"From Impasse to Dialogue in Psychotherapy: Trainee Perspectives on Using Psychoanalytic Thinking in Tertiary Psychiatric Settings"

Abstract

Psychotherapy in tertiary psychiatric settings necessitates structured, symptom-focussed approaches which can be applied by trainees and staff. However, given the complex presentations, impasses in psychotherapy are common, and may result in unplanned termination if unaddressed. Containment in supervision, and using elements of psychoanalytic thinking may be especially helpful in such situations; here we discuss trainee perspectives from a tertiary psychiatric institute in India. Patient presentations at the institute include chronic and severe psychiatric illnesses including dissociation/conversion, personality disorders, substance abuse and self-harm, and psychotic conditions; commonly low-education and low-income; a complex history of previous psychiatric/psychotherapeutic consultations; from across the country and neighbouring countries. Clinical psychology trainees at the institute undertake a two-year full-time advanced training, with a focus on diagnosis, psychopathology, assessment, and psychotherapy. The psychotherapy training emphasises structured, manualised treatments (e.g., cognitive-behavioural, dialectical behaviour therapy, mindfulness), which are suited in these settings for providing a structure and framework, building trainee confidence, and quick symptom relief. However, trainees frequently encounter impasses in psychotherapy, such as patients displaying excessive verbal compliance without matching insight or action, too much/too little verbal content in sessions, frequent crises, boundary violations, hostility/antagonism, and splitting of the multidisciplinary team. When "the techniques don't work", trainee therapists often struggle with feelings of 'stuckness' and self-doubt, resulting in avoidance and potentially, unplanned termination. In supervision, psychoanalytic thinking offers several insights. Firstly, for trainees burdened by outcome expectations, there is immense relief in noticing and verbalising a difficult therapist-patient dynamic. Secondly, containment in supervision allows for a greater tolerance of the patient's affect in the session. Third, shifting the focus to listening and 'not-knowing' allows the patient to explore previously forbidden experiences. Trainees highlight the experience of "using no technique at all…only the basics of therapy", using themselves and the relationship as vehicle of change. These elements of psychoanalytic thought appear to stabilize trainee therapists when the ground shifts, and manual-based techniques fall short. More importantly, when used within a multidisciplinary team, psychoanalytic thinking may make room for an understanding of the patient's internal psychic reality as it plays out in external events, rather than acting on it. Trainee psychotherapists may lack skills to navigate roadblocks, particularly with difficult-to-treat patients, in tertiary settings. This is a critical gap to be bridged in training and supervision, and indeed, training of supervisors. It is important that psychoanalytic thinking be accessible and usable alongside...