TIFT #5 Psychotherapy Training in the 21st Century

The Problem

For the past 11 years I have been blogging about serious psychotherapy, especially about “attachment to your therapist.” Far too often I have been saddened to hear about patients abandoned by their therapists or harshly discharged by clinic administrators when they dared to disclose the intense feelings that should be the focus of discussion in their treatment.

In one case, the therapist had a sophisticated understanding of attachment issues and encouraged her client, who had a history of early life neglect, to form a deeper attachment to her, which she did. After some months of intensive sessions, as the attachment was evolving, she dropped her client, declaring that the client needed a psychoanalyst instead. The client was devastated with sadness and anger, feeling lured into a connection, then abandoned. Not surprisingly the referral did not work.

How can such experiences of rejection and abandonment be prevented? Further tightening of licensing and credentialing seems difficult to achieve. Strong laws and the easy availability of malpractice suits doesn’t seem to be effective. If not that, then one possible solution is better education of clients and training of therapists. It is time to take a fresh look at training. Here are the issues as I see them:

Training is the Answer but How?

• For psychiatrists, who used to be the bulk of psychotherapists, training has been diminished in favor of psychopharmacology, perhaps due to the erroneous belief that psychotherapy is not "scientific." There is still enthusiasm for therapy among psychiatrists. 76% of psychiatric trainees planned to practice psychotherapy, while fully 46%, realized that their training was inadequate and expected to pursue additional learning.
• Clients only know to expect a competent therapist who can help them with the problems they bring. They have no way of knowing that what they get depends heavily on the history and whims of the academic department where therapists get their training.
• Training is stuck in tradition. Most programs identify themselves with one school or orientation, whose theories and explanations don’t make sense in the terms that belong to other schools. From the beginning of our field, no theory was more valid than another. As in the Middle Ages, when Ptolemy's theory was as good as that of Copernicus, there has been no scientific consensus about how therapy works and the choice of one school over another has been based on personal preference or admiration for the founder.
• Times have changed. In the 21st. Century, science has begun to give us clarity about the universal infrastructure that underlies all therapies. Single school training is limiting and inefficient, discourages use of a range of techniques, and narrows the options for a given patient. Therapists either remain limited, or have to learn an entirely different theory and set of practices to treat patients who don’t fit their original training. This needs to change.
• A significant number of thinkers have embraced psychotherapy integration, but many, if not most, of them still don’t believe that the theories behind various therapies can ever be reconciled. I am doubtful that we will get far in trying to convince older teachers and academics, who have invested a career in a single school, that they should be more open. They are happy with what they have known, practiced, and taught. Why should they change now?

An Answer for Today

That is what has led me to the belief that younger people and those who are not invested in a single school will be happy to learn that there is a well founded core of science to explain how all therapies work. They will be open to learning about the common infrastructure and how to recognize foundational change processes and the conditions that allow them to take place. Once they have learned to follow process, rather than protocol or method, sharp distinctions between different schools no longer seem important. They tend to become irrelevant. Instead, there will be opportunities for research on questions like how best to support Memory Reconsolidation or Extinction in a given situation or how best to match technique to the individual client.

Jeffery Smith MD