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Jordan Bawks: [00:00:12] Welcome to PsychEd, the Educational Psychiatry podcast by Medical Learners for Medical Learners. If you're a return listener, welcome back. If it's your first time, thanks for checking us out. Today's episode is an introduction to psychodynamic psychotherapy. Your host today are yours truly Jordan Bawks, a fifth year psychiatry resident at the University of Toronto. And I'm also joined by Anita Corsini, a social worker who works in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. She's a new member of our team and I'm excited to have her co-hosting with me today. She's been working behind the scenes for a number of months now. Our guest expert today is Dr. Rex Kay, a staff psychiatrist at Mount Sinai Hospital and an assistant professor at the University of Toronto. He is the U of T Psychiatry Department modality lead for dynamic psychotherapy and a graduate member and faculty member of the Toronto Institute for Contemporary Psychoanalysis. He's an award-winning teacher of both undergraduate medical students and psychiatric residents. And on top of all that, he's a pretty nice guy who has a stunning book collection, which is a way to win affection in my heart. So I'll let our two colleagues introduce themselves. We'll start off with you, Anita.
Anita Corsini: [00:01:38] Yeah, I'm really excited to be here. I think you might have mentioned this, but I am a social worker and I work in Knowledge, Translation and Exchange at the Centre for Addiction and Mental Health in Toronto. My official job title is education specialist, and what that means is I develop online training curriculum for therapists and other mental health professionals. Previous to that, the majority of my frontline experience has been working as a counsellor with adolescents and young adults in the field of mental health.
Jordan Bawks: [00:02:11] That's awesome. We're super happy to have you. Knowledge translation is the name of the game in podcasts, so welcome to your first episode. And Dr. Rex Kay. Why don't you tell us a little bit about yourself, your clinical interests, a bit of your kind of training history and your, I guess, your relationship and interest in psychodynamic.
Dr. Rex Kay: [00:02:38] So first of all, Jordan, Anita, thank you so much for inviting me to be a part of this Knowledge Translation indeed, the project is so important that it feels like it should have been around for a lot longer than it has been, and I'm really delighted to be a part of this. So thank you for inviting me and I'm looking forward to talking to you. I am a psychiatrist, I trained at the University of Toronto and psychoanalyst, I trained at the Toronto Institute for Contemporary Psychoanalysis. And as Jordan noted, I'm modality lead for dynamic psychotherapy. What's a little misleading about that is that what I fundamentally am is a general psychiatrist. I trained as a child psychiatrist while I trained as a child psychiatrist. I was told that the definition of a child psychiatrist is somebody who used to treat children. And I'm guilty of that. I used to treat children. Now I work with transitional age, older adolescents, young adults as much as I can. But I've got a general practice ranging from mid teens to mid 80s, and I treat a wide, wide, wide range of psychiatric illnesses. Um, quite happily using whatever comes to hand that's going to help somebody.
Dr. Rex Kay: [00:03:57] Prominently among that for me is dynamic psychotherapy. But I see myself and I would hope that I am seen as fundamentally a general psychiatrist who uses dynamic psychotherapy a lot, along with whatever else I can. My interests are, I'd have to say, first and foremost, education. I spend a lot of my time teaching. In any given month, it can be up to a quarter of my time is spent teaching in one capacity or another, and I love it. I have a long standing interest in creativity, both in terms of the standard creative arts output, but creativity in living and in work and a strong interest in the arts. I am co-founder of a literary journal devoted to issues of medicine and health Ars Medica. I encourage all of you, here comes the shameless plug. Ars Medica do a search for it. We're very proud of it. It's been going for about 15 years now, and I am proud to also be a co-developer. Along with two colleagues at Mount Sinai of Narrative Competence Group Psychotherapy, a program that uses the writing of narratives in treatment. That's my background.
Jordan Bawks: [00:05:17] Fantastic. We'll expect some royalties if you get any extra subscribers to Ars Medica, but we'll work out those details later.
Dr. Rex Kay: [00:05:26] I'll take it up with my co-editors.
Jordan Bawks: [00:05:28] All right. So I'll quickly go over our objectives for the episode today. Psychodynamic psychotherapy is an enormous topic that you can only do so much with in 60 minutes. And so I would encourage listeners to take this as a kind of teaser. We want you to be familiar, you know, when after listening to this episode, when psychodynamic psychotherapy comes to mind, we want you to be able to sort of have a recognition of what that is, what that means, the kinds of patients that you're going to be that are going to be treated in psychodynamic therapy. So here's our explicit kind of objectives. So first off, listeners should have a sense of what psychodynamic therapy is and a bit of an idea of how it works. Number two, we want you to have an idea of who it's for, what kind of problems it's for, and a bit of a sense of the evidence that supports its use. And third, I hope that by the end of the episode you can compare and contrast psychodynamic therapy to other psychotherapies because there's a large degree of overlap. And that's something that we'll talk about towards the end of our time together today. So let's start at a pretty high level. Rex, why don't you walk us through what is psychodynamic psychotherapy?
