Well, hello everyone, and welcome to our session today. Really excited to have you here. We're going to be talking about the role of psychodynamic psychotherapy and psychiatric practice. And I'm really honored today to actually be with a number of my colleagues here to discuss this really important topic. Just before we start, I wanted to... It's a little soft. Is that a bit better? Thank you. So just before we start, just also wanted to remind everyone that this session is recorded, so if you do have a question, to go to the microphones to ask. And sort of as a warm-up, just wanted to ask everyone to kind of just pull the audience a little bit. How many of you would say that you are familiar with psychodynamic principles and or use them in your psychiatric practice right now? So that's great. So it looks like a large majority of the audience. So maybe talking to the choir a little bit, but I think there's still a lot of important information here that we can discuss and think about together. So as I mentioned, I'm honored to be here with three of my colleagues and just wanted to take a moment to introduce each of them. So the first person that I wanted to introduce is Dr. Richa Bhatia. So she is a clinical associate professor in psychiatry at Stanford University, and she works as the director in the Anxiety Clinic at Stanford, and she's also dual board certified in both child, adolescent, and adult psychiatry. So that's Dr. Bhatia right there. And then Dr. Mann, who's kind of at the end there. So Dr. Mann is also a clinical faculty at Stanford University. She is a training and supervising psychoanalyst and geographic child analytics supervisor at the San Francisco Center for Psychoanalysis here in SF. She is also the chair of the Child Abuse Project at the International Psychoanalytic Association and is intimately involved in psychoanalytic research. Sitting to her left is Dr. Alexander, and Dr. Alexander is also a clinical assistant professor at Stanford University. She is the director of the Student Mental Health Fellowship. And my name is Dr. Swapnil Mehta. I'm a fourth-year resident at Stanford University. I'm completing a two-year fellowship in psychodynamic training and have also obtained a master's in clinical epidemiology. So again, it's a pleasure to have all of you here. Just to go over some of the learning objectives for our course today. So at the end of today's session, we hope that some of these will be recognized. So recognizing the clinical relevance of psychodynamic psychotherapy in psychiatric practice, demonstrating an understanding of the available evidence base for the efficacy of psychodynamic psychotherapy in treating psychiatric conditions, and identifying the key practice points of psychodynamic psychotherapy. And then lastly, recognizing how psychodynamic psychotherapy principles can be utilized in the psychiatric diagnostic formulation. So all of these sort of tie together. Before we start, no disclosures that we have, so no financial or non-financial conflicts. And the views that we're expressing here are our own and not necessarily representative of Stanford University or Stanford Health Care. So with that, I'll turn it over to Dr. Mann. Thank you, Saul, for the introduction. Most of you, I'm sure, are familiar with the principles of psychodynamic psychotherapy. And the first slide, we already went through that disclosure, right? Yes. Okay. Here we go. Make sure. Okay. Yes. We all know that there is a declining practice of psychodynamic psychotherapy. It's not a big surprise. However, you know, the last decade, the use of the psychodynamic psychotherapy in psychiatric residency training programs and clinical psychiatric practice has been active in some psychiatric training programs, but not others. There are some that they have dropped. As we know, DSM generally does not direct attention to causes of emotional suffering in research projects. There has been the dismissing of research on the benefits of psychodynamic psychotherapy. Now, we want to know what is psychodynamic psychotherapy. It's a form of psychotherapy that emphasizes and explores the unconscious and the effect of past experience on mental and emotional processes of the present. Psychodynamic psychotherapy is rooted in psychoanalytic theory, but it's a less intensive and lesser lengthy process than psychoanalysis. It allows individuals to reconcile past experiences with what they are experiencing today. Psychodynamic therapy emphasizes the patient's relationship with the outside world while psychoanalysis focuses on the patient and therapist relationship, in other words, transference. Exploring those aspects of self that are not fully known and especially as they are manifested in the therapy relationship, that's another aspect of this form of therapy, and it will help gaining insight into emotions. So what are the conditions that does psychodynamic psychotherapy treat and helps? Depression, anxiety, social phobia, other kinds of phobias, borderline personality disorder, post-traumatic stress disorder, stress-related disorders, physical symptoms without a biological cause, obsessions and compulsions. Techniques commonly used in psychodynamic therapy, number one, free association. It is defined as expression of the first thought and image that comes to mind as well as the emergence of unconscious feelings and thoughts. Second, transference. Attempts are made to reach the unconscious mind by bringing to light feelings and thoughts patterns formed towards an internalized object from one's childhood which will emerge in the current relationships with the therapist. Countertransference. Countertransference, as we all know, is ubiquitous and it's happening in any relationship. This is after the patient projects and projects transference feelings, therapist reacts to them differently. I'm continuing the techniques that we use, dream analysis, just like in psychoanalysis we do that. Sigmund Freud in 1900 declared that dreams constituted the royal road to a knowledge of the unconscious. Dreams are a vital part of therapy work which facilitates discovering the unconscious meaning of the dream. Therapist helps patient examine various elements of dream content and manifest and latent content. The manifest content of a dream cannot be directly decoded to reveal the meaning of the dream. Dream is exclusively individual, as Leo Rangel in 1987 had mentioned in his book. And it cannot be understood without the help of the dreamer's association to it. So attention must be paid to the symbolic value in the dream, events the patients report, and when and how they go through and the felt emotions. Changes in dream content and dynamics often reveals progress in therapy. Psychotherapist helps the patient by understanding personality and psychopathology, but not from the technical preferences of the psychotherapist. What helps one person can potentially be detrimental to another, even if the presenting problems of two people seem comparable. Each individual has unique personal subjectivity, temperament, defense mechanism, and background history. Creating a precise psychodynamic formulation is essential in our work. One needs to organize the clinical materials about the patient's behavior, traits, attitudes, and symptoms into a structure that helps the therapist understand the patient and plan their treatment effectively. Giving suggestion is not considered psychodynamic. Merton Gill in 1994, and later Fred Pine in 1997, stated he does as much psychodynamic therapy as needed so that he can practice as much psychoanalysis as possible. So you know the word psychodynamic psychotherapy is one aspect that they share and they differ from one another. Psychoanalysis is one aspect of the psychodynamic or psychoanalytic therapy. All psychodynamic psychotherapy done by an analyst or dynamically oriented therapist have elements of psychoanalysis. Therapeutic goal with the differences between psychodynamic therapy and psychoanalysis. Number one, therapeutic goal with psychoanalysis aiming at restructuring personality and psychodynamic psychotherapy seeking to stabilize the psyche. Therapeutic aim and psychoanalysis exploring the unconscious and psychotherapy more directly therapeutic toward the symptoms. Number three, technique with psychoanalysis is centering upon interpretation and psychotherapy upon clarification. And of course that clarification is not the only element that goes into psychodynamic psychotherapy. But principally that's clarification, it's a very important part of it. Number four, methods rest upon free association and psychotherapy rests on free communications which remains around topics. And furthermore about the differences between psychoanalysis, psychodynamic psychotherapies. Number five, locus of therapeutic concern with analysis, analytic situation and with psychodynamic psychotherapy with life situation. Treatment values with psychoanalysis putting a premium on self-knowledge and psychodynamically psychotherapy on self-improvement. Number seven, degree of discovery with psychoanalysis aiming at radically new discovery