LAUSR

To the Editor: Graduates from psychiatry residency programs are still required to be competent in long-term and short-term psychodynamic psychotherapy [1]. Psychiatry residents receive more didactic instruction in psychodynamic psychotherapy than in cognitive behavior therapy or supportive therapy [2]. Despite the evidence of the efficacy of psychodynamic psychotherapy [3, 4] and the continuing administrative and academic push for psychodynamic psychotherapy training, its clinical importance has seemed to subside over time. We argue for the benefit of teaching and applying a psychodynamic understanding outside the traditional outpatient therapy clinic, focusing on seven key features found in most psychodynamic psychotherapies [5]. The key features as described by Shedler [5] are (1) focusing on affect and expression of emotions, (2) exploration of attempts to avoid distressing thoughts and feelings, (3) identification of recurring themes and patterns, (4) discussion of past experience with a developmental focus, (5) focusing on interpersonal relationships, (6) focusing on the therapeutic relationship, and (7) exploration of fantasy life. A thorough understanding of these principles can benefit psychiatrists in a broad variety of treatment venues. Psychiatrists should help patients recognize and express their emotions through focus on affect and expressions of emotion. For example, an internal medicine team has consulted psychiatry because Mr. A. was sobbing after his heart attack. During the initial interview, Mr. A. repeatedly apologizes for crying and wasting the time of the resident, Dr. B, who responds, “There is no need to apologize. Something important has happened to you. It might change your life and the life of your entire family. It’s worth crying about. Let’s keep talking, and if you feel like crying, go ahead.” Psychiatrists may explore attempts to avoid distressing thoughts and feelings even though patients may use deliberate decisions, psychological defenses, and resistance to avoid feeling upset. The psychodynamically informed psychiatrist helps patients identify what they are avoiding and why they are avoiding it. For example, Ms. C. is seen in the emergency department, where she is minimizing the impact of a recent sexual assault. She says she just wants to go home, shower, and forget everything. Dr. D. responds, “I know this is difficult to talk about. It is probably difficult to even think about but ignoring it won’t make it go away. Something terrible happened to you. Wishing everything was okay feels safer than talking about what happened, but it is not more helpful in the long run. Maybe you don’t feel comfortable talking to me, but you should eventually talk to someone.” Psychodynamically attuned providers help patients identify recurring themes and patterns of relationships and behaviors. Patients are then free to explore different patterns of behaviors. For example, Ms. E. was admitted to inpatient psychiatry following a near-fatal overdose prompted by her husband having an affair. She now denies suicidal ideation and wants to be discharged. Although Ms. E. looks as if she is doing well, Dr. F. is concerned about the chances of future attempts. They discuss her tendency to end up with unfaithful men. She realizes that she does not believe she deserves someone who treats her well. That pattern and belief are discussed during her time on the inpatient unit. Because past experiences influence present interactions and experiences, discussion of past experience with a focus on development helps the patient develop a narrative that explains current decisions, emotions, and beliefs in light of the patient’s past. For example, Mr. G. has been diagnosed with stage 4 colon cancer but refuses to discuss treatment options with his oncologist. Instead, he tells the doctor he needs to leave the hospital for his regular poker game. The consultation and liaison team is consulted to assess Mr. G.’s capacity to make medical decisions. It becomes clear that Mr. G. is trying to avoid thinking about his prognosis because it seems * Allison E. Cowan [email protected]