Dr. Rex Kay: [00:07:03] You're starting not only at a high level, you're starting at probably the hardest level you possibly could have. And I just want to note that, you know, you're starting at the hardest level you can and I will remember that because apparently I'm only a pretty nice guy. Let me answer that, Jordan, by actually moving up one level, because whenever I start talking about psychodynamic psychotherapy, I always find I'm starting a little bit too late in some ways. I want to talk about psychotherapy because it's very easy to lose how audacious the idea of psychotherapy actually is in and of itself. Uh, if we, if we go back historically, people probably since language developed. Have gone to other people with problems that we would broadly put in the emotional range. Typically what we expect are people giving advice, what we would call counselling, maybe doing teaching something educational. Often religious leaders would provide a moral slant on it. All of those factors are to some extent or another part of all psychotherapy. We haven't abandoned that, but the notion of all psychotherapies is that in some way we can help people with mental illness and mental anguish and suffering. Just by helping them talk through their problems, feel more deeply. Understand more deeply. And change. And that's audacious. And and it's remarkable.
Dr. Rex Kay: [00:08:47] And it's only a century and a third old in formal sense. Uh. And it is still, to me, a remarkable human endeavour. And that applies to all psychotherapies, short term, long term, very brief, performed by psychiatrists, psychoanalysts, social workers, psychologists and anybody else that I think we have to start by appreciating that what the attempt here is to use language, relationship, experience together to effect change in the horrible, horrible toll of mental illness and mental suffering. So bringing down from there what is psychodynamic psychotherapy, a lot of what psychodynamic psychotherapy is overlaps with other forms of psychotherapy. But here's my best way of trying to summarise it for you at a basic level. It's about pattern recognition. That people will suffer. And suffer not just anguish, but suffer diagnosable mental illnesses as a result of their patterns of behaviour. Their patterns of being able to process inner experience, emotions, outer experience, process their thoughts and the characteristic patterns at times leads to tremendous suffering, which at times leads to maladaptive behaviour and attempts to cope. So what psychodynamic psychotherapy is about at its most fundamental level is helping somebody gradually elaborate these patterns, collaborate with them in exploring where the patterns come from, to give somebody the chance to alter those patterns and reduce the suffering and illness.
Jordan Bawks: [00:10:47] Well said. And somehow you didn't even mention Freud.
Dr. Rex Kay: [00:10:56] That was an error, but the sentry was the reference.
Jordan Bawks: [00:11:02] That's wonderful. So what I'm hearing in that is that, you know, before we begin even to talk about psychodynamic psychotherapy, it's important to to really root ourselves in the psychotherapeutic endeavour, which is to help people with suffering and including when that suffering reaches the point and fits the sort of pattern of a diagnosable mental illness is to through relationship with another, through talking with another try and. Transform that suffering or alleviate the symptoms associated with the disorder. I mean, I'm not doing justice to your explanation, but talking to the key points that I heard there. If you could speak even more to like what's unique to, as you see it, psychodynamic psychotherapy, like what are the aspects of a therapy that are the hallmarks of, of psychodynamic? How would I know that I was watching somebody doing psychodynamic therapy as opposed to watching somebody do CBT?
Anita Corsini: [00:12:08] Can I just kump in there?
Jordan Bawks: [00:12:09] Absolutely.
Dr. Rex Kay: [00:12:10] Please do, because I really don't want to answer that question.
Anita Corsini: [00:12:14] You're not off the hook, Rex, But I had a quote that I wrote down and it's kind of speaking to Jordan's two questions, right? And it is I read in chapter one of this book, it was maybe the first line. "The dynamic treatment is hard to describe but easy to understand when you watch it unfold". So not only Rex, did you do a superb job of explaining what it is you were actually did an incredible job at describing it. But now I think that Jordan is asking you to help us imagine how it unfolds in the therapy room and wonder if you can.
Dr. Rex Kay: [00:12:54] So I have a feeling that we're going to elaborate on the answer to that question throughout the duration of our conversation. Um, so let me give you just 2 or 3 initial ideas. One. Psychodynamic psychotherapy takes place in four different time frames or spaces. We attend to. The early experience that somebody had. It's a developmental model. It says that early experience shapes those patterns we were talking about. Shapes the characteristic ways that people process experience, internal and external. So we talk about the early experience. We talk about the lived life experience from those early days until the person walks into the office. Again, looking for the patterns, the characteristic development and how that life altered those patterns or reinforced those patterns. We talk about the current lived life, What has happened to the person in between the last session and this session? And explore those And then and this is probably the chief hallmark of dynamic therapy. We spend a lot of time also looking at the relationship in the room. We look at what's unfolding between the for generic purposes. I'll refer to patient and psychiatrist. We can talk about patient and therapist, client and therapist, but we look at what's happening between the two people in the room as a source of understanding pattern. We do that. We refer to this as the transference and countertransference the therapeutic matrix. We do that not because Freud said it was important. Freud said a lot of things were important, some were, some were not. We do it because all of experience and as increasing studies have emerged from a wide range of fields, we know that he was right in supposing that early experience shaped the relationship in the room. But that in and of itself isn't enough to justify it. We do it for two other reasons.
Dr. Rex Kay: [00:15:18] We talk about what's happening in the room because it's happening live in our patients. They're having the experience now. There's no filter. There's no time to reflect. There's no time to revise. It also live for us. We are participants in the process. We are experiencing something. We are observing something. Because it's live between the two of us. Something else is going on that's really important. And for that, I turn to the neuroscience. That's when something is experienced emotionally and intellectually simultaneously. Then the brain is most open. The the the limbic lobe on the right side wherein rides the affect the sense of self, a sense of empathy is engaged. The frontal cortices of the brain. The rational, logical thinking in the upper left is engaged. And what we know from the neuroscientists is that when multiple parts of the brain are engaged, is the time when rewiring has the best chance of happening. But it's also the time when we can explore the patterns most clearly. So we're looking at those four times early childhood lived life current life relationship in the room as a way of seeing how they play into one another and form one another and can help us and the patient together elaborate on those patterns. So if you see a conversation that is focused on affect and experience and looking at those four different timeframes in emotionally charged, meaningful relationship. You were looking at what I would call a dynamic process. I will quickly add that that can unfold in cognitive behavioural therapy, in interpersonal therapy, in acceptance and commitment therapy, in group therapy, in couples therapy. There's no exclusiveness. But in psychodynamic psychotherapy, we are deliberately setting out to court that kind of process.