with psychodynamic psychotherapy doing it much to a lesser extent. Relationship to time with psychoanalysis being timeless with psychodynamic psychotherapy being a time bomb. Patient population with psychoanalysis being more suitable for higher level neurotic individuals with psychodynamic psychotherapy being suitable for lower level, narcissistic, borderline and eschizoid patients. Of course there's variations in the whole set of spectrums of borderline, eschizoid and so forth and other personality disorder. Therapeutic goals. Number one, symptom relief. Primary objective is relief of the problems for which patient requests treatment. One can often get someone to stop behavior in a self-destructive way but it takes considerable amount of time and work to get that person to a place where there is no longer a vulnerability or temptation to do so. Number two, developments of insight. Creating a narrative that makes sense of the patient's background and predicament. Self-understanding is a central goal. Knowing the truth sets people free. Constructing a sense of agency is another therapeutic goal. An internal sense of freedom is probably one of the most precious aspects of everyone's personal psychology. Patient seeks help because something is compromising their subjective sense of agency. They're being controlled by their depression, anxiety, obsession, compulsion, phobia and have lost being the master of their own ship. The psychodynamic psychotherapist clarifies that patient is free to disagree with the therapist's formulation and observations if they choose to. Understanding how a particular person feels about the agency having been compromised is crucial. Number four, solidifying sense of self-identity. Individuals need to feel understood, mirrored, accepted, validated in their subjective experiences. One needs to know what they believe, what they want, who they are, how they feel. Developing a strong and cohesive sense of self is another goal. Building robust self-esteem is another goal. Through experiencing one's therapist being flawed and imperfect will prove to the patient that despite the therapist's imperfection the therapist still can maintain the capacity to help the patient through empathic understanding. It enables the patient to feel good about their less than perfect self and distinguish between healthy and realistically based self-esteem instead of narcissistic inflation. Number six, recognizing and handling strong and complicated feelings. The patient learns what they are feeling, to understand why they are feeling that way, and to have the internal freedom to handle their emotions in ways that benefit themselves and others. Pennebaker, in 1997, did extensive research that provided solid empirical support for the notion that openness to feelings is associated with physical and mental well-being. Technique derived from an understanding of personality and psychopathology, not from technical preferences of psychotherapists. What helps one person can potentially be detrimental for another, even if the presenting problem of the two people seems comparable. Each individual, as I said this before, they're unique, and unique. So I go to the next speaker. Let's thank you for listening, and if there are other questions, maybe at the end we will have a question and answer. Thank you. Thank you. Thank you, Dr. Mann, for that introduction to psychodynamic psychotherapy, including its tenets, techniques, and some of its core objectives. Can you move your mic up a little? Even more? Is that better? Yeah. Okay. So, as we're here today to think about psychodynamic psychotherapy and where we can integrate it into our clinical practice, it seems an obvious question that we can ask ourselves, well, what's the evidence for psychodynamic psychotherapy? And if we think about in the last 30 years or so, where evidence-based medicine has gone, this seems to be particularly important. Not only that it's been an important point for us to consider as psychiatrists, this is something that's also very important in medicine as a whole. But before we go into the data, I want to take a step back and actually frame the issue a little bit as it pertains to psychodynamic psychotherapy. So there's a study by Frank et al., fairly recently, in 2022, it was more of a review actually, and they kind of looked at the trajectory of psychodynamic psychotherapy throughout the years and how it's evolved over time. And what they noticed was that time spent on learning and delivering psychodynamic psychotherapy has decreased in terms of its proportion over the years. And this is for many reasons, but some of it being that there's been increases in psychopharmacology, we have new therapeutic modalities to learn, and some would even argue that psychodynamic psychotherapy and other therapies would be better placed in the hands of non-psychiatrists. I'm not saying that's a majority, but there are some people that have that view. So for a myriad of reasons, there's been a relative decrease on the emphasis of psychodynamic psychotherapies. This has also been correlated with changes in public perception of psychodynamic psychotherapy outside of our practice. So in 2009, for instance, there were two articles, one in the Washington Post and one in the Newsweek. The first was saying, is your therapist a little behind the times, referencing psychoanalysis and psychodynamic psychotherapy. And the Newsweek article was entitled, ignore the evidence, why do psychologists reject science? The obvious implication being that some therapies are evidence-based and scientific and some are not. This has paralleled what we've seen in some parts of the academic literature and in the mental health landscape in a general sense. Shedler in his 2018 article, for instance, noticed that evidence-based medicine in many corners has become a code word for manualized cognitive behavioral therapies. The implication again here being that some therapies are evidence-based and others are not evidence-based. Textbooks have noted that there's in clinical and basic psychology that psychodynamic psychotherapy and its cause in psychoanalysis may be outdated or obsolete. And some textbooks even represent psychodynamic psychotherapy as unscientific or an even higher claim would be pseudoscientific. This is sometimes translated into different ways in which psychodynamic psychotherapy is outlined in treatment guidelines. Abbas et al. in 2017 noted that the Canadian network of mood and anxiety treatments listed psychodynamic psychotherapy as a second-line treatment for depression. They did this despite evidence that they cited within their own guidelines that there were a 54-study randomized controlled trial meta-analysis that suggested strong evidence for psychodynamic psychotherapy with effect sizes that were equal to, as large as, and equivalent to what they listed as a first-line therapy. In the NIMH health topic section, which is essentially a resource for consumers, on sections on anxiety and depression as well as complex mental health disorders, psychodynamic psychotherapy was not listed, but CBT and its associated modalities were. Now, this is not making a direct claim, but it is interesting that if you go to a place where you're looking for a resource for what kind of therapy I might look to expect to improve in my life, that a valid therapy may not be on that list. The last thing I'll note here is that there have been designations of gold-standard treatments and non-gold-standard treatments in some areas of the literature. Some authors have even stated that many or even most mental health disorders would find CBT to be the most effective treatment. And one author, just as a quote, noted that CBT is directly stated, CBT is the most effective treatment approach based on solid yet ever-evolving scientific models and methods. So with all of this, we might take a step back and say, well, the evidence for psychodynamic psychotherapy must be pretty shallow, or that there's insufficient evidence, or there's clear evidence that it's inferior to other types of therapies. So I think it's important that we actually take a look at the literature and see what's out there. So on this domain, we can look at the hierarchy of evidence overall. And this is a general gestalt that people talk about in the literature, that as you move up this pyramid, basically, towards more systematic reviews and randomized control trials and meta-analyses, that the quality of the evidence gets higher. I would argue, of course, that all parts of this evidence hierarchy are important, and they each provide valuable pieces of information that can help us update the probabilities of us making an informed and judicious choice for our patients. So I want to just kind of take a pause there to recognize that while I'm not going to be showing all of this evidence and just focusing on the top of the pyramid, all of it's very important, but I would say that it's somewhat coherent. So speaking of meta-analyses in particular, which is what I'll go through in some detail, I just want to say that there have been