When I started researching internship sites, I began to think of the game "Where in the World is Carmen Sandiego." I hated this game; the music drove me bonkers and it was a requirement for one of my early grade school classes. When trying to find sites, I felt like I was playing the game, trying to find internship programs that parallel my clinical interests such as psychodynamic and psychoanalytic therapies. It got me thinking about the state of psychotherapy and the forces of academia, insurance companies, and drug companies. Here are some of my thoughts:
There is a drastic split, in every sense of the word, between academic and clinical psychology. Most academic psychologists do not see clients, yet they are the ones publishing and influencing drug and insurance companies, the DSM, and teaching future clinicians and/or researchers. Furthermore, an academic's currency and status is substantially correlated to the number of papers they publish, the number of students they have in their lab, and how much money they are able to bring in for their research.
I follow Jonathan Shedler on Twitter and I cannot help but align with some of his anger and frustration with academic psychiatry/psychology. Here are a few of his (many) posts:
"Meaningful help often not available for ppl [sic] relying on health insurance. It's not that system is designed to profit from mental suffering—ALL healthcare in U.S. care occurs in for-profit system—but insurers learned they can ration/restrict *mental health* care & get away with it." September 29, 2020
"Show me a clinician who does not know how to work with transference and defense and I will show you a patient with a "treatment resistant" condition." September 27, 2020
More of Dr. Shelder's work can be found below.
This post is certainly not saying that academic psychology/psychiatry should go away. We need it. However, we also need to think about how academic psychiatry is influencing how we reach our patients in the therapy room and how we are able to best help them.
Manualized treatment is much easier to research. It’s cheaper, shorter-term, and easier to implement, not to mention easier to teach and learn. Psychodynamic psychotherapy and psychoanalysis are (often) longer-term term therapies, making researching them laborious and expensive, despite them being extremely durable, helpful, and efficacious in the long-run. Psychodynamic therapies are also effective at reducing relapse rates of several disorders a few years (or longer) after the patient has terminated.
As a student sliding, or tripping, into a professional career, what should I, or we, do about this? What is the ethical thing to do for our patients? Psychoanalysis certainly has created some of its own problems in academic circles, in more ways than one. This is no secret. For one, psychoanalysis can be painfully inaccessible to many people, both intellectually (as a clinician) and fiscally (as a patient and also as a trainee). I am interested, however, in what we can do as young, or seasoned, clinicians who will have a significant impact on our patients, supervisees, and the field and society at large.
When in my school's required CBT class, I tried so incredibly hard to keep an open mind. CBT ideas and concepts are very difficult for me to understand and implement, but I tried. My professor was very generous with his feedback, saying something like, "I see how hard you're trying, but it seems like you're still looking at some of these ideas through a different lens." I'm not so sure that people are doing the same with psychodynamic psychotherapy. There is a noticeable resistance to keeping an open mind and learning about some of these concepts and interventions. I'm not sure what to make of this, but I think it is more of an institutional problem and less of an individual problem. I'm going to end this post in the same essence that I feel every day about this issue; ending without a solution I can't hold in my mind.
Jonathan Shedler's work:
- cg
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