Jordan Bawks: [00:17:29] Yeah, I think that's. Uh, that's lovely. I mean, looking at those different kind of spaces that we work in. And I'd say it's a pet peeve of mine when I hear people have described psychodynamic therapy to a patient of mine or a patient who is referred to me for psychodynamic therapy as a then in their therapy as a therapy where you're exclusively going to talk about the past. Now, there's no doubt that that's important, right? Like people are shaped fundamentally by their life experiences. So we need to get a sense of that, to get a sense of who they are now and the way in which they respond to things. But. My sense of the literature and my experience is that the therapeutic change happens most in the relationship, in the live relationship and the examination of that experience in that relationship.
Dr. Rex Kay: [00:18:30] Jordan let me add to what you just said, because another of the misunderstandings of psychoanalysis, psychodynamic psychotherapy, is that it is mother bashing, it's parent bashing and or blaming. If we tone the word down a little bit and think I'd like to clarify that while we absolutely see those early years and early experiences as profoundly shaping and all of the evidence supports that, the purpose of understanding that. Is not to wash our hands of the affair because we have discovered that it was Dad's fault. Mom's fault. The only purpose of looking back like that is to help somebody transcend. We are looking at the ways in which an individual made sense of their early experience. We believe with some evidence that there is a rough approximation between what people remember and what happened. There's enough corroboration, but it's only a rough approximation. What matters most is the way you made sense of your childhood, the way you made sense of those experiences, the way they shaped you, given your temperament, your other experiences. And we're doing that to help you transcend the patterns, not so that you can simply lay blame.
Anita Corsini: [00:19:58] Yeah, I kind of feel like it's emerging. For me, that part of what I'm hoping for this episode and I feel like it's already happening, is that we are going to debunk, I think, some of the misconceptions. And for me, I don't think I mentioned this at the top, but I'm really new to psychodynamic therapy. I was aware that it was existing, that it was in the aether, that it was foundational. But in terms of really understanding it, this working on this episode has really sort of like, um, illuminated a lot of things for me. And I feel like even debunking my own misconceptions like through this conversation. And I think that's, that's one of the big ones that then and their idea that sometimes people bring the assumption that we're only going to talk about the past and it's everything that you've said has kind of challenged that notion.
Jordan Bawks: [00:20:54] I'm going to put you on the spot. Anita, What are some of the other misconceptions that you either came to this episode with or things that you really wanted to understand? What's the dirty rumours about psychodynamic psychotherapy on the street?
Anita Corsini: [00:21:12] Mm Um, no disrespect, Rex.
Dr. Rex Kay: [00:21:17] None. None taken!
Anita Corsini: [00:21:18] Some of the things that came to come to mind for me are, like, outdated, out of fashion. These are these are all words I'm using that have negative connotations. Like inefficient.
Dr. Rex Kay: [00:21:44] Those are good. I'm glad Jordan put you on the spot. Feel free to come up with more. But but I want to I want to address a couple of those ideas quickly and in a way that might surprise you. Uh. There was a time not all that long ago. When think the early claim that you just made from the street was becoming true. Psychoanalysis had succeeded a little bit too well. And by the late 70s, early 80s had become a bit of an out of step dinosaur. And if it had not evolved, I would not be an analyst today. There was a. An attack on psychoanalysis for multiple directions from the Psychopharmacologists a term I don't love, but the people using medication and the rise of medication from cognitive behavioural therapists, from the neuroscientists, from the philosophers, from the psychologists, from the feminists, from queer theorists, and from the memory researchers, from the from all of these sources, there was an attack. I would love to say that the field dealt with that in a very open non-defensive way, but the initial response wasn't. There was actually a double initial response, though the outward facing response was, you know, it's the standard Vietnam line.
Dr. Rex Kay: [00:23:38] You know, you weren't there, man. You don't get psychoanalysis. And if you did, you'd know that you're wrong, which is a horrible argument and fundamentally not true. The second line of response, though, was to stimulate a period of creativity within the field. Between the late 70s and early 90s, that was astonishing. And psychoanalysis revamped itself without abandoning its core principles. It recreated itself. Taking in the input from all of those fields. Neuropsychoanalysis over the last 20 years has been a really hot topic of research influencing treatment, attachment theory, serious research coming out of the psychologists. It is incorporated Feminist theory, queer theory, Post-structural theory. There is a wide range of responses to these very legitimate attacks that has produced. A different version of psychoanalysis and psychodynamic theory. That still holds onto for me a lot of the gold that goes all the way back to Freud. But made it a much more vibrant and meaningful field. So fair criticism. But I like to think that it's the criticism itself is now largely out of date.
