The Remaking of a Therapist

Guest Post by Stephanie Foster

Stephanie Foster is a Registered Psychologist in Calgary, Alberta. She is in private practice and has provided short and long-term psychotherapy in a variety of treatment settings.

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“I’ve got nothing for them.”

I was alone in the office and talking to myself – perhaps the first sign of trouble. My newest case was a parent who had recently lost a child, scheduled for their first session later that day. I was fresh out of graduate school and working towards licensure as a psychologist. Like many clinicians, I worked at an agency that offered brief therapy. The treatment of choice for most presenting problems was cognitive-behavioral therapy (CBT). Patients were seldom granted more than a dozen sessions, and some only had coverage for six. If a therapist could end the treatment in even less time, all the better, as the schedule was jam packed. As an early career therapist, I felt immense pressure to succeed within these parameters. Determined to make the most of every clinical hour, I would plan sessions in advance. I regularly assigned homework. I had a worksheet for everything. I was no stranger to pep talks. Although I had the nagging feeling that I was being pushy, I chalked it up to inexperience. When my suggestions were met with awkward silences, I took it as a signal to come up with better suggestions. I thought I was a therapist in the making.

Then the new case arrived. I had never encountered a clinical situation like this. I was going to be in the room with immense grief, for which there was no solution. Obviously, I was not going to present the bereaved with worksheets. But I noticed that the idea of simply witnessing, with nothing tangible to offer, made me incredibly nervous. It dawned on me that in-session busyness was masking a lot of anxiety. I felt a great deal of pressure in the therapeutic role which I coped with by “doing.”  Just listening felt unproductive, a bit like slacking-off. But common sense told me that my new patient didn’t need an agenda - they needed a therapist. As I stood in my office that morning, feeling professionally empty-handed, I began to understand the problem: I had an overdeveloped mouth and underdeveloped ears. While the external pressures of the setting were real, they had found a hook within my personality. Always productive, I managed to fit in a full existential crisis before lunch.

Then the patient arrived. And in that first session, I went right back to basics. Listening. I shelved all the techniques and just tried to be human. To paraphrase Philip Bromberg, I stumbled along and hung in. I begged the higher-ups for more sessions, and they were mercifully accommodating. With the support of my supervisors, I saw the patient for several years, giving my listening skills a much-needed workout. As heart wrenching as the sessions were, I looked forward to them. That treatment was very meaningful to me, and I can only hope that the process was useful for them. Even after all these years, that case stands out as the dividing line between my training and the realities of clinical practice.

I wish I could say that this dividing line was an overnight sensation for me, but life is not that poetic, and people don’t change that quickly. To cope with the dissonance, I rationalized to myself that the aforementioned case was an aberration. Otherwise, it was “busyness as usual.” As it turned out, the feeling of having “nothing for them” came back time and again. Most of the problems I encountered were long-standing and complicated. The fantasy patient, ready and eager to accept my suggestions, showed up about once a year. In the interval, I had patients who were at risk. Patients who struggled with addiction. Sessions that nearly came to blows (if anyone asks, family therapy is not for the faint of heart). I was routinely overwhelmed. I wondered if I had been sick the day they discussed the messiness of clinical work in graduate school. There was a stark contrast between the types of patients short-term therapies seemed designed for and the patients that actually show up for psychotherapy. Practitioners ought to know that this is indeed the case. Research trials for brief treatments often exclude complex cases, leading many to question their generalizability to real-world patients (Stewart, Stirman, & Chambless, 2012; Westen, Novotny, & Thompson-Brenner, 2004). I used to think that complex people had a map to my office. It turns out that people are complex.

In addition to the complexity, we return to the matter of techniques. I had a lot of great techniques, but there was one problem — most patients had already tried them. They had attempted all manner of self-help approaches and a sizable percentage had been to therapy before. It was embarrassing when they listed things that I was about to suggest, and I often felt like I was fumbling for another “tool.” The clock was ticking — and I felt anxious about doing “nothing” — so I ended up giving the patients more of what had already failed them. I felt exhausted and demoralized. I kept wondering what I was missing. 

Cut To: Alone in my office again. No longer talking to myself, I had graduated to burying my head in my hands. I was struggling with a patient who seemed uninterested in my help. While their ingratitude made me angry, I felt simultaneously eager to win them over. I was having trouble making sense of my reactions. I consulted with colleagues who told me not to work harder than the patient. I was not satisfied with that answer. Finally, I went where everyone goes in desperation – the Internet. I came across the paper, “On Gratitude and Gratification” by Glen Gabbard, the renowned psychiatrist and psychoanalyst. I had never heard much about him during my training — a fact that will forever have me wishing for a time machine. The paper was a revelation. I was so engrossed, I read it standing up. The level of recognition was extraordinary, as though Dr. Gabbard had been sitting in my office since day one. Although many lines from the paper resonated, this one was searing: “The patient has no obligation to conform to our expectations” (Gabbard, 2000, p. 713). Although it seems obvious now, it was a real lightbulb at the time. I was exhausted because I had been playing therapeutic tug-of-war. The patients were pulling for their agenda (rightly), and I had been pulling for mine (wrongly). I had to accept that things were not working. I started to remake myself as a therapist.

