Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Tuesday, November 19, 2013

The Couch, First Session

I've been thinking about writing this post for a long time, and I'm still not sure what I want to express with it, but it feels important.

I read this post on 1BoringOldMan. It's about how psychoanalysis wasn't focused enough on signs and symptoms, and DSM, starting with III, is focused too much on them, resulting in the loss of ability to really understand ones patients.

This struck me because as much as this blog is about the practice of psychiatry, and as much as I post about coding and insurance and medications and policy, I mostly leave out what I mostly do, which is psychotherapy, and specifically, psychoanalysis.

I think I'm cagey about it because analysis has so fallen from grace that it's a little embarrassing to acknowledge that this is what I trained to do. If I were 85 years old, I could say I trained back in the days when all psychiatrists did analytic training. But I'm not 85. And I graduated from my training institute about a year and a half ago.

I feel like it's discrediting to "admit" I'm an analyst, that I won't be taken seriously as a psychiatrist, or as a physician. And I have this sneaking suspicion that many of the folks who speak derisively about analysis don't know much about it. And that many of the people who disparage Freud haven't read him.

So what I'm gonna do here is write about what's involved in analytic training and practice, and then describe some of my thoughts and feelings about what I do, and why I chose to do it, and why I think it's worthwhile, in several posts.

To become an analyst, you need to apply to and be accepted by a psychoanalytic training program or institute. I filled out an application which asked for my demographic information, my education and work history, publications, memberships in professional organizations-basic CV stuff. It also asked for 2 references, where else I was considering applying or had applied, and names and dates of any psychotherapy or psychoanalysis I've had. That last was the most personal piece of information on the form, which might seem surprising. They could've asked about my toilet training or primal scene exposure. Or at least about why I want to be an analyst. But there were no short essays or personal statements.

They don't need that kind of personal information on the application. Instead, they have interviews. These are very different from the kinds of interviews I had for college, where it was mostly informational, or medical school or residency, where interviews function as supplements to an application. These were the grueling crux of the application process.

I interviewed with 2 different analysts, 2 times each. I don't remember for sure, but I think each of the 4 interviews lasted at least an hour, maybe 90 minutes. Or it might have just felt that long. The first interview with each analyst was a get-to-know-me session. The second involved more getting to know me, following up on things I spoke about the first time around. And I also had to present a case, which seems like it would be the hardest part, but it wasn't. It was the easiest.

I bought two suits. I wore one to the first interview with Dr. G, and the other to the first interview with Dr. E. Then I had them dry-cleaned, and I switched off for the second interviews. I also prepared two different therapy cases, each of which reflected certain challenges, and the ways in which I work with patients, and my ability to think analytically.

I had a lot of internal debate about how I wanted to come across. Specifically, just how neurotic did I want to appear. Too much, and they'd think I was unstable. Too little, and they'd know I was lying. I had an intuitive sense that I was about the right amount of neurotic for this kind of training-you don't train to be an analyst if you're not at least a little screwed up-but I wanted to make sure to seem like it.

I discovered pretty quickly that how I wanted to seem was irrelevant. And that discovery made me want to do psychoanalytic training all the more. Because the people I interviewed with did not shy away from asking difficult questions about my family, my motivations, my conflicts. And they did not settle for pat answers. And they pursued important topics. And they did so with kindness and without judgement. And I realized that I wanted to be able to do what they were doing.

My residency did a pretty good job with psychodynamic psychotherapy training. It was emphasized strongly. And I'm grateful for that. But my feeling now is, "If that were all the training I'd ever had in insight-oriented therapy, I wouldn't be able to do therapy in a way that I consider meaningful."

It shocks me when I think about the things I missed with patients early on, often transference issues, that are now so obvious. Ten years from now I'll probably be thinking the same thing about my 2013 work. But that's good. Because it means I'm constantly trying to improve.

They talk about the "tripartite" model of training, at my institute, at any rate, and others like it.

Part 1-Classes
Part 2-Supervised Analytic Cases
Part 3-Personal Analysis

Part 1-Classes
Mondays and Wednesdays, 7-10pm, 4 years. The readings are extensive. There are papers and case descriptions to be written. There are nerve-racking case presentations, reading ones process notes to an analytic deity and waiting to hear what people think about the work you're doing. Examples of classes:

Freud, Early Theories
Freud, Infantile Sexuality
Psychoanalytic Listening
Child Development
Adult Development
Character and Neurosis
Case Development
Cognitive Neuroscience
Psychic Trauma
Theory of Narcissism
Borderline Conditions and Paranoia
Empirical Approaches to Psychoanalytic Thinking
Relational Psychoanalysis and Intersubjectivity
Affects and Affect Pathology
Gender and Sexuality
Universal Phantasies
...and more

Part 2-Supervised Analytic Cases

Around the end of the first year of classes, you're expected to pick up an analytic patient, usually from the low-fee treatment center. Analyses last quite a long time, so you can expect to accept a low fee for quite a long time. And most analytic candidates have finished their residencies, or PhD's, or Psy-D's, or Social Work Degrees, and are seeing private patients. In other words, this is a loss of income.