Jordan Bawks: [00:25:25] And I'll jump in to talk a little bit about the evidence base, because I think this is also a misconception about psychodynamic psychotherapy, including psychoanalysis, is that it's not evidence-based or that it doesn't have a robust evidence base. And I think this will also bleed into answering your question about efficiency, which I think is a very valid question to be asking in, you know, from a systems perspective. Um, uh, so I'll briefly, um, there are a couple of pretty comprehensive and high level reviews that I'm going to link in the show notes. Um, Leichsenring I'm going to butcher their name, unfortunately, but it's a giant in the field of psychodynamic psychotherapy, and there have been a number of high quality studies published in The Lancet. There was a Cochrane Review. There was a pretty rigorous meta analysis in the American Journal of Psychiatry, all within the last 5 to 7 years that have shown that psychodynamic therapy is equal, in effect, size to most other standard interventions and may be superior in some situations. One situation where it actually looks like it's superior to other kinds of treatments is in the treatment of what they call complex mental health disorders. So these are personality disorders, people with chronic mood anxiety conditions or people with multiple disorders and in comparison to treatment as usual, to medications, to shorter-term psychotherapies, a variety of modalities, long term psychodynamic psychotherapy as defined by more than a year of weekly treatment, shows superiority in outcomes for those kinds of situations.
Jordan Bawks: [00:27:34] Um, and then the other kind of piece of this is that I, I think one of the things that happened as well is that a lot of psychodynamic psychotherapies were semi-manualized and so made themselves a bit more amenable to treatment. So there's also a pretty robust evidence base for those short-term psychodynamic therapies as well. And you know, a debate around the manualization of therapy is beyond the scope of our talk. And I think there is something that's lost in that setting, but it's also something that was necessary for psychodynamic psychotherapy to sort of prove itself on the same playground as something like CBT, which I think at this point in time it's done extremely convincingly. And I think for me as a, you know, a psychiatry resident who's about to graduate, who is a real, I'd like to think a student of psychotherapy, like I train in CBT, mindfulness, acceptance, commitment, etcetera.
Jordan Bawks: [00:28:30] I think the place where Psychodynamics kind of separates is in some of these situations where people have failed multiple other therapies, you know, they end up in this complex category. They failed sometimes like 10 to 15 medications. I'm talking about chronic conditions and people who've had neurostimulation treatments who haven't gotten better. And, you know, this is an evidence-based intervention for these people where there are almost no evidence-based interventions. And so when we talk about efficiency in the health care system, there's a lot of talk right now about a stepped-care model that we sort of start at the lowest level of intervention. And to me, just based on the evidence, psychodynamic therapy has a place either in the sort of early steps when you're looking at it like you can short-term psychodynamic therapy as being a non-inferior treatment to CBT, and we can look at patient preference and go from that. And once we get to the higher steps, the higher complexity and chronicity, then I think psychodynamic therapy has a robust evidence base to deserve to stand on those treatment steps when there really is not a lot of other stuff that has that kind of evidence base.
Dr. Rex Kay: [00:29:49] Jordan that was really well summarised and nothing in there that I don't agree with. I'd like to provide a slightly different perspective and this addresses the efficiency question too, and it does address the stepped treatment model. But I want you to start by imagining what people come out of childhood with. That's a temperament, a fit between a child and parent or parents. An early experience. Produces. A character, a personality, a way of being, characteristic ways of being in the world. And what we know is, you know, the biography of Jim Morrison, No one gets out of here alive. No one gets out of childhood unscathed. But what we can say is that some people are more damaged by that combination of temperament, fit and early experience than others. The patterns that we talk about can be luxuries for people who suffered sufficient trauma and sufficient adverse childhood experience that the damage done to their capacity to process inner and outer experience, to manage the complexities of just living can be extreme. Now those people go through life and life happens to them. Life can be physical illness. Life can be life events. And life can actually be the onset of a psychiatric illness that isn't directly related to the features we just talked about that are more genetically or biologically driven.
Dr. Rex Kay: [00:31:37] For those people who came out of childhood relatively unscathed. When life happens, they can often get back on track with nothing but themselves or a close friend or partner. Maybe a little bit of advice from a family doctor. Maybe a single visit to an emergency room or a single visit or a few visits to a psychiatrist. They may require a short-term treatment. They may require medication, but they're likely to do well. For those people. For whom early life was damaging. When life happens, it can be astonishingly difficult. And what we what I think of and what evidence suggests psychodynamic psychotherapy is at its best dealing with is helping those people. The complex problems that the desperately suffering damaged individual who may have a psychiatric diagnosis, who may have a physical illness or who lost a job or a partner. And for those people. We can move through the steps, but very often there is nothing else other than long-term intensive psychotherapy, which I think of typically as being based in dynamic principles, but drawing on everything that the practitioner is capable of drawing on to help from all schools of thought to try to help these people get through.
Jordan Bawks: [00:33:19] So you've hinted I mean, both of us have hinted at this already. Who are the kinds of patients that when you see you think this person needs or deserves psychodynamic therapy?
Dr. Rex Kay: [00:33:38] So part of the answer to that question is contained in what I just said, which is usually somebody who's tried other things. Very few of the patients who come to me come to me without having tried other treatments, medication, shorter term therapies, other approaches. There has to be a level of suffering. Uh, not just of. But of suffering in order to justify a longer term treatment. Psychodynamic psychotherapy itself typically lasts 2 to 3 years. Psychoanalysis itself, a fuller, longer version still only typically lasts four and a half years. We talk a lot about the commitment of time of the psychiatrist. Efficiency comes in there, Anita. We talk about the expenditure of the health care dollar of Doug Ford's taxpayers of Ontario, which is a perfectly legitimate standard. What often isn't talked about, but is very much in my mind is the commitment we're asking of our patients. If somebody is going to come and see me once or twice a week for three years, two years, four years, that is an enormous commitment of time and it's a commitment of emotion. Though the therapy is often useful and often enjoyable, it's also often very hard. We're asking a lot of our patients in order to justify that there has to be a level of suffering. And by and large, there should be an attempt at other solutions that hasn't worked. That's not quite the spirit of what you're asking, Jordan, But that's the background to what I think is really important is a consideration.
