Living between three and seven

Despite my mostly psychodynamic approach to psychotherapy, I sometimes include cognitive interventions as well. I think of this as choosing from a variety of tools to suit the moment. Generally speaking, cognitive techniques (and psychiatric medications) aim for symptom relief, while psychodynamic work aims for structural personality change, with symptom improvement as a byproduct. There’s […]

My goal as a therapist: to make myself obsolete

Traditional psychodynamic therapy is often caricatured as endless, with a complacent therapist silently growing cobwebs, listening to a patient who never plans to leave. This isn’t completely unfounded: there are therapeutic advantages to losing track of time, “swimming in the material,” and letting one’s therapeutic focus be broad. The patient’s chief complaint, i.e., the […]

Third-party payment for psychotherapy: (2) Medical necessity

In my last post I outlined some complexities of third party payment for office psychiatry, and especially for psychotherapy. As my example I used Medicare, the only third party payer I bill. Some of the problems include complex billing (i.e., collecting from multiple parties), partial reimbursement, unrealistic documentation requirements, loss of patient confidentiality, and a […]

Resistance: "I have nothing to talk about today"

There comes a time, fairly early in many psychotherapies, when there is nothing left to talk about. The identified problems have been named and discussed, there is no more need to bring the therapist up to speed on one’s history. In essence, the patient’s conscious agenda for coming to therapy has been exhausted. I tell […]

Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called “What Brand Is Your Therapist?” The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master’s degree in clinical psychology. Yet she found herself […]

Psychotherapy as generic conversation — Sloppy thinking in psychiatry 4

This fourth installment in my “sloppy thinking” series turns to psychotherapy, or what passes for it in some psychiatric practices. A very brief history: Sigmund Freud, a neurologist, invented psychoanalysis and its offshoot, psychodynamic psychotherapy, about 120 years ago. It was, first and foremost, a treatment that involved talking — not merely a conversation that […]