger people and those who are not invested in a single school is the answer. They will naturally be open to learning the common infrastructure and how to recognize what is happening clinically in universal terms. Once they have learned to follow process, rather than protocol or method, sharp distinctions between different schools will fade. They will tend to become irrelevant. Instead, there will be opportunities for research, for example, on broader questions like how best to support Memory Reconsolidation or Extinction, or how best to calm a person who is in a state of hyper-arousal and unable to make therapeutic changes.

Jeffery Smith MD

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