Dr. Rex Kay: [00:35:29] A patient who shows little or no curiosity about their own past life and the possible connection to current issues does not scream psychodynamic psychotherapy. A patient doesn't want to do that, but yet wants help is still fully entitled to help. Should probably try other things. Before, if at all, trying a commitment to psychodynamic psychotherapy. Uh, somebody equally. Who? Uh. Has little or no proven capacity to form a relationship. Little image in their mind. That a relationship can benefit them. Should probably try a shorter term psychotherapy or medication or other treatment. Before trying psychodynamic psychotherapy, because the one thing I can promise you is that that therapy is going to be very difficult for them and probably for the practitioner. But if nothing else is working, I deeply believe that for those most unfortunate of people, psychodynamic psychotherapy is rapidly going to become the only game in town, the only treatment that can provide an experience in which a first beneficial relationship can occur. Providing a vantage point for those patients to start exploring their life and their responses and their patterns and begin to change. So ironically, the most difficult patients are also often the ones who scream psychodynamic psychotherapy most, whether they've experienced physical trauma, sexual trauma, relational trauma. They often end up screaming once other treatments still have been tried and failed. Anybody have a thought?
Anita Corsini: [00:37:34] Think Yeah, I was totally reacting to the word trauma because that was like the question that was on the tip of my tongue as you were talking. Just about like complex almost seems sometimes like a euphemism for having like a trauma history. And I just know that, you know, often, you know, adults who have had like adverse adverse childhood experiences, trauma histories and, you know, can have the most difficulty just, you know, dealing with day to day life, as you were saying. And then so then my question was, you know, I haven't come across that in any of the reading I've done so far. But in terms of thinking about patients who might be most appropriate and, you know, having had that early trauma history or, you know, significant series of traumatic events that processing, I wonder if that's possible in dynamic therapy. It seems to be beneficial.
Dr. Rex Kay: [00:38:36] The evidence would tell us there are some really valuable and really helpful, trauma centric therapeutic approaches that are creative and thoughtful and very moving, even to read about when they don't work or when they only get somebody so far is really when dynamic therapy should kick in because they tend to be shorter term and very nicely focussed and often are very helpful. When that hasn't worked is when you ask for the commitment to a longer term therapy if you can get.
Anita Corsini: [00:39:16] So transference and countertransference are sort of key concepts in psychodynamic therapy. And I'm wondering, Rex, if you could talk a little bit about what they are and if you could offer some examples of how they play out within the therapeutic relationship.
Dr. Rex Kay: [00:39:34] Yeah, absolutely. They are central ideas and they've evolved. Transference began as Freud's concept that people make false connections between people in their past and people in their present, which is a perfectly fair way of thinking about it. But to Freud, it seemed to imply that the transference, feelings, the feelings that a patient has for their therapist are in some way not real to the relationship with the therapist. They are simply transferred from their past. Uh, this is a case where I'm going to give him his due. He fought hard trying to argue that a transference feeling was false because it was just a recreation of the past and it didn't apply in the present. And as hard as he tried, he ended up shooting down his own argument. And I just want to make this point because I think that it's it's it's so underappreciated even today. Uh, for Freud in the end. The important point about transference is ethical. Freud noted that we as practitioners, as psychiatrists, can anticipate that for many of our patients, as they work with us, the patients will experience strong emotions about us. Not all, but many. Some of them might be unpleasant for us to experience. What Freud argues. Is that as somebody experiences these feelings, we have an ethical obligation. To use that experience of our patient for their benefit, no matter truly how unpleasant it may be up to limits of personal safety, but that the idea is that an individual based on their past is, we hope, going to experience us as an emotionally significant person in their life.
Dr. Rex Kay: [00:41:42] And as such, their old patterns will be reactivated and as the emotional significance of this other person who is in the room with you. Listening struggling as that intensifies, often the feelings will intensify. And that it is our job to not make that go away. But to use that to help our patient. Similarly countertransference which Freud did not develop at all well. Countertransference initially referred to the feelings that the therapist has about the patient. And usually to the early gang, indicated that the therapist hadn't been properly analysed or therapist that went away a long time ago. And now what we see is countertransference. Is the experience of being the other person in relationship with our patient. And it's a source of information. So transference are the patterns that the patient brings into the room intensified by the gradually increasing meaning and importance of the relationship with the therapist. Countertransference can be. My bringing my issues into the room. If that's the case, I need to address that myself and do something about it. But very often counter-transference is me experiencing something that I can use to help me understand my patient. And again, the ethical obligation. Is to use that to benefit the patient.
Jordan Bawks: [00:43:33] I'm glad we're talking about Transference Countertransference because to me this is one of the most useful contributions of psychodynamic thinking that applies in almost all clinical settings, even outside of psychiatry, because it's natural that we're going to have feelings that are arising when we see patients and patients are going to have feelings that are arising as they see us and about us in particular, and having an understanding of the dynamics of transference and countertransference allows us to use those, as you said, to the patient's benefit. I'm wondering, Rex, do you have a clinical example to bring this to life for us?