many different meta-analyses that have been done on the disorders that I'm about to outline, and that they select different groups of populations. They have different outcome measures. They have different inclusion and exclusion criteria for the randomized control trials that they include. And the randomized control trials within each meta-analysis can have differences in terms of their quality and the validity of the RCT that's included in them. Just to give you one sort of stark example, there was a study looking at post-traumatic stress disorder where the therapist that was a psychodynamic therapist was not allowed to talk about trauma. That's obviously going to change the way that the outcome of that trial is going to be, and so just noting that there are some caveats in this literature that are important. So what I'm going to present is actually I went through PubMed and collected all the meta-analyses that I could find over the last 20 years, and then I went through those documents and then cross-referenced to see any trials that I didn't find in my search and pulled them in. So this isn't a systematic review, but it is sort of a global summary of what's available in the literature. And then I looked at the meta-analyses and what their outcomes were, and these included them looking at what happens when you just receive psychodynamic psychotherapy. So before you come in having no treatment, you get psychodynamic psychotherapy and what happens afterwards. What's the effect size? I looked at the studies that compared psychodynamic psychotherapy against a non-active comparator. So this is a weaker comparator. So that would be a wait-list control group, a treatment-as-usual control group, and many others. And then I also looked at psychodynamic psychotherapy versus active treatments, and this is predominantly cognitive behavioral therapies and their cousins. I'd say about, like, 80% were CBT itself, and then the rest were variants of that. And then the disorders that I'm going to focus on in the next few slides are anxiety disorders, depressive disorders, and complex mental health disorders, and the latter is particularly important because it's a catch-all group, including personality disorders, patients that have comorbid conditions because these are often excluded in other trials, and chronic mental health disorders. So again, just exclusion was anything less than 2003, and if a meta-analysis didn't have more than two psychodynamic psychotherapy studies. So to walk through the kind of results and how that would be presented, you're going to see a graph that kind of looks like this, and on the left-hand side, you'll see essentially effect sizes. So anything that is between zero and 0.3 would be considered classically in the literature as a small effect size. 0.3 to, like, 0.66 is medium, and above that would be considered large. Anything above zero would favor psychodynamic psychotherapy. Anything below that zero line would favor the comparator treatment. And just to give you an example of this, the first column's going to look at pre-post, so if you just received psychodynamic psychotherapy, how much of a benefit do you get? If we compare this versus non-active treatments, how much of a benefit do we get compared to the non-active treatment? And then compared to an active treatment, so CBT, how much of an additional benefit is there as compared to traditional CBT? And on the bottom, you'll see all the studies that are included in the analysis. The important thing to note is that the number of studies is based on the color coding, so there are essentially, like, four meta-analyses here that looked at different outcome measures, which are included in the dots here, and those are color-coded as well. But for the purpose of this talk, I just want to focus on the overall effect sizes, because I think that'll be interesting. So looking at depressive disorders, to start, we can see that when we look at pre-post treatment, that the overall effect size for psychodynamic psychotherapy appears to be large. I just want to remind you that each point in here actually is a collection of many randomized control trials, so it's not an individual RCT, it's a meta-analysis, and that the outcome measures here are across several different domains. When we look at non-active treatments, the effect size in terms of its treatment relevance to non-active comparators becomes moderate, so it's moderately more effective than being on wait lists, receiving a placebo, or receiving a non-active control of other type. And then the active treatment, we can see here, that there's no significant difference between what are classically, like, cognitive behavioral therapies and their derivatives in psychodynamic psychotherapy. And you can see that because the confidence intervals cross zero, and the overall effect sizes are close to about .2 in both directions here. It turns out when we look at anxiety disorders, we find a very similar pattern. Pre-post effect sizes are large. When we compare to non-active comparator, again, wait list, treatment as usual, online therapies, we get moderate effect size differences in favor of psychodynamic psychotherapy. And when we look at active treatments, the overall effect is essentially indistinguishable from a statistical perspective. Lastly, when we look at complex mental health disorders, we again see this similar trend. Large effect sizes are pre-post. When compared to non-active treatment, it's about moderate. And when we look at active treatment, there's some differences here. And the part that I just want to point out is that the measurements that are in those red rectangular boxes are actually a comparison between long-term psychodynamic psychotherapy and short-term cognitive behavioral therapy. So the conclusion there, I would suggest, is not that long-term psychodynamic psychotherapy is better than all therapies. I think the only thing that we could say is that direct comparison, that when we have a longer-term treatment for a complex mental health condition, and we compare it to a shorter-term treatment, that we find a benefit for the long-term psychotherapy. So just to reiterate those conclusions, I know I've done it like four times now, but it will drive home the point, I think. So the overall effect size for psychodynamic psychotherapy appears to be large. Just getting psychodynamic psychotherapy gives you quite a bit. When we compare it to non-active treatments, the effect size compared to that is moderate. And that when we look at complex mental health disorders, long-term treatment seems to be better than short-term treatment. The last thing I wanna point out is that you can see across all of those conditions that we looked at, that the difference between psychodynamic psychotherapy and cognitive behavioral therapy was statistically indistinguishable. Now, that's not a claim on its face to say that they are, in fact, equivalent. You'd have to actually run a study to do that. And there have been very few studies that have actually sought this out. There is one that was a very high-quality study, I would say, that used meta-analytic data to gain power, and actually used one of the smallest equivalence margins that have been used in the medical literature. And that was a study by Steinert et al. So, unlike classical studies where the null hypothesis is what you're testing, this study actually tested for the direct conclusion that there is likely to be an equivalence between psychodynamic psychotherapy and CBT. And what they found is that the overall estimate, which is that orange symbol there, fell within the equivalence margin. So that is direct evidence that there's actually an equivalence between psychodynamic psychotherapy and cognitive behavioral therapy. And I'll just mention that this type of study requires significantly more power than classical other meta-analyses that you might do. So, what can we say as a final conclusion around this part of the data? I would say that the current evidence does not support the claim that CBT therapies are more effective than any other form of psychotherapy for the disorders that we looked at today. There is, in fact, no gold standard treatment. What I would suggest, and what is suggested by many authors in the literature, is that research, in fact, supports a plurality of treatment approaches, and that this treatment approach should be tailored to the individual patient and to the clinician's own clinical judgment. I would note that all of the outcome measures that we looked at in these graphs had to do with symptom measures. And as Dr. Mann pointed out in the beginning part of her lecture, psychodynamic psychotherapy and psychoanalysis goes beyond these elements of care into things like self-agency, understanding of oneself, many of which are not measured in these sorts of trials. So, there's something to be done in the evidence base in the literature. So, again, pointing to the importance of what does your patient want, what does our patient want, and what do we think would be most useful for them? This conclusion that I just mentioned