I had been curious about psychodynamic theory since my undergraduate days, but it was often presented as more of an artifact than a viable clinical approach. Besides, everyone was on the CBT train and I went along for the ride. But Gabbard was my psychodynamic gateway drug. Once I had read one of his papers, I could not wait to read them all. His work reignited my interest in psychodynamic theory. As I began to study more, I realized that I was woefully underinformed in two key areas: transference/countertransference (the feelings of patients towards their therapist, and vice versa) and personality styles. The first time I read Nancy McWilliams’ Psychoanalytic Diagnosis, I almost fell off my chair. McWilliams described every patient I had ever seen and every countertransference reaction I had ever had. I was thrilled to have discovered such a treasure trove of clinical wisdom. At the same time, I was angry that psychodynamic theory had been relegated to the cellar while CBT seemed to be in the water supply.

Gabbard was my psychodynamic gateway drug… The first time I read Nancy McWilliams’ Psychoanalytic Diagnosis, I almost fell off my chair. McWilliams described every patient I had ever seen and every countertransference reaction I had ever had.

While many brief approaches cross their fingers for simplicity, psychodynamic theory honors complexity: “We do not fully know our hearts and minds, and many important things take place outside awareness. This observation is no longer controversial to anyone, even the most hard-nosed empiricist. Research in cognitive science has shown repeatedly that much thinking and feeling goes on outside conscious awareness… It is not just that we do not fully know our own minds, but there are things we seem not to want to know. There are things that are threatening or dissonant or make us feel vulnerable in some way, so we look away” (Shedler, 2022, p. 407). In bringing these thoughts and feelings into awareness, the therapist helps the patient gain greater mastery over their emotions and behavior. Psychodynamic therapy places particular emphasis on the therapeutic relationship, which is a window into the patient’s relationships with others. Personality styles, not just DSM diagnoses, are used to guide case formulation and treatment. In-depth therapy for the clinician is a cornerstone of this approach, considered vital for the development of a therapist. I finally found what I had been looking for. I dedicated myself to psychodynamic study, in-depth personal therapy, consultation, and supervision. It is an enormously engaging and rewarding journey. I will always be sorry that I did not begin sooner.

In what mirrors my personal experience, Enrico Gnaulati writes: “It would not be farfetched to claim that the average psychotherapist educated and trained in sanctioned evidence-based methods faces the peculiar dilemma of having to discard a substantial part of his or her learning simply to ongoingly and thoroughgoing be emotionally present with clients, uncluttered with internal demands to be directive and productive” (Gnaulati, 2021, p. 598). If a therapist is under too much pressure to be productive, they end up bringing their own goals into the consulting room. This poses a genuine problem for treatment and is how I ended up playing therapeutic tug-of-war. Whatever the particulars of my story, it seems far from unique. I often hear from colleagues that the relentless pressure for productivity makes receptivity all but impossible. This typically results in therapists who become disconnected from their work. Much like I did, they ask themselves: “Is that all there is?”

Fortunately, it isn’t. Patients want more than an intervention-dispensing technician: “When you survey clients, they overwhelmingly want a therapist who is a good listener and who has a warm personality, not someone skilled in the latest techniques” (Gnaulati, 2018). The person of the therapist matters and has always mattered. In our field, new acronyms and techniques get most of the attention, despite the fact that they are the weakest contributor to treatment outcomes. Instead of burying therapists in acronyms, we would be better served by cultivating in them the qualities that matter most to our patients — empathy, patience, and tact.

I am skeptical about staking out parcels of theoretical land, as effective psychotherapists do many of the same things (Jennings & Skovholt, 1999). If pressed, I will describe myself as psychodynamic-integrative. I am anchored in psychodynamic theory, but flexibility is critical for any practitioner. CBT continues to inform my practice, as most effective psychotherapy will involve challenging thoughts and beliefs (Gabbard & Westen, 2003). The difference now is that CBT techniques are woven into my overall understanding of the problem and used only when indicated by the patient. However, a funny thing happened on the way to the thought record — by the time we get to this stage, the patient usually has enough self-knowledge to challenge their own thoughts. I sometimes joke that I am training the patient to do my job, which is said only partly in jest. At the end of successful therapy, the patient is able to internalize the therapeutic relationship, continuing to do on their own what they once did in psychotherapy (Shedler, 2020).

Undoubtedly, psychodynamic therapy has a public relations problem. It is often characterized as outmoded and debunked, despite the fact that neither is true (Leichensen, Abbass, Heim et al., 2023; Shedler, 2010; Shedler, 2022). In my neck of the woods, psychodynamic therapy isn’t even popular enough to be unpopular. As I began integrating psychodynamic principles into my work — and worked up the courage to tell my colleagues about it — I received more shrugs than sighs. A number of early career clinicians have expressed curiosity about it, while the senior ones are often more wistful. A professional role model of mine, who has practiced for five decades, told me that it heartened him to see a young clinician practicing psychodynamically. I was thrilled to hear that and was equally delighted to be referred to as young. 