Dr. Rex Kay: [00:44:15] Okay. Let me preface my comment by saying that I'm going to tell you a rather sketched out clinical story. Mm. But I have the permission of the individual involved to tell this story, even though it's very sketchy and there's no identifying features. I want to reassure your listeners that I have explicit permission from the original to tell this story in teaching. Um, here's a common experience for a lot of people in the healthcare world, whether they're in any area of healthcare world. I'm working with somebody who. Rejects every single idea I propose. Uh, practical idea. Uh, perspective. Interpretation, whatever it is I have to offer. Is rejected. So we can see a characteristic pattern, perhaps. But what matters here, I'm going to talk about the Countertransference at this point. What matters is that I become aware that I'm not simply frustrated. That either I'm not good enough, I'm not putting forth useful ideas or frustrated that this person is shooting down all of my ideas. I begin to feel. Like. My university made a mistake in admitting me to a medical program, let alone a psychiatric or psychoanalytic that I should never have engaged in this work because I'm utterly incompetent, that anybody would be able to do a better job than I am doing. And I'm feeling quite worthless. Fortunately, that's not an experience I have all that often.
Dr. Rex Kay: [00:46:15] And I begin to feel like that's an interesting response on my part. It takes a little while to gain control of my own emotional state, but as I do, I start saying it's interesting that I'm experiencing this so intensely. So I start attending to the way the patient is rejecting my ideas, suffering, individual. And yet they're rejecting my ideas. Not with a sense of sadness. I wish my doctor could come up with good ideas. Not with a sense of despair. Oh, no, he can't help me. He's not coming up with anything useful. Not even quite with the sense of frustration. He's rejecting my ideas with what I can only describe as a sense of glee. And malice, and I start reflecting on what I know about him. And the way he had described and I've known this person for a little bit of time and the way he described. His parents as being really quite supportive and very encouraging and. Having high standards for their children and for him always wanting him to do his best and always encouraging him to be the best person he could possibly be. Which sounded to me like pretty good parents and that he experienced them as pretty good parents. But I'm starting to wonder about somebody who is rejecting my ideas with this intensity and begin to generate an hypothesis based on my countertransference of feeling so belittled.
Dr. Rex Kay: [00:48:11] And so incredibly incompetent. And I start thinking about two things. One is, I think is there evidence that this is how this person feels as he goes through life? I generate an hypothesis that my countertransference may capture his lived experience. It's not the way he narrated his life. But over the time that I've known him, as I reflected on it, I start to think. He's got a narrative of his life, but it could easily be connected to this kind of feeling that he's avoiding and warding off. And then go back and think about the parents and look at other authority figures in his life. And I look for parallels there as well. How has he described bosses? How has he described teachers? And I begin to generate some hypotheses. Don't say anything because they're just hypotheses. But over time, I'm listening in a slightly different way. I'm exploring his rejecting feelings towards me in a different way. And I'm asking different questions. Over time these things don't happen quickly. Over time, together, working together, it's such a fundamentally collaborative process. We gradually come to recognise that the way he experiences me is a way that he's experienced bosses and teachers in the past.
Dr. Rex Kay: [00:49:48] That he did experience his parents exacting standards as standards that he could never live up to. He did not see his parents particularly as attacking, he said, but they were impossible to live up to and it made him feel horrible. But then we so we've done really good work. We're laying out a pattern that he is now talking about benefiting him. In his lived experience that he is slower to anger. Slower to ascribe malice to others. But then we take one more step. And this is more transferential. That we start looking at the moment when he becomes attacking. And we start looking at the moment that came just before. And how he heard me and how he experienced my suggestions. And what emerges is that. He didn't experience my suggestions as possibly helpful ideas that would benefit him in life. He experienced my suggestions as evidence of his failure to have thought of those ideas himself and enact them. He experienced me not as saying, Hey, why don't you try X? But he experienced me as saying, Well, aren't you stupid for not trying x? Why the hell haven't you tried X? And as he experienced that repetition of the childhood experience of not living up to even though my tone was mild, as his parents were, he knew what I meant. He turned the tables on me. And he stopped being himself in the presence of what he experienced as a judgemental other. And he became the judgemental figure and I became the attacked other. Now that unfolded over months. But that can give you hope. And again, I recognise it's an inadequate summary, but I hope that gives you a little bit of a feel for how transference and countertransference can play out in effect change.
Jordan Bawks: [00:52:05] I mean, if you could summarise months and months and months of dynamic work in only five minutes, I know that you were short changing us and leaving out the richness of the work, but I think there's first off, that was a helpful illustration of transference and countertransference, you know, looking at the way in which the patient was transference, being the way in which the patient was experiencing you, the countertransference, and how you were able to use that experience of you as a way into his world, into his life, in a way that was helpful for the both of you working together and also how you were able to use your own experience with him also as a way into his life that wasn't immediately apparent. And along the way, I think you've kind of hinted at, um, you know, a question that's implicitly throughout this whole podcast is how does psychodynamic therapy work? And when I when I listen to that story, I hear it come through. Like there's that sort of almost relentless attention to the patient's experience. Their thoughts, their emotions, their inner world. Um, that is so important for the work that you do together.
