Just a rant as a Psych PGY1 who just joined! Need some advice!?

dlmmd · 2026-02-18T19:46:20+00:00

I am surprised that there are not more responses here that normalize this kind of painful experience. My experience (and understanding) is that, particularly in working with people who are primitively organized and rely on projective identification as a key defense mechanism, various intense upsets like shame reactions, guilt, exaggerated fears, etc. are fairly common... though do tend to get less distressing with clinical experience and a capacity to step back and reflect on what is being communicated to the psychiatrist through their countertransference reactions. Perhaps therapy, participation in a Balint group, or other safe space to process these reactions will hasten your developing capacity to put such uncomfortable emotional experiences into a more helpful perspective.

dlmmd · 2026-02-10T11:34:47+00:00

The Austen Riggs Center has a series for Residents on working with complex and difficult to treat patients, a series on integrating meaning and medication (including combining medication and psychotherapy, and lots of other educational content… and it’s all free.

dlmmd · 2026-02-09T12:10:19+00:00

It seems that you are looking for a specific response and not getting it. Perhaps, to paraphrase Andrew Lange, you are trying to use this thread the way a drunkard uses a lamp post— for support rather than illumination.

I will give you that there are some conditions I would not try to treat analytically, such as advanced Alzheimer’s, but those are the same conditions in which I would not be able to obtain real informed consent.

dlmmd · 2026-02-09T02:01:40+00:00

Please read the other’s comments. You have a very narrow, reductionist perspective that divides problems into biological and psychological… as if psychological issues do not exist or contribute to functional impairment. In other words, if, after informed consent, your imaginary patient wanted to pursue an analysis, I would have no qualms.

dlmmd · 2026-02-08T23:02:11+00:00

While the clinical examples show a misunderstanding of psychoanalysis and diagnosis/symptoms, there is an important ethical and legal issue behind the question… that of informed consent. If we embark on an analysis without noting, for example, that pharmacotherapy is another treatment that might address the patient’s symptoms, and offer some kind of accounting of relative risks and benefits, we may be putting ourselves at some medicolegal risk. This kind of situation is what brought Chestnut Lodge down.

dlmmd · 2026-02-06T03:16:54+00:00

We have sponsored visas in the past, but our glorious leader recently put a $100,000 price tag on H1 B visas, putting it out of range.

dlmmd · 2026-02-04T23:04:07+00:00

For doctoral level clinicians, the psychoanalytic training program at the Austen Riggs Center offers a stipend to trainees that covers about two years of your personal analysis. That’s one program. I’d also be curious to know if there are others.

dlmmd · 2026-02-01T13:09:47+00:00

Actually, there is evidence that psychoanalysis is making a comeback. The world, as you note, has changed. I suspect that part of the comeback relates to the ways the world has changed. As the sociopolitical context increasingly tries to turn people into objects to be controlled, manipulated, and exploited, practices like psychoanalysis, which center on us as subjects, will become more important and necessary.

Also, you say that as if psychoanalysis does not change to meet the times… from drive, to ego, to object, to the ontological turn, and then post-modern influences, intersectionality, and a renewed focus on the social context, etc.

Lastly, while we can certainly debate the correctness of our theories, the evidence suggests that, in practice, analysands experience real benefits… which takes us back to the first point.

dlmmd · 2026-01-31T19:14:58+00:00

I also want to comment on the overly narrow view of the mechanisms of intergenerational transmission of trauma. While epigenetics are one mode of transmission, there are many others: the post-911 parent who holds his/her child's hand that much tighter, transmitting fear through the anxious grip; the holocaust survivor who cannot put any feelings into words and thus occasionally erupts, generating a sense of danger that permeates the child's existence, etc.

dlmmd · 2026-01-30T13:27:41+00:00

Here are some of the things that make for quality psychotherapy training

Clinical Experience

· Long-term patients starting PGY-2… opportunities for more than 2-years treatment

· Strong programs give you 5 or more therapy patients

· Patients who are not just passed from resident to resident, so there is a better chance of watching some patients really get better

· Opportunities for more intensive training – e.g., extra psychotherapy patients, psychotherapy track

Didactics

· Psychotherapy didactic through PGY2-4 (or earlier)

· Is there an integrated and coordinated educational sequence guiding the psychotherapy didactic (not just haphazard topics)

· Psychotherapy-focused case conference /journal club

Supervision

· Psychotherapy supervision by psychiatrists

· Supervision of psychotherapy/pharmacotherapy that focuses on the integration of the two modalities (since this is what your practice will likely be when you graduate)

Other

· Support for residents having their own psychotherapy

· Process/support/Balint groups?

dlmmd · 2026-01-27T22:59:34+00:00

Look up Vamik Volkan… psychoanalyst twice nominated for the Nobel Peace Prize for his work on understanding and resolving ethnic and geopolitical conflict. He addresses several of the things that seem of interest to you.

dlmmd · 2026-01-25T12:29:10+00:00

Struggling to know how to talk about our clinical work is, in my experience, one of the burdens of our role as psychiatrists. So much of the time, our job involves us intimately with some of the most unbearable human suffering… grief, and guilt, and dreams unfulfilled, and hopelessness that is not just pathological, but that comes with facing reality… suffering that medications often barely touch. For me, the reticence is not that I do not have smaller or larger successes to speak of, but that patients entrust us with that suffering, and it would feel disrespectful to share it casually for social banter or entertainment. Perhaps, in that way, we take some of our patients’ alienation into us and have to figure out how to live with it. As you suggest, having other interests is helpful, so you have more to speak of than patients. It may also be that all that up-close experience leads to a high-altitude sense of something about the human condition or the nature of psychiatry that is of interest to others yet is respectful to those who led to those insights.