is in line with the American Psychological Association's own conclusion, where they noted that there are variations in patient characteristics, and the clinical and context factors may be more important than the particular diagnosis or the specific treatment or brand that's being employed. As a brief sort of connection to all of this, I just want to note that we're in the age of looking at the brain, and really we have a lot of fancy things that are coming up to kind of investigate this. So, we'd expect that there'd be some changes that correlate with psychodynamic psychotherapy and changes in our brain. There are very few studies out there for psychodynamic psychotherapy and psychoanalysis on this. So, it's a very limited literature, but I think it's one that's growing. And two areas that people tend to look at, just briefly I'll mention, are the prefrontal cortex and the other areas of emotional functioning, such as the anterior cingulate cortex. These areas might be familiar to many of us because of TMS and the way that we might treat depression with that instrument. So, looking at two studies just very briefly, Wisswit et al in 2014, they looked at depression after the patients had undergone psychodynamic psychotherapy and I just want to focus briefly on the right side of that panel. It's kind of a complicated slide, but the point that I want to make is if you look at T1 versus T2 and just looking at the gray bars there, we find that when patients are prompted with distressing sentences, that essentially their limbic system gets hyperactivated. And when you get psychodynamic psychotherapy, so when you move from T1 to T2, there's a normalization of that signal across many different parts of the brain. Buckheim et al in 2012 also looked at psychotherapy for major depression and they found similar changes in prefrontal cortex and anterior cingulate cortex. And that these changes correlated with changes in a patient's depression inventory scale, so how depressed they were, and their overall global functioning. And that's kind of demonstrated here. And just as a last point here, there are many different disorders that people are starting to look at. So, people have looked at somatic symptom disorders, panic disorder, borderline personality disorder, and I'm sure there are others that are in the works. So, with all of this, I'm now going to transition over to Dr. Bhatia, who's going to talk a little bit about the principles of psychodynamic psychotherapy. Thank you. Hi, everyone. So, I'm going to talk about the key principles behind psychodynamic psychotherapy. So, one of the main goals of psychodynamic therapy is to go beyond symptom remission, not only alleviating symptoms, but also developing insight. And developing insight is associated with developing capacity for more fulfilling relationships, understanding self and others in more nuanced ways, effectively utilizing one's talents, building a more stable sense of self-esteem that's not contingent on external factors, tolerating greater range of affect, and facing challenges with greater flexibility. Another goal is to explore the underlying meaning of symptoms, getting to the root cause. Not only what the symptoms are, what the thoughts or emotions are or beliefs are, but also why and how they developed. And some of the key features are focusing on affect and expression of emotion, identifying recurring themes, exploring past experiences, examining the dynamics of the therapy relationship itself, and attending to defenses and resistance. Other key features, unstructured, open-ended dialogue, as you all know, drawing attention to feelings regarded by the patient as unacceptable, might be anger or envy, and interpreting warded off or disavowed wishes or feelings. Identifying and exploring recurring themes in thoughts, emotions, but also self-concept, relationships, and life experiences. A patient may be aware of these patterns, but may feel unable to escape them, or may be altogether unaware of these patterns. For example, a 32-year-old woman exhibits a lifelong theme of feeling like she has to be perfect in order to be worthy, and this manifests both at home and work. Growing up, she had to try to behave perfectly in order to receive approval by her parents, and that's why it's important to explore past experiences and link feelings and perceptions happening in the present to any past experiences. In the therapy relationship, this may manifest, for example, as excessively apologizing or feeling like she's not being a good patient when she's five minutes late for one session. So drawing connections between the therapy relationship and other relationships is an important piece, too. The therapist encourages exploration of the full range of a patient's emotions, facilitating patients describing and putting feelings into words, especially conflicting feelings, feelings that are troubling, and feelings that the patient may not be able to initially recognize or acknowledge. And we know that having intellectual insight is not the same as emotional insight. Emotional insight, which is one of the goals of psychodynamic therapy, resonates at a deeper level and leads to change. This is an example of a vignette from Markowitz and Melrod, and the therapist says, "'Nice to see you. "'How are you?' The patient, Mr. A, says, "'It's been a difficult week. "'I've been feeling sad.' The therapist says, "'Let's talk about how you handled it.' Mr. A says, "'It was difficult. "'I've been feeling nightmarish.' The therapist says, "'Were you able to do the homework exercises?' Or the therapist says, "'I can increase the dose of your medication.' Or the therapist says, "'I wanted to follow up on what you were saying "'about your mother last time.'" These therapist responses are all examples of therapist retreat from affect. The therapist is brisk, trying to be efficient, cutting the patient off, and imposing their own agenda while limiting the patient's affect exploration. Now, therapists of all backgrounds can do this, but this may be more common in manualized approaches which focus on teaching patients skills, more like a fixed approach. Now, many patients view emotions as dangerous or bad. The capacity of the therapist to respond to affect with empathy and without retreat is a crucial skill. It allows patients to identify and express painful feelings in words, then to gain some distance from the affect and learn that feelings may be intense, but they are not inherently dangerous. The therapist provides a safe holding space, conveying that if one tolerates feelings, they'll diminish, and one can verbalize them, understand them, leading to better insight and change. So, another version of this example by Markowitz and Milrod, the therapist says, "'Nice to see you. "'How have you been?' And Mr. A says, "'It's been a hard week. "'I've been feeling down.' The therapist says, "'I'm sorry to hear that. "'What's going on?' Mr. A says, "'I've been working long hours at work "'and then doing chores at home, "'but I feel I'm failing on every front.' The therapist says, "'Sounds like you've been going through a terrible time. "'What's making you feel this way?' Mr. A says, "'My boss lashed out that I'm not working fast enough. "'Dave makes it harder. "'No matter how hard I work, "'it seems not good enough. "'When I get home, "'my wife is upset for me being late, "'and then I get more down.' The therapist looks concerned and says, "'That sounds awful.' Mr. A says, "'Yes, it is.' And therapist explores further, "'What did Dave do?' Mr. A says, "'He acted like I'm stupid,' and said, "'How are you so behind?' The therapist says, "'And how did you feel then?' And Mr. A says, "'I felt stupid. "'I felt like I'll never get promoted "'if I continue working with Dave. "'And I also felt like I wanted him to suffer "'for making me suffer, "'but then I felt terrible about feeling this way.' And the therapist says, "'Sounds like you were feeling a bit angry.' And Mr. A says, "'Yes, frustrated and a bit angry. "'And I feel guilty about feeling this way.' And the therapist explores further, and the session goes on. Now therapists with a chipper or bright stance or limited emotional range may miss out on these opportunities and likely come across to patients as distant. Therapists can emotionally mirror patients with nonverbal responses like eye contact, facial expressions, or posture. Now going to exploration of past experience, it's important because both adaptive and non-adaptive aspects of personality and self-concept are created through attachment relationships. Past experience, especially early attachment experiences, impacts one relationship to an experience of the present moment. Then attending to defenses and resistance. The therapist explores attempts to avoid distressing thoughts and feelings. For example, a patient's missed sessions, being late, or focusing on facts to the exclusion of affect. Therapist notices subtle shifts of topic. Now a word about therapeutic alliance. As we know, the quality of the therapeutic alliance is the strongest predictor of outcomes. The patient's