Dr. Rex Kay: [00:53:35] Let me step back in, because for time's sake, I left out the last piece, but. But I think that for your listeners, it's important to hear this as well. Uh, he experienced me as being attacking. My professional identity, of course, is someone who would never be sharply critical or attacking of a patient who is suffering and coming to me for help. But doing my job and taking my job seriously involved really looking hard at myself and wondering if when I said, Why don't you try X? At least some of the time. My frustration with his typical rejecting behaviour wasn't creeping into my voice and I decided that it was, and I talked to him about that. Uh, because I think it did. And I think that his response was based on his transference. But it was also responding to a level of frustration. That he heard in me accurately. Now, that's hard. That's hard as a therapist to own. But jerking with a patient's reality and denying that piece is counter-therapeutic. So at some point it was necessary for me. I felt. To explore his response, to explore mine, and to own up to the possibility that at times he was hearing frustration, which was very meaningful to him. So that's the last chapter. And think think it's necessary to round it out in that way.
Anita Corsini: [00:55:16] Like Jordan, you were just pointing out that sort of very close and sensitive attention to the patient's inner world or what the patient is bringing into the room. And it sounds like, Rex, you're also drawing attention to paying close attention to what's happening in that relationship, What's happening between the both of you? In terms of affect, in terms of emotionally, but also sort of cognitively as well.
Jordan Bawks: [00:55:50] All right. So I want to just take a step back and kind of summarise where we've been and check in on our learning objectives. So number one, we wanted people to have a sense of what psychodynamic therapy is and how it works. And I think Rex, through that example, through our kind of discussion throughout, I hope that we've given our listeners a taste of that. I'll make an aside here to say that psychodynamic therapy and writing is extremely diverse. There's a sort of an enormous richness to psychodynamic thinking. And so this is really a taste. This is like a flight and it's like a flight in comparison to a beer hall. And so my hope is that you like what you've had so far and you want more. Secondly, we talked about who it's for. We talked about the evidence base. Our third objective was around contrast and comparing psychodynamic psychotherapy to other therapies. And I think we've done a decent job of that. I mean, just to make it explicit, I mean, I think the things that are common to all therapies is that we're attending to the therapeutic relationship, the working alliance. I think what psychotherapy psychodynamic therapy adds to that. It is a sort of explicitly looking at investigating, talking about the therapeutic relationship rather than just sort of relying on a warm, supportive stance that's going to facilitate a good therapeutic bond. Um, I think we've talked about the ways in which psychodynamic therapy pays attention to patterns. Patterns from the past to the present, from outside relationships to the therapy relationships looking at these kinds of patterns, um, looking at patterns of emotions, thoughts, and in relationship to other people and relationship to the therapist. Um, and you know, it's funny actually, the more I get into all psychotherapies, the more I see tons of commonalities that I think many psychotherapists do these things in very similar ways. Like in cognitive therapy, there's maybe just people are a bit more explicit, like they're actively talking about it with the patient, someone's core schemas, their core beliefs, the assumptions that they have. But I think psychodynamic therapists do that anyway. You're looking at the way in which people interpret the world think about themselves. It's just a sort of slightly different language and a slightly different frame. Um, so now I want to kind of take a step back. This wasn't explicitly in our objectives at the very beginning, but I think this is something that we want our listeners to leave with. I want our listeners to leave with. This is why I fell in love with psychodynamic therapy. Um, that psychodynamic therapy, something about psychodynamic theory, psychodynamic thinking feels really relevant to general clinical work. Like there's always some aspect of a clinical encounter where I kind of lean on what I think of as my own psychodynamic training and principles. And Rex, you're a few years further down the road than me in this path, and I'm wondering if you can talk about the ways in which psychodynamic thinking influences your general psychiatric care.
Dr. Rex Kay: [00:59:22] Yeah, a few years down the road. Jordan, way back in my childhood when I was about your level, I decided that I wanted to train as a psychoanalyst, not because at that time I envisioned doing psychoanalysis at all. Uh, but because I felt that I needed to understand these principles in order to be the kind of psychiatrist that I wanted to be. That's what pulled me into the Analytic Institute initially. Along the way, I discovered that very long term intensive treatment is useful for some patients, and I still believe that and my experience goes with that. But I wanted to be a really good psychiatrist who used psychotherapeutic principles. You could be a tremendous psychiatrist without studying in an analytic institute, but the way I envisioned the work and what I felt drawn to do this seemed to be the route for me. What I feel all good psychiatrists have learned are the basic principles that we've been talking about today. They may not explicitly think of them as psychodynamic, but a lot of them do. Most every psychiatrist that anybody works with today has been trained at least somewhat in these principles and uses them. But if they weren't trained in their residencies, they were trained by their patients. That in order to do the work well, you simply have to learn to attend to the meaning that a patient is drawing from what their life is affording them. The meaning that a patient draws from handing over a prescription for an antidepressant. The way in which a patient is experiencing affective states. And when they learn to and enhances the work. If you can attend to what's happening in the room. As even a consultation progresses. And it is my strong belief that every good psychiatrist.
Dr. Rex Kay: [01:01:41] It does use dynamic principles, but we also all use including the analyst cognitive behavioural principles, dialectic behavioural principles. Systems thinking developmental thinking that mental illness is a vicious, multi-headed beast. And those of us who work with mental suffering and mental illness need to be able to use everything that we possibly can to help and that these principles, I find, achieve their greatest value not in the hands of people treating patients directly with psychodynamic psychotherapy. But in the hands of people using the principles in their general psychiatric work and their general therapeutic work, whatever mental health profession they come from.