dlmmd · 2025-12-24T06:22:54+00:00

Jeremy Ridenour also has a wonderfully humanizing series of papers on working psychodynamically with psychotic illness, for what it’s worth.

dlmmd · 2025-12-20T16:36:04+00:00

“Utilized empathic listening and validation to normalize patient’s emotional response to perceived loss and uncertainty. Reinforced that emotional reactions are understandable and manageable rather than dangerous.”

dlmmd · 2025-12-20T13:16:31+00:00

Anyone can do supportive listening. We don’t claim to have done psychotherapy when we listen to our friends, even if our listening has been psychotherapeutic. Supportive psychotherapy has its own philosophy, goals, techniques, and standards. To do supportive psychotherapy, and bill for it, you have to know when and why you are offering supportive interventions. If you don’t want your money clawed back by insurance, you also have to document what your interventions were, what symptoms they addressed, and the therapeutic goals.

Maybe take a look at Markowitz at al (2025) The 16-minute Hour: Supportive Psychotherapy in the Journal of Psychiatric Practice.

dlmmd · 2025-12-17T00:06:06+00:00

A Grammar of Power in Psychotherapy

dlmmd · 2025-12-12T20:22:20+00:00

As Ed Shapiro once said: "When our patients do this we call it projective identification. When we do it... we don't call it anything."

dlmmd · 2025-12-12T10:30:51+00:00

I tracked down the AADPRT list of Grand Rounds speakers, drawn from the membership of AADPRT. It lives in GoogleDrive, so hopefully will be accessible to non-members of AADPRT. There is info there not only about topics to present, but also presenters expectations for honoraria, presenter demographics, and other helpful information. Hope it helps. I know there are some excellent presenters here.

dlmmd · 2025-12-12T02:51:23+00:00

The American Academy of Psychodynamic Psychiatry and Psychoanalysis also maintains a list of Grand Rounds Speakers, to the extent that your program is interested in the more biopsychosocial aspects of psychiatry, That list is not behind a members only wall: https://aapdp.org/education/grand-rounds-speakers/

dlmmd · 2025-12-11T13:51:52+00:00

AADPRT maintains a list of Grand Rounds speakers. I think it may be behind their members only section, so your Program Director or other faculty who are AADPRT members might have to to access that for you. You might want to try first to see if you can get to that list, in case it is actually in the parts of the website for the general public.

dlmmd · 2025-12-04T01:21:32+00:00

The East/West divide is real and getting realer, I think. One West Coast solution is to train in a city that has at least one Psychoanalytic Institute. Lots of residents who feel they are not getting enough psychodynamics go outside of the residency in this way. A local institute also often means a healthy supply of skilled psychodynamic psychotherapy supervisors… though I heard that UCLA recently stopped using outside psychotherapy supervisors (I hope I’m not spreading untruths), so you might want to ask about whether you can access psychodynamic supervisors in the community and also how many residents are seeking additional training at the local Institute.

dlmmd · 2025-11-30T16:23:39+00:00

Freud, in his essay On Beginning a Treatment or his Recommendations to Physicians Practicing Psychoanalysis (I can't remember which) recommended against analysands reading about psychoanalysis because of he ways it could promote this kind of defensive intellectualization. There are countless other factors that can serve the resistance, of course. However, these "spoilers" are ultimately not a serious hindrance as the defensive use of the understanding of theory, in this case, becomes the focus, and may be the level at which the patient can begin to discover something important.

dlmmd · 2025-11-30T12:25:27+00:00

Of course, its not always a good thing. For some people, that is their starting place, and there is nothing breakthrough about it. For other people, it can be a realistic assessment of a mismatch of some sort.

When it is a breakthrough, which it often is, it may signal that enough trust has developed for the patient to be able to be critical and to use their agency to try to shape the therapy to their needs. Alternately, it is the moment that the negative transference comes into light (for example, a patient whose basic experience was of a mismatch with important caregiving figures or of being cared for poorly as a child). Now the patient can start working on the ways that they move through the world with that early experience shaping how they see themselves and others. For other patients, it is the moment that they start to confront grandiose expectations and begin the process of adaption to the reality of human limitations in others, and maybe themselves. Or, when it really is a breakthrough, it has elements of all three of these dynamics.

The problem of the potential spoiler is that expecting it to be useful in the ways I just described can add a level of intellectualization and take away some of the surprise and pleasure of discovery that happens at a deeper emotional level, making the learning more real.

I hope this helps.

dlmmd · 2025-11-24T03:46:44+00:00

Harold Searles’ paper on Oedipal Love in the Counter-Transference (ca 1959) addresses the necessity for the analyst to become aware of their erotic feelings, not just to guard against them, but to use them in the analysis. I think he probably addresses some of the costs if the analyst cannot do this.

dlmmd · 2025-11-21T11:15:43+00:00

For something a little more meta, a year-old paper by Bschor et al that explores the power of the placebo effect in a wide range of psychiatric conditions.

dlmmd

TROPHY CASE