Training Psychotherapists

Today there’s a short article in the New York Times written by a psychiatrist who trains psychiatric residents who are learning to do psychotherapy. Why is it that psychotherapy patients often want to know whether or not their therapists have, themselves, been in therapy? Here are some excerpts from the article:

• [The] question… made me wonder whether one could be a good therapist without having been in psychotherapy. If the answer was no, it would appear to be at odds with what we do in the rest of medical practice.
• After all, we don’t require neurologists to have a spinal tap or cardiac surgeons to have undergone bypass surgery before performing these medical procedures.
• But there is something special about psychotherapy, I think, that sets it apart. Of course, the doctor-patient relationship is important in any clinical encounter. But in therapy, the relationship is the very instrument of the treatment.
• One way to think about it is that a therapist should not start exploring a patient’s mind without really knowing what is in his own. Therapists, just like their patients, bring their own life experiences into treatment, which influence their feelings about their patients — a process called countertransference.
• Therapists who do not understand their own countertransference run the risk not just of misunderstanding their patients, but of confusing their own hang-ups with those of their patients.

Becoming a psychotherapist carries challenges that are different than those confronted by trainees in other professional fields. Becoming a dentist, for example, requires (among many other things) the mastery of instrumentation and techniques that involve manual dexterity. Becoming a competent psychotherapist requires the capacity to reliably and accurately recognize, tolerate, and manage all kinds of thoughts and emotions, both one’s own and also those of one’s client/patient. When I am teaching counseling practicum students and interns, I tell them that they must take on a task similar to that of a detective: they must become “emotion detectors,” and “thought detectors.” Some people are already good at this when they enter training in psychotherapy; others are not.

If one is not “naturally” good at reading and responding to emotions, is it hopeless? Is there any way to get better at this task? One way to do so is, as the article points out, engaging in one’s own psychotherapy, as a patient. These days (unfortunately, I believe) few therapist trainees take this route. This leaves them at a disadvantage, in some ways, to those who have been in therapy; for one thing, despite their academic study of psychotherapeutic schools and methods, they remain essentially ignorant as to how psychotherapy is really “done.” The beginners tend to remain convinced that what they will really be doing, as therapists, will consist of dispensing advice; seeing where people are engaging in counterproductive behavior, and telling them to “stop doing that.” They tend to skip over the part about emotion, other than perhaps asking the terribly clichéd (and usually unproductive) question: “And, how do you feel about that?” They tend not to really understand the power of our thoughts (and, especially, our belief that our thoughts represent TRUTH) to influence our emotions and behavior (in part because they probably have spent little time observing their own thoughts).

Another way to get better at reading and responding to emotions and thoughts is to engage in the practice of mindfulness (or Vipassana) meditation. Dan Siegel has written about this practice as a way of becoming “one’s own therapist,” in that one treats one’s own phenomenal world as a therapist would: with accurate awareness and labeling; and with compassionate responding. In the Practicum program I designed and ran, the practice of mindfulness meditation was an essential component. That seemed to work very well, for nearly all of the students who went through that program (and, more importantly, for their clients).

But what if one does neither of these things, and is not naturally good at dealing with emotions and thoughts? This is where we, as teachers, might need to gently point out that becoming a counselor is not for everyone. And we hope that the aspiring student will be able to shift gears into another area, one in which s/he can succeed. This is a very difficult aspect of the task of training psychotherapists, because no one that I know of has yet devised a fair, accurate, and objective way to measure a person’s capacity to recognize and effectively work with emotions (one’s own, as well as the emotions of others). Moreover, there is today a sensibility within the training of counselors and psychologists that frowns upon, or even forbids, the requirement of “experiential”-type exercises that might involve self-disclosure. Certainly, students today cannot be required to engage in psychotherapy as a part of their training. The practice of mindfulness meditation, on the other hand, does not necessarily involve uncomfortable self-disclosure (to others, anyway!) and so is probably permissible. However, one might question whether meditation undertaken solely as a course requirement (and thus, arguably, under “duress”) might not sometimes be ineffective, or even counterproductive. That is, as we say in science, “an empirical question,” and it awaits exploration. Certainly, the requirement that one read books and write papers is a form of duress that is apparently beneficial to students, without causing irreparable harm. How could a little bit of silent sitting, in compassionate awareness, be any worse than reading Freud, or (God forbid!) Otto Kernberg?