Episode 154: The Integration of Psychotherapy as a Treatment Modality

David Puder, MD

David Puder and Dr. Mary Jo Peebles have no conflicts of interest to disclose.

Introduction

In today’s episode of the podcast, I speak with Dr. Mary Jo Peebles, a renowned psychoanalyst, speaker and author, about the significance of psychotherapy from her most recent book, When Psychotherapy Seems Stuck. Dr. Peebles received her Bachelors of Psychology from Wellesley College and her PhD in clinical psychology from Case Western Reserve University. She currently works at her private practice in Bethesda, Maryland.

There is an observable lack of training in psychotherapy among psychiatrists, with often little value even being placed on it. Most proceed in a psychopharmacology route, using medication as their primary treatment method.  Only 13% of depressed patients see a therapist whereas 48% receive medication (Puyat et al, 2016).

Dr. Peebles discusses the important role of psychotherapy for patient treatment and also how a therapist's own psychotherapy journey broadens their ability to better connect with and understand their patients.

Personal Therapy As A Therapist

Personal therapy for the therapist is very important, especially considering the unprecedented times we are living in. We have lived in relatively fortunate times for the last 60-80 years, and now that we are experiencing similar hardships as previous generations, we must learn a new resilience and be able to harness that for patients. Doing personal psychotherapy, depth therapy, allows our own internal world to be explored with a trusted other, experiencing the nooks and crannies we usually avoid so when those things come up with our patients we are not as afraid and do not have to use defenses that, in turn, affect the patient.

Psychotherapy Takes Time

The duration of patient treatment is on a continuum; no time frame is exact or can be widely applied. Dr. Peebles routinely encourages new patients to attend one to two sessions with her before offering her perspective of a treatment plan. Depending on whether she perceives simple traumas or more complex traumas influences her thoughts on treatment duration.

She analogizes that a shorter time frame (ex., 10 sessions) could be compared to a simple home update that would include painting walls and changing out the windows—a lesser-impact change. When it comes to an overhaul, likened to significant structural work on a home, it takes time to confront complex traumas and rebuild the foundational structures that may have been operated from for extended periods of time.

Therapy Beyond Sessions

A study presented in Dr. Peebles' book found that it took students who spent one hour per day, five days a week learning Braille, a total of 650 hours to consistently maintain the new brain maps that studying the Braille produced. Applying this transformation process to one hour of therapy per week equates to years of work.

Because the structural therapy change takes time, it is imperative to integrate treatment modalities to compound this therapy process. Multimodal learning densifies interrelated neural firings and web mapping, so it is not either/or when it comes to therapy modalities. It is not helpful to patients to use only one method of treatment. It is the integration of the many types of therapies—biological, behavioral, cognitive— and understanding the different empirically researched body of truths for each, that quickens therapy outcomes. People are multifaceted, so multimodal feedback is needed. 

Communicating The Value Of Therapy

Extensive therapy does not come without financial investment. There is often a struggle to place the value on therapy that is placed on other things such as travel, homes, experiences. Dr. Peebles gives patients honest, nonjudgmental feedback and perspectives, offering that therapy is an investment into themselves and their future. The payoff of the investment is that with consistent work, good therapy continues after the therapy is discontinued because it has created systemic, sustainable change which will shift future trajectories to increasingly positive outcomes.

Creating Connectedness With Patients

Therapists are the instruments that facilitate the connection of the patient with their emotional understanding and experiences. Dr. Peebles cites Carl Rogers work where he concludes connection is realized through the therapist's empathic capacity, warmth, and genuineness. There are no gimmicks that can force the trust/relationship to form. Trust is earned over hundreds of interactions.

This is where the benefits of personal therapy become useful. If the therapist is the instrument then, like any other instrument, they should be fine-tuned through their own deep work. Pursuing an understanding of their own emotional experiences and biases creates awareness of areas that will make empathy hard to give and how personal attachment patterns and transference translates into different relationships. Being aware of these elements within ourselves equates to a wider breadth of accessible empathy, warmth, and genuineness for ourselves and, therefore, to our patients. 

Increasing Patient Emotional Awareness

Often psychotherapy patients need help feeling safe in their own sensations and making sense of their emotions. As the therapist, paying close attention to facial expressions and asking questions are ways to help patients put words to emotions and give them a sense of their experience. Being curious about their experiences and giving feedback helps them understand the physical sensations that may be accompanying their emotions, eventually leading to the ability to verbalize their internal emotional experiences. These are the building blocks of emotional awareness. 

Hypotheses Not Conclusions 

We may be explicitly or implicitly taught that the goal of therapy is to figure out what is going on with the patient and tell them. But whatever conclusion we come to is simply an interpretation of their experiences. Instead, the goal should be to teach them to make up their own mind about what is going on inside them, making them purveyors of their own world. Instead of assuming we know, ask questions. We can have hypotheses and gather evidence, but not our own conclusions. The ultimate outcome is to stimulate the patient to think so they become discerning and develop a sense of their own mind.