experience of the therapist as warm, genuine, with unconditional positive regard, and patient's experience of being understood and heard is very important. The therapist's comfort with strong emotions can help this alliance. In the case of an impasse, Safran and Muran say the therapist's premature attempts at pattern identification are typically experienced as blaming by the patient. Interpretations made in the context of an impasse are sometimes delivered in a critical or blaming way. This may reflect the therapist's own frustration and attempts to put responsibility for the impasse on the patient rather than in the therapeutic relationship. Being cognizant of this can decrease dropout rates. And I'll hand it over to Dr. Amy Alexander and Dr. Mann. Thank you. Okay, welcome. I'm Amy Alexander, and we'll be doing a case presentation with Dr. Mann. And so, I will first introduce the details of the case. So in this case, there is a supervisor who is working with an advanced MD trainee who is interested in incorporating psychodynamic psychotherapy in their practice. The trainee is also interested in possibly pursuing further training in psychoanalysis. Here's the trainee's case. So the case is that of a 33-year-old Indian man presenting with sadness, unmanageable anxiety, and insomnia. He reports no prior treatment or medical psychiatric history. He says there's a lot of work stress, that he is thinking about work all the time because there is too much to do. The work stress is keeping me up at night, and he's having difficulty falling asleep. He says, I don't know what is wrong with me. Everything in my life is actually very good right now. Work is busy. It's almost too busy at times, but it is my dream job. When asked about his home life, he says, everything is great there too. My wife is pregnant with our first child, and the baby is coming in three months. And they are both doing very well so far. Then he reveals that, I just feel sad sometimes as having this baby makes me think about my mom, and that she's missing out on all this. I bet she would have liked to see this and meet her grandchild. And with this, he describes being almost ruminative of his mother, and thinking about this all the time. These are one of the thoughts that really occupy his mind. The trainee notices that there is something more to explore here about the relationship with the mother, so they ask more about this. And the patient replies, well, my mom passed away from cancer when I was nine years old. The last few years of her life were really sad because she was so sick. It was almost a relief when she went. After that, my dad and older sisters and I moved on, and we didn't talk very much about our mom. They tried to cheer me up, and I think throughout the course of their treatment, he reports that his older sisters actually kind of took on the role of mother for him. They tried to cheer me up since I was so young, and I felt like I should just be okay and move on. And so, to be honest, I haven't thought that much about my mom all this time up until now. But now I find myself thinking about her a lot, especially when thinking about raising this child. And I have to admit, I don't think I really processed losing my mom. When asked about his relationship with his wife, he states he is in a loving relationship with his wife. His wife is Caucasian and is close to her parents. Her parents were not initially accepting of their relationship, and they told her, quote, that she could do better. Her parents were not familiar with Indian culture and had no Indian friends. His wife staunchly defended their relationship, and gradually over the years, they came to accept the marriage more. Especially finding out about their first grandchild, he noticed that they seem even more accepting of him now. Then he also states, my wife can't understand how I feel because she can't relate, and this makes me feel alone when I miss my mom. Some initial symptoms, he says he feels stressed all the time, stressed at work, and I feel overwhelmed at work. He reports difficulty falling asleep and staying asleep, and that it can take two to three hours to fall asleep because he is up thinking about these things. He reports sadness, anhedonia, insomnia, reduced appetite, and less interest, sorry, I should say less interest in eating, and fatigue. Passive thoughts of death, once or twice, but nothing serious. And I feel sad and depressed that my mom is not here. He also reports feeling anxious, especially about work performance, and also about how his home life will change when the baby comes. There will be even more work to do when the baby comes. He feels anxious about his ability to succeed at work, especially when the baby comes. He's having anxious thoughts, difficulty concentrating, sleep disturbances, and fatigue. So for this process note, could we have two people from the audience come and read off what we have on the slide there? We'd like somebody to take on the role of the trainee, and someone to take on the role of the patient. So, could we have two volunteers, please? Okay, and we'd like you to speak loud into the microphone, because again, this is being recorded. Yeah, come up to the microphone and read off the screen. And did you say you're going to be the patient? Okay, and then I think, do we have a trainee? Thank you so much, we really appreciate it. It sounds like you've been thinking a lot about the end of your mom's life. Yes, in the last years of my mom's life, she knew that things were bad with her stage four cancer. And looking back, she talked with me very seriously a number of times. She made certain that I knew she will always love me, and that she will always support me, even if she is not physically present. That she accepts me fully, the boy that I was then, and whoever I would grow up to be. My mom really, really loved me. The last 20 years, I didn't think that much about her, as it was just too hard. But now I think about her all the time. I really miss her. I think experiencing the lack of acceptance from my in-laws was hard and more painful than I have admitted. I don't like to tell my wife, because that puts her in a bad place, in the middle of my in-laws and me. I've met too many people like my in-laws, just racist, full of assumptions, and not accepting of people like me. I can feel that they don't want me here. That they don't want me around them. It's not a good feeling. It makes me miss my mom more, because she was the opposite. Sorry that things have been so hard. Thank you for sharing all of this with me. You mentioned how others have treated you unfairly because of your race, and that there is a lack of acceptance. I'm curious about how you felt about me, since we are not from the same background. Yes. I noticed this when I first walked in the room. To be honest, you first reminded me of the people in my wife's family. I didn't think you would understand where I was coming from. And I felt that maybe you are kind to me because you have to be. I mean, if we met in a social setting, sometimes I wonder if I would be as interested, if you would be as interested in accepting of me. You haven't shown any of this to be true. And I really like and respect you. It's just, I think, this is a fear I always have about people in the back of my mind. Wonderful. Thank you. Wonderful job. APPLAUSE So Dr. Mann would like to know if there are questions about the case before she gives her comments. I was wondering, with this case, how many hours of treatment are we talking about? How many hours was the patient treated? The question is about how many hours were they treated for? So this is sort of the course of over a year, and this is the middle to the end of the treatment. Yes, uh-huh. Once a week, right? Yeah. So this case brings up some interesting ideas about how a supervisor, role of the supervisor in teaching psychodynamic psychotherapy skills to the supervisee. And we see that there are two different levels that this case simulation brings up for us to think some more. Can I? Do you want me to go to the simulation slide? Yeah, I have it right here. Good. So before I go, I'm sorry to clarify. So the trainee sees the patient once a week for an hour, and then the trainee also discusses the case with the supervisor for an hour a week as well. Well, before I start talking about this particular case, I want to say a few points about how we use the psychodynamic formulation. I don't have any slide over there, but I'm just speaking directly to you. We know that we don't really treat a diagnosis, we treat a patient. And a personalized dynamic formulation fills a gap between diagnosis and planning treatment. In every clinical encounter, we observe our situation, share some aspects of formulation with the patient, and decide whether to and how to act at that moment. Keeping the theoretical framework in mind helps clinicians in the present moment, using it to answer that frequent internal questions, what do I say now, you know, to the trainee. We need to identify a patient's most salient problems and then devise goals for addressing these