Jordan Bawks: [01:02:38] Yeah, I'm. You're preaching to the converted here and I guess you literally you are because you converted me over my residency training that and now I take this work on for myself as one of the reasons I was eager to take this on is that for me, you know, again, not that this is entirely unique to Psychodynamics, but that the things that psychodynamic thinking emphasise, which is seeing the individual, seeing the person as an individual, paying attention to their past experiences, the value of attending to their relationship with you, the value of attending to their emotion. And the you know, this is, I think, one of the late developments of psychoanalysis relatively, that you hinted at that sort of transformation in the 80s and self psychology is how valuable it is to just to empathise to enter the patient, to make a really concerted effort to understand the patient's world and their experience and how healing that is, how stabilising that is, that those are things that I have gained from my psychodynamic training and things that have really greatly enriched my psychiatric work.
Dr. Rex Kay: [01:03:57] Let me pick up on one thing you just said, Jordan, And this will illuminate the cross-fertilisation between psychotherapies. There was a time, and I can still slip into the language of saying that there's a tension in psychiatry. There was a sociologist who wrote a book about psychiatry called of Two Minds that American psychiatry is of two minds, and the minds are along a kind of biological orientation, a psychological orientation. We can talk about a tension between the desire and the need to see people in categories to make psychiatric diagnoses. And that's an extraordinary, valuable pursuit. Starting in 1980, Bob Spitzer and the DSM proposal was incredibly important and remains incredibly important because it's trying to establish categories that we can compare. So we need to make diagnoses and put people in categories, and that's crucial. The other pool that can be called attention is in seeing every individual as an individual. And focusing on their individuality as a person with a unique history and a unique way of experiencing the world. And we can call that attention. But my colleagues in the dialectic behavioural therapy world have helped me recognise that that's not attention. It's a dialectic that the two live together and they actually benefit one another at their best. And that it's actually our job to not choose between the two, but to constantly be integrating and seeing from the two perspectives and integrating what we see to the betterment of the patient.
Jordan Bawks: [01:05:51] Yeah, I totally agree with that. Rex, I'm going to ask you an annoying question, which I've been doing all episode, putting you on the spot with these hard, monolithic questions. But we like to ask at the end of our episodes, our experts if they have any recommendations for interested listeners who want to learn more. If you were to recommend a resource, a website, a book, or even just kind of a general idea to our listeners if they wanted to learn more about second and psychodynamic thinking or therapy, where would you direct them?
Speaker4: [01:06:26] Oh, that's such a hard question.
Jordan Bawks: [01:06:27] I know.
Dr. Rex Kay: [01:06:28] The literature is, as you noted, a complex literature, but it's also an enormous literature. So it's rather difficult to recommend general texts. Probably the best single volume. And Jordan, you could put this up on the website is Jeremy Safran's introductory book. Uh, as a single volume describing the therapy in about 150 pages. The best introduction to theory is probably Stephen Mitchell and Margaret Black's Freud and Beyond are a fascinating introduction to attachment theory, which also helps understand from an evidentiary base. The role of early experience is Robert Karen's Becoming Attached, which looks at the history of attachment theory, but in the process of doing so and it's a fascinating story and he tells it very well, but in the process of doing so, he helps review the literature of just how early experience shapes later. So there are three places that people could start, but I would also encourage people, especially in the field, who are interested. In any given Non-covid year there are six or 8 or 10 people coming in to speak on broadly psychodynamic themes to various groups. Through the Toronto Institute of Psychoanalysis, the Toronto Institute for Contemporary Psychoanalysis, the Child Psychotherapy Institute, the Ontario Psychiatric Association. There are multiple websites that people can keep an eye on. What I would encourage people to do, if they're interested, is grab and follow in exactly the same way that we try to do as therapists. Follow your curiosity. Don't try to start with Freud and work your way up or study the classics. My strong encouragement is to read what is interesting to you and read it until it's no longer interesting and see if that leads you somewhere else and follow your curiosity.
Jordan Bawks: [01:08:52] Wonderful. I'll make my own plug to add to those resources, which I would generally agree with is to try and find your own Rex Kay wherever you live. Look up your local Rex Kay. Can you tell Rex that I'm trying to get you back for another episode?
Dr. Rex Kay: [01:09:18] Where you're going about it the entirely wrong way.
Jordan Bawks: [01:09:21] But truthfully and I'll chop this up with audio. Um, I would also encourage people to look up their whatever your local institution is and try and find a mentor. A mentor if you can so like if you do clinical work asking around in your local clinical department for people who have psychodynamic training or they do psychodynamic therapy is the best way to learn. As much as I love books and podcasts is to is through real relationships. And so I strongly encourage you to ask around for your local psychodynamic expert or trainee or whoever's keen and go through that exploration together. So I want to thank you guys both. Anita, well done your first episode. Rex, thanks so much for joining us and tolerating all my questions and admiration.
Dr. Rex Kay: [01:10:26] No disrespect, Jordan, but Anita, coming at this from the outside, uh, stimulated my questioning mind and I think really facilitated this discussion. So thank you. And Jordan, as always, thank you just for being Jordan.
Jordan Bawks: [01:10:47] Can't be anybody else. Thank you for listening to PsychEd the Psychiatry Education Podcast, by medical Learners for Medical Learners. Our theme song is by Olive Musique. I want a special thank you to our guest expert today, Dr. Rex Kay. Post-production was done for this episode by Jordan Bawks and Anita Corsini, and we hope to have you back on our podcast sometime soon. Take care!