There is a tendency among young psychiatric residents, including me, to experience significant anxiety when providing outpatient psychotherapy for the first time. This anxiety often leads to rigid adherence to structured sessions aimed at a specific therapeutic target. Unfortunately, as patients begin to stray from the mold, this model breaks down and leaves the resident with little direction.
As a resident with an engineering background, I felt a strong affinity for this targeted approach, and have struggled for direction with patients whose symptoms or willingness to engage therapeutically did not match this method. I have slowly come to appreciate a more nimble approach that balances elements of both a structured method (such as cognitive-behavioral therapy [CBT]) with more free-flowing psychoanalytic techniques. This approach is based on several principles, including relinquishing a desire for a grand therapeutic arc, gaining comfort with silence, and, finally, allowing the patient to do the work.
Perhaps the most difficult part of this evolving realization is learning to resist the desire for an overarching path from session to session. As a novice therapist, I struggled with the apparent disconnect from session to session, and attempted to force this need for a therapeutic arc on each subsequent visit. This meant that rather than meeting the patient in his or her current state, I was forever reaching to the past, attempting to create a link between what was discussed previously to the topic of today’s session. While some patients readily identified with the concepts of CBT—where maladaptive cognitions are identified and challenged via reflection on past progress—there was another subset of patients who seemed unwilling to do so.
In his Notes On Memory and Desire,1 psychoanalyst Wilfred Bion proclaimed, “Do not remember past sessions.” As I discussed this concept in psychotherapy supervision, I began to understand the value of a less directed approach, and to try it with patients. I soon discovered interactions were more rewarding, and I gained a deeper understanding than I had before. Without a formulaic approach, patients were free to give voice to any issue, whether or not it conformed to their perceived “chief complaint.” It was refreshing to see the work progress over time as we began to slowly integrate the seemingly disparate themes of each session.
In addition to the naive idea of forcing a formulaic arc on the therapeutic process, I felt a strong desire for tangible results. Perhaps it was my engineering side yearning for the quantifiable, but nonetheless, I fell into the trap of trying to push patients to gain insights they may have not been ready to make. This led to dissatisfaction on both sides. I was reminded of another directive from Bion: “Desires for results, cure, or even understanding must not be allowed to proliferate.”1 It was interesting: the less I focused on results, the more patients began to open up and explore. By using their present experiences to examine patterns of behavior, we were able to slowly reach new levels of understanding.
The corollary to gaining comfort with relinquishing my desire for results was gaining comfort with silence and learning to meet patients where they are. The concept of using nonverbal cues to communicate is not a novel one. However, the idea that one might communicate by doing nothing at all is somewhat profound. I began to explore the use of silence with my patients, and have found an unknown richness that was previously hidden by my own tendency to interject. Psychotherapist Mark Epstein wrote, “When a therapist can sit with a patient without an agenda, without trying to force an experience, without thinking that she knows what is going to happen or who this person is…when he falls silent…the possibility of some real, spontaneous, unscripted communication exists.”2 Sitting in silence and allowing my patients to grow in their own insight has given them a sense of empowerment and mastery, and has greatly enriched our sessions.
Psychotherapy is not an easy thing for most embryonic psychiatrists or therapists, and many cling to formulaic methods because such methods are an easy approach. Initially, I, too, clung to this rigid approach, but it ultimately left me unfulfilled. I have learned to be more nimble, embrace silence, and relinquish my desire for results. I was initially uncomfortable with this unstructured model of psychotherapeutic interaction, preferring the more concrete thinking I had come to expect from engineering. It is likely that few residents will share this unique background, and thus may not struggle as I have, but I believe that the process of adaptation and change is relevant to all. As a young psychiatrist, I have gained much joy from being able to work with patients in psychotherapy. It is my hope that other young trainees, regardless of background, will learn to let go of their preconceived ideas and embrace change, for it is only through change that we grow.