problems. Patients and therapists gradually change goals in progressive phases of treatment. So that's very important. The last comment that was made, the lady who asked about what phase of therapy, so it's a dynamic kind of process, the making a case formulation in our mind, because it does change as we go along. So it's not fixed right at the beginning, middle, or end. We have to stay flexible to form. So the aims range from the reductions of symptoms to personality growth. So that's the aim, to reach the personality growth. Successful treatment can increase a patient's capacity for a stable identity, affective relationship, meaning managing and regulating affect, and self-control of those emotional behaviors. And we use psychotherapeutic technique to facilitate process of personal change. And we also help the patient to learn how to reflect on personal meanings through gaining self-reflective capacities after irrational and dysfunctional beliefs. So dysfunctional beliefs gets modified as we work and move forward. And this is not just the belief, the experiential part of it matters too. So it would create new modes of thinking and planning and acting. So overall, it reflects in the behavioral change. These changes in beliefs and behavior may need to be integrated with previously segregated aspects of the personal meanings by learning and practicing new attitudes and behaviors in therapy and in the social world of work, friendship, and love. And the patient learns new ways to resolve longitudinal ideas about how to resolve from the past to present, to resolve the life dilemmas. And one needs to assess the patient's developmental stage. That's very important too. Those of us who work with children and adolescents, we keep that in the back of our mind. So where they are standing developmentally. So that's important because we are going to have to also apply the new learning and modifications of the attitude depending on where they are at in their developmental line. Patient can establish new narratives and goals to gain a sense of self-mastery of the psychopathology. So yesterday there was a speaker talking about the narrative therapy, and that was very helpful also. So the narrative change from the beginning of the therapy as we go along until the termination time. In psychodynamic formulation, we create an understanding of a person that will inform the direction and the tone of the treatment. And it is basically inferential and subjective, and also there is artistic and playfulness goes into that. The concept of the psychodynamic psychotherapy involves symptoms relief, developments of insight, as we said before, agency, identity, self-esteem, affect regulation, ego strength, and self-cohesion. That's important, self-cohesion. Also a capacity to love work and play, and basically an overall sense of well-being. So in this case that Amy had described, it's very interesting issues that come up with the case vignette. This 32-year-old man with a chief complaint of sadness and unmanageable anxiety and inability to sleep, insomnia, and he claims that his dream job also was perfect at the beginning or at least his perception or descriptions of the job. But then as you get to know the patient, he does say, no, it's causing him stress and keeps him up at night. There are a lot more to it as we listen to the case vignette. His home life, everything seems to be great. This is the report from the beginning. Everything is fine. Work is great. Wife is pregnant with the baby coming, but then gradually he really gets into that. So his home life, he reports that was great, and he puts it that way. So here we are hearing that there is a very important maternal object loss very early in the patient's life, which was age nine. So there was substitute maternal figure in his life, a sister, and maybe other extended family figure. But that's not the same as losing your mom to cancer. And I assume this cancer was terminal cancer that was lingering for a while, and he must have been witness of the failing health of his mother. And that brings back the issue around deaths and dying of parents of children, which is we have to be also prepared as psychiatrists, psychodynamic thinker, how to help the children who lost a very important attachment figure in their lives. The other part that made me wonder about the cultural differences, this is a cross-cultural couple, and then they decide to have children. And you heard the story that there was lack of acceptance on the part of the in-laws, and it took a long time before they really warmed up to that. This sounds to me a milder case, but I have seen in my practice much more intense fighting, infighting, and the in-laws problem, and alienation and isolation. It brings up all kinds of issues, because it goes along with, I assume he wasn't born in this country, right? Yeah, he was brought to this country, and so this brings up the whole dynamic of the immigrant people. Immigration, as Salman Akhtar talked about in his own book on immigration, there is another separation individuation process, that the motherland you leave behind, and it's representing a mother that you leave behind. So that grief or grieving process goes on and on, and until you come to some kind of equilibrium, this kind of acceptance that you're not going to be living there, and the loss is there. Just like any other grief process, it's ongoing, it never stops. So this adds to the immigration and the loss of mother, so it gets revived. Pregnancy also revives the memories, because it must have been repressed for a long time, as he says, that he doesn't remember anything until now, that the pregnant wife is going to give birth to a baby. So this re-emerge in his conscious mind, it makes him anxious, as you can imagine. It's an internalized conflict of a loss and object, and in addition, the immigration challenges how to acculturate one to the new culture, to the host culture. So these are important factors. I assume this case sounds to me that very resilient young man, who is doing very well in his job, trying to manage it, but it's interesting, the timing of his symptoms, it came up, erupted around the pregnancy of his wife. And he also doesn't have that intimacy with the wife, because the wife represents a different culture, and given what you've heard, you know, that's been quite challenging for him too, both psychologically and practically. The other item is that the relationship between this young man and the therapist, the therapist is a Caucasian, and so this is sort of a revival of, you know, another ground of having to deal with someone who he doesn't think he's being understood. Not from the same language, not from same custom and culture. So in a way, it runs parallel with the wife, who he chooses to be from another culture. Despite of that, they may have loving relationship, but there's something that's missing. So he reports that, my wife does not understand me, so he doesn't want to discuss that. There he is with the Caucasian therapist. So the role of the therapist is also very complex, I would think, in such cases. It doesn't mean you have to go and see exactly same race, same skin color therapist. It means that you ought to learn how to increase your sensitivity, and handle your own countertransference where you're dealing with a case like that. So to be able to allow yourself to understand, putting yourself in that place, and using empathy and good use of your countertransference in order to help the patient in making therapeutic gain. So the task of the therapy, it kind of, it become a bit more of a challenge, and it's good that he was able to say so in therapy. So at the beginning of therapy, I assume they don't, they feel shy about it, not to say, but as the relationship get deeper and more intimate, it allows a sense of freedom that the patient is able to express thoughts and feeling regarding the therapist. It's an analytical situation, that's what the patient is going to feel free to be able to talk about that, whichever range of emotion, negatives and lack of trust and all the other things that has to be worked through. So I'm going to have to... How are we doing time-wise? Okay, I would like you to, you know, come up with questions and comments that you have, I hope you would do that. Thank you. Thank you for listening. Hi. Andrew Chalko. Thank you so much for talking, the presentation is really interesting, and this is not meant to sound nearly as judgmental as it probably will, but I'm just wondering, they've been seeing each other weekly for quite some time, it sounds like, nearly a year. Why do you think it took so long to get to some of these core issues, and is there something they could have done to start investigating this even earlier, like really start getting to some of these feelings? Is there something a therapist could have done maybe to really create this safe space for him to disclose that, or just throwing it out there? Yes, I think as we were conceptualizing the case, we were just thinking that it's a trainee case, and this might be one of the first times they're providing