You see the patient, on the couch, 4-5 times per week, and you have supervision once a week. Over the course of training, you pick up at least 2, but often 3 or 4 additional analytic cases, often low-fee, 4-5 times per week, and supervision once a week for each. And you have to treat both genders.

Yes, I did write, "On the couch." And yes, it feels like you're in a Woody Allen movie. Patients lie on the couch, and you sit behind them. As archaic as it sounds, it's quite useful.

There are initial writeups of your "control cases", 6 month summaries, and a final summary, either before you graduate, or when the patient terminates treatment, whichever comes first.

Part 3-Personal Analysis

In some ways this is the easiest of the three parts. You show up, 4-5 times per week, you lie on the couch, you free associate, or try to, and you leave. And you pay your monthly bill. The fee is set between you and your TA, or training analyst, so if you can't afford it, the TA will cut you some slack on her regular fee.

The truth is, this is the hardest part of the process. One well-published senior analyst likes to say that an analysis is like getting a PhD in yourself. It forces you to look at all the things about yourself you've been trying to hide from since childhood-shame, guilt, anger, aggression, sadness, longing, sexuality, tenderness, competition, cruelty, to name a few. It forces you to question your assumptions about yourself, the people in your life, and the world around you. It asks you to give up your accustomed ways of interacting with the world, defenses that have protected you most of your life, and move on to other ways to be that don't cause as much pain. And it asks you to establish an intimate bond with someone you can never truly get to know.

You can say that all good therapies, of whatever stripe, try to achieve the same goal-a better adjusted self. But it's not the same. And I'm not knocking other therapies-I practice them.

Before I began my training, I was in face to face psychodynamic psychotherapy twice a week, for several years. And my therapist was an analyst. It doesn't even come close to what analysis is like. The frequency, the supine position, the wacky isolation from not seeing the analyst with the simultaneous vulnerability of being totally exposed to this stranger, these induce an intensity that I can't imagine being replicated in other types of therapy.

The personal analysis has evolved over the years. It used to be a "reporting analysis". This meant that your analyst, in whom you confide your deepest, darkest thoughts and feelings, and into whom you pour all your transferential feelings towards primary figures in your life, would report on your progress to the progression committee, which included people you regularly work with. Nice.
What often happened was that candidates would stay in their training analyses until they graduated, and then they would quit the training analysis, and change to a private analyst, with whom they could be honest.

At some point, someone figured out that this wasn't a good setup, and reporting analyses were done away with.

TA's are a bit of a controversial issue these days. After you graduate from a training program, you can go on to get certification, which involves being immersed in the treatment of several unsupervised analytic cases, over several years. and an extensive writeup of these cases, which will be presented to a national certifying body. Once you've done that, you can then go on to be even further certified as a training analyst. I don't even know what's involved. I think you may have to sacrifice sheep. Or emotional support ducks.

The idea is that training analysts have so much more, uh, training than everyone else, that they're the only ones who are qualified to treat analytic candidates, who represent a special subgroup of analysands, because they're also students, and eventually colleagues, and you WILL bump into your analyst outside of his office, at conferences, or the annual institute dinner, or in the tiny elevator that takes you to your classes. The only reason that never actually happened was that I walked away and took the stairs. For real. The nice thing about analysis is that it's okay to be rude to your analyst. It's all grist for the mill.

I'll continue in a later post. For now, we do have to interrupt.

(For the next post in this series, Use the Couch, Luke, Click HERE).


  1. Thank you for this most thoughtful post. The section on personal analysis rang particularly valid, but you make so many good points. It is so true that the vast majority of clinicians know nothing about analysis and Freud except for simplistic stereotypes, yet is is also true that much of what he discovered has become almost "common sense" today.

    1. Thanks, Jesse. A lot of Freud's ideas are so pervasive that we don't even think about them anymore. Words like "ego" and "neurotic" are completely commonplace, although they're not used in quite the same way.

  2. Hi, Did you make the stylized couch sketch? It is genius. I am with the Dallas Psychoanalytic Center, can we use your sketch in our logo? I am trying to create a logo that is fresh but expressive of what psychoanalysis is...