My psychodynamic turn has been nothing short of a professional boon. I feel more fulfilled in my work, my patient retention is higher, and the outcomes are better. It has been my experience that approaching patients with a sense of curiosity and neutrality — what Roy Schafer called the “analytic attitude” — engages them in a profound way. This engagement enables them to stay in therapy long enough to derive benefit. Moreover, the ebbs and flows of the therapeutic relationship are not auxiliary to the work — they often are the work. Without the internal prod of an agenda, I have a greater capacity to focus on what really matters in the room — the relationship. Although brief treatment remains a financial reality for many, I have seen that even single session treatments can profit from a psychodynamic approach. The time can be used to give the patient an analytic experience, hopefully planting the seeds for further self-reflection. At a minimum, patients tell me that they feel more understood after a session like ours than they did after being bombarded with strategies — an experience they frequently report having had elsewhere. It is humbling to hear that many patients have no appetite for what I used to dish out. Taking a hard look at myself and the work is now par for the course.

It has been my experience that approaching patients with a sense of curiosity and neutrality — what Roy Schafer called the “analytic attitude” — engages them in a profound way… Without the internal prod of an agenda, I have a greater capacity to focus on what really matters in the room — the relationship.

In reflecting upon my professional journey, I used to have a topsy-turvy view of things. I thought the interventions mattered more than I did, and that personal limitations could be hidden behind them. Although I feel foolish, the profession made it easy to be bamboozled. Current therapy trends favor a grab bag of “tools” without giving much thought to the hand reaching in the bag. Once they get into the trenches of practice, many clinicians discover, as I did, that patients are not coming for interventions. They are coming for a professional who understands. We have generations of clinical wisdom that tells us what works in therapy, as evidenced by scores of research and several existential crises on my part. Let’s face it — the next magic bullet usually ends up being a blank. It is time to do the hard work of making, and remaking, the next generation of psychotherapists.

* The title of this paper was inspired by “The Making of a Therapist” by Louis Cozolino.

** To maintain confidentiality, the clinical cases described are composites.

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                                                                   References

Bromberg, P. M. (2011). The shadow of the tsunami and the growth of the relational mind. Routledge/Taylor & Francis Group.

Cozolino, Louis J. (2004). The making of a therapist : a practical guide for the inner journey. New York :W.W. Norton.

Gabbard G. O. (2000). On gratitude and gratification. Journal of the American Psychoanalytic Association, 48(3), 697–716. https://doi.org/10.1177/00030651000480030901

Gabbard, G. O., & Westen, D. (2003). Rethinking therapeutic action. The International journal of psycho-analysis, 84(Pt 4), 823–841. https://doi.org/10.1516/002075703768284605

Gnaulati, E. (2018, February 15). Is "Evidence-Based" Off Base? Psychology Today. https://www.psychologytoday.com/us/blog/in-therapy/201802/is-evidence-based-base

Gnaulati, E. (2021). Relational healing in psychotherapy: Reaching beyond the research. Psychoanalytic Inquiry, 41(8), 593–602. https://doi.org/10.1080/07351690.2021.1983403

Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of Counseling Psychology, 46(1), 3–11. https://doi.org/10.1037/0022-0167.46.1.3

Leichsenring, F., Abbass, A., Heim, N., Keefe, J. R., Kisely, S., Luyten, P., Rabung, S., & Steinert, C. (2023). The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders - an umbrella review based on updated criteria. World Psychiatry, 22(2), 286–304. https://doi.org/10.1002/wps.21104

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.

Schafer, R. (1983). The Analytic Attitude (1st ed.). Routledge. https://doi.org/10.4324/9780429481024

Shedler J. (2010). The efficacy of psychodynamic psychotherapy. The American psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378

Shedler, S. [@jonathanshedler]. (2020, August 13). Ideally in termination phase, patient internalizes the therapy relationship (or more accurately, consolidates the internalizing). In other words, the.[Tweet]. Twitter/X. https://twitter.com/jonathanshedler/status/1294020238992793600?s=46&t=4SiHxcFtCi0vXs4Qua2XJw

Jonathan Shedler Ph.D. (2022) That was then, This Is Now: Psychoanalytic Psychotherapy For The Rest Of Us, Contemporary Psychoanalysis, 58:2-3, 405-437, DOI: 10.1080/00107530.2022.2149038

Stewart, R. E., Stirman, S. W., & Chambless, D. L. (2012). A qualitative investigation of practicing psychologists' attitudes toward research-informed practice: Implications for dissemination strategies. Professional Psychology: Research and Practice, 43(2), 100–109. https://doi.org/10.1037/a0025694

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials. Psychological Bulletin, 130(4), 631–663. https://doi.org/10.1037/0033-2909.130.4.631