psychodynamic psychotherapy, and perhaps some of these themes have come up before, but in this situation, it was more clearly, clearly, yeah, delineated. The timing of it, of course, we can't really decide. It has its own timing. If I understood your question, well, I mean, it really has to do with the development of the transference feeling of where you stand, and how trust develops and shapes itself, and one begin to say things that it's kept hidden from oneself, not consciously, even unconsciously. I have a question. Since this is a supervisee case, so Dr. Mann, how would you encourage your trainee to build that sort of trust with a patient? Well, I think it's very much similar to what we talked earlier about how to cultivate a kind of trusting connections, respect, and hearing, active listening, and being motivated, and have a passion for wanting to help people, and you're not there just artificially. It's like to do a job, you really have to put your mind and your heart into it, to be committed and dedicated to want to improve the life of another human being, and so that's in a nutshell. I mean, I can go on and tell you more, but ... Great. Thank you. Yes. Next question. Actually, it's just a response to the previous question. As a licensed professional counselor, I will just say it is all about cultivating the relationship. Sometimes clients with the most traumatic backgrounds, you must sit with them. You must make them feel validated, and sometimes that does take up to a year, to two. It's not truly a reflection on the clinician as much as it is just where the client is at or the patient. So I would say sometimes a client or a patient will stay in their narrative, and instead of going in after just two months and saying, your narrative is incorrect, it's irrational. No, you sit with them for a little bit, and you work on gaining that trust, you're building that rapport, and truly meeting them where they are. So just saying, it takes time. Yeah, with the traumatized patient even, it's more challenging. Because some of the newer therapists are very eager to want to interpret right away, and it has its own timing and tact, and the timing of it is very important. Once, you know, Winnicott talked about that, how you don't want to be coming across as being clever. You know, that's what he said in one of his papers, that rather waiting and seeing how it develops the connection at the level that it would have to be talked about, not with non-verbally and then verbally afterwards. Yes, hello. Hi. Excuse me, I got a few notes while you all were talking, so excuse me for reading from them. But I just want to talk about evidence-based treatment. All treatment is evidence-based. And when we use that term, we're attempting to make ourselves sound scientific and responsible, but the accepted evidence must fit a reductionistic and mechanistic framework, which a priori excludes many forms of treatment, like psychodynamic psychotherapy, and more broadly excludes human endeavors that don't fit that epistemology. And trying to appear scientific, the entire field, we actually are engaging in pseudoscience. I think there were two main reasons we really need to address as to why psychotherapy has declined so much in its use. One is cost. The current fashionable therapies like DBT and CBT and all the other alphabet soup therapies are much less costly and will be favored by the middlemen who hold the purse, what we call insurance companies. Additionally, as a field, we tend to be very self-congratulatory about how well we help our patients. The reality is that the quality of most therapy and therapists is quite poor and the outcomes are poor. At least these forms of treatment, the alphabet soup ones, you can teach and paint by the numbers. But to offer psychodynamic psychotherapy requires far greater skill and we're already doing a bad job. Years of intensive training and hopefully years spent in the therapist's own therapy so we can help prevent our own biases, transferences, counter-transferences, from screwing up the patient, we can give all the logical arguments and objective evidence we can muster and it's likely to go nowhere in terms of advocating for doing more psychotherapy. If we don't address the actual and strong underlying forces that have kicked dynamic therapies to the curb, it's unlikely we'll have any serious impact on our field and have a cadre of therapists who can offer true insight and healing to our patients. I just want to say thank you for that. I think that's like a very thoughtful sort of encompassing about many of the issues that come up with psychodynamic psychotherapy in the evidence space. I kind of as a brief response to that will just say that there's a really interesting, I think it's a meta-analysis or a systematic review by Leish and Ring that comments on the point that you were making about what is the overall efficacy of all of our therapies and I think to take a look at that would be kind of instructive and valuable. I think it's in 2022 or 2023 and then would echo some of your sentiments. I think that there is many fronts to be thought about on this, both I think philosophically, evidence-based, insurance practice, and I think approaching it from all angles and having an honest discussion about where we're actually at is probably the best place to start, kind of as like we'd like to do with our patients, to start from a place of honesty and openness and receptiveness and to see where we can go from there. Leish and Ring, L-E-I-C-H-S-E-N-R-I-N-G, that's my best attempt at a pronunciation. Thank you, Swap. Hey, thank you for this wonderful presentation. I come from an institute where we're trying to do this with the trainees and I'm doing my first psychodynamic case formulation and it's harder than it looks but very interesting. I'm thinking about the feelings of this man towards his unborn child. I mean, if he has this sense of alienation from his wife's family, how would he feel about his child who is essentially a product of him and his wife? Thank you. I think the question was about he feels, the feelings that he has, how would he be feeling towards the baby when it comes? Meaning how one, did you mean the trainee or was it the patient? I meant the patient. So, I was wondering whether the patient's feelings of alienation are extending to the child and not just his wife's family. Yeah, yeah. Of course, you know, there's all kind of complicated feelings are going to be going on in his mind. You know, he's part, you know, half Caucasian and the other half Indian and so there are all kind of dilemmas are going to be in his mind, you know. Is he going to accept the baby? How he himself also, that matters too, how receptive is he? Because the other half of this is a half Caucasian part, so it's complex, I must say. But it's remained to be seen, you know. One other comment I wanted to make, the integrative aspects of our work is very important because I know the therapist, the trainee was able to medicate this case, I think rightfully so. We're going to have to use whatever tool we have in order to help the patient, so I'm one of those people that I really believe that it's helpful to be open-minded, not to be too rigid. Yes, and we have a couple slides at the end, so we'll leave five minutes for that. But go ahead, we can take your question. Hi, thank you again for the presentation and this may be covered in your slides, but I noted that in the blurb about this presentation that you would have some takeaway messages for what do, how do we apply this in the clinic, what parts of the psychodynamic psychotherapy can we bring to even just a medication management review? If you could speak to that a bit. I might need you just to repeat the last part into the microphone a little bit. Yes, sure. That you can bring some of these concepts or tools from psychodynamic psychotherapy, even if it's just, you know, a 20-minute medication management review of a patient, how are you actually, how can we utilize things from this lecture? Yeah, I believe this is more of an attitude of the prescriber, and if you're really thinking dynamically, it's bound to come out and get communicated, even if it's 10 minutes or 20 minutes, medication management, that's what I believe, that it could be also very helpful. It doesn't mean that you would have time, extensive amount of time to do a lot of interpretation and whatnot, but I think that that's also useful in a hospital setting, consultation liaison, many other kinds of setting, that attitude and training, it matters and it enriches our understanding of the patient. I think that's a very important question, and it goes directly with the theme of our talk, that psychodynamic therapy can be integrated with regular psychiatric practice, and even if it just entails exploring the meaning of prescribing, what does the medication option mean to the patient in this case? Are they perceiving it as something punitive? Do they consider that prescribing a medication means they can't get better on their own, or they don't have self-agency, or are they considering it as a gift from the therapist or the psychiatrist? So there can be many meanings, depending on what the patient's clinical situation and background is, but to your question, it can be performed, elements of psychodynamic therapy can be integrated into routine psychiatric practice. Thank you for the great questions. We'll take two questions and then go back to our slides to wrap up. Alex Smirnov, I have a comment and a question. So thank you for sharing this wonderful case. I think it's already been fruitful for this guy, being in therapy and being able to conceive a child. However, if therapy can be open-ended, pregnancy is not. While the clock is ticking, there are some imagined and real dangers, like in-laws gaining more momentum, being more present in his wife's life, or this guy just being merely terrified of things that grow inside women's bodies after his mother died. How would you address the timing of everything that is coming upon him and everything that he has to do? We apologize. I think that microphone is a little soft. Could you summarize it or retell us? Yes. So the question is how to address the timing of his baby coming into the world and all the anxieties that he's starting to experience. How he's going to just deal with everything in three months. Yes, because that birth is going to be a reminder of the mother's death, so is it... In my way of thinking, right, it's conflicted. For him, it's an area of conflict. It certainly brings up his memories of his mother's death and makes him question the therapeutic relationship. If he's experienced enough regression, then he is the baby and the therapist is the mother. He's wondering how his wife is going to... How his Caucasian wife is going to care for his Indian baby. Questions about how his Caucasian wife may deal with the baby, with the Indian baby? Is that correct? Well, I mean, it would be a mixed race, and that is another good and productive discussion that we can have in intercultural marriage. So it really goes back again, how the wife who is Caucasian is going to experience the baby, who is a different race. So that too, the anxiety that he's experiencing, I think, is at a multi-level. He's only anticipated what... It's an unknown situation, the baby is born, who is accepting whom, how well-received the baby is going to be on both ends, both patients and also the wife, or the family of the wife. That's unknown, but it remains to be seen. But the anxiety that he's experiencing, lack of sleep, I really think is connected to that too, not knowing how he's going to cope with that, how he's going to see the wife coping with that. You know, we don't know enough about the wife's psychology to be able to make any comments. Yeah, I think that's a very good point, because it's both sides, okay, it's like, it's not like one, one side, I mean, the other side, we have to also take into consideration. Yes. So. Yeah. Exactly. Yes. It's a long way to go to help this patient. Yes. Right. This is a really good point. You know, our case has focused on a snippet or one small area or piece, which is often uncovered or not as talked about, but this is an excellent point. I also wanted to say, as a follow up to the previous question, that all of this may not be resolved by the end of the pregnancy, but just as we discussed in a previous slide, allowing the patient to ventilate, express these feelings, put these painful and conflicting feelings into words, itself can be therapeutic at some levels. Hi, I'm Sherry Katz-Biernat. I'm both trained as an analyst and also as a CL psychiatrist. So I want to address just a couple of the points that were made by previous questioners. You don't have to, it can't, in CL psychiatry you don't have forever to build a transference relationship, but you can always have a psychodynamic frame, whether you are seeing a patient for a very long period of time or whether you're doing a very quick evaluation, and the psychodynamic frame is always useful, whether you can build a true transference relationship over time. But we learn to plant seeds, you know, and to harvest them in 15-minute med checks, and we teach that to our primary care colleagues and to psychiatrists who have to do that. But I'm going to give a resource that does this in an organized way. There's a wonderful book written called The 15-Minute Hour, which I recommend to people who have to do that kind of assessment. It's a wonderful tool. It's not the only way of organizing it, but it's a wonderful, Marion Stewart and Joseph Lieberman have done a wonderful job at trying to organize a way of picking a focus. Thank you. Thank you so much. Thank you for mentioning about this book. Thank you. Yes. Yes, that sounds like a wonderful resource, and thank you for the rich discussion and questions. We just have some final slides. We have an epilogue here. So the training worked weekly with the patient, as we discussed, for both medication management and psychodynamic psychotherapy. The patient experienced increasing anxiety symptoms, and eventually the trainee treated him with buspirone and a sleep medication to help with primary insomnia. The depression improved with this combined with the psychotherapy. Oh, I'm sorry. The depression had improved with the psychotherapy. While seeing, we discussed how often they were working together, and the trainee enjoyed working with this patient and felt they were able to help them. There was a positive transference between the patient and the trainee, and this positive transference helped to create a trusting relationship to develop insight and amelioration of the intense symptoms. The trainee then felt motivated to use psychodynamic therapy in their practice and sought further training after graduation. This next slide is for trainees, as well as even practicing psychiatrists who want more education in this area, and also for training directors to let their trainees know. For psychodynamic psychotherapy training, there is the AAPDPP, an affiliate organization of the APA. They meet here at the APA, and they welcome interested colleagues to join. Many areas, but just this local one, we have the San Francisco Center for Psychoanalysis, and there is a training program and a two-year curriculum in San Francisco, Palo Alto, and Sacramento that's open to residents. Some residency programs have psychotherapy tracks, and if you're someone who's a medical student who might be interested in this type of therapy, to look for that in programs. And then there's also resources for further psychoanalytic training, including the American Psychoanalytic Association. The website is over there. There's also a fellowship program, which is a two-year program for psychiatry residents, early career psychiatrists, psychologists. And then finally, further directions. Again, some of these were brought up in terms of why psychodynamic psychotherapy has seemed to decline in use, despite everything we discussed today and how helpful it can be to patients. So the financial considerations, as somebody mentioned, costs and funding and health insurance coverage. I'll end with a story at our own institution at Stanford, which is that—and also just to encourage everybody who's in this field and interested in continuing with this field and care about the future of psychodynamic therapy—well, right now, we've noticed that there has been much more of an interest in mental health. You hear it in the media and celebrities, and more of a push for mental health coverage. And in our own residency training programs at Stanford, the residents have made it known—and actually, it's not just the residents in psychiatry, it's residents in all fields—have wanted more mental health care, more mental health coverage. And so Stanford Health Care, wanting to support the residents, actually negotiated an arrangement with the insurance company such that now a lot of therapy that is provided by private practitioners in the community who might be practicing psychodynamic therapy, the insurance actually helps to cover actually a lot, if not most, of the cost of that for the residents. And that—I didn't train that long ago, but that was not there when I was a resident. So this is—there's an opportunity here with the interest in mental health to push insurance providers to provide this coverage. And likewise, especially with COVID, there's a lot more interest now in understanding of how detrimental that has been for mental health. There's also an opportunity for research and to encourage people, young trainees who want to do research in this field, to help build and continue to build the evidence base. Because as we know, that is what a lot of people are looking at, insurance companies are looking at for treatment coverage. I want to thank all my speakers today, and thank you as well for being here. Thank you.

psychodynamic psychotherapy

psychiatric practice

unconscious thoughts

past experiences

Dr. Swapnil Mehta

Stanford University

cognitive-behavioral therapy

individualized treatment

transference

cultural dynamics

therapist-patient interactions

mental health awareness

post-COVID