Welcome back to Psychiatry Boot Camp. If you are tuning into this episode and you have never been exposed to the work of Dr. Jonathan Shedler, you are in for a real treat. Dr. Shedler is a psychotherapist, researcher, and writer, and he has a way of explaining psychotherapeutic concepts that resonates on an intimate level. I am positive that by the end of this episode you will see what I mean. And then I actually think you might listen a second time because his content is so refreshing, understandable, eye-opening, and layered. Dr. Jonathan Shedler, welcome to Psychiatry Boot Camp, and like all of our guests, I will ask you to introduce yourself to our audience.
I'm Jonathan Shedler. I'm a clinical professor in the Department of Psychiatry and Behavioral Sciences at UCSF. I'm also the chair of science communications for the American Psychoanalytic Association.
Dr. Shedler, I'm so excited to have you. I want to start out with a personal thank you. I have never had the opportunity to speak with you before, although I have truly pondered many times if I should book myself an intake with you, but I've read a lot of your work over the years, and it's been really important to me during really formative years in my personal life and formative years in my professional development. And one of the reasons that I decided to start this podcast a few years ago is that I feel called to education in psychiatry is that I am gravely concerned about the soul of psychiatry, by which I mean in the popular press, on social media, and I think even in professional level training programs, psychiatry is often reduced to checklists, symptoms, prescriptions, and it breaks my heart, and it makes me really angry, and when I read your work, I feel so refreshed, and I'm so grateful that we have a thought leader in our field who pushes back against the oversimplification of the psyche. I think you promote rigorous thinking about the problems in our field and offer a deeper understanding of what it means to be human than is found elsewhere in our field. So, thank you, thank you, thank you.
I will start off with a very loaded question. What type of psychotherapy would you say you practice? Would you classify your particular approach under any existing modality in our alphabet soup of therapy techniques?
Yeah. [laughter] Let me push back on the question here cuz I think what you just asked contains certain assumptions and I think those assumptions are so common that they're invisible and I think they're destroying psychological thinking and destroying the field of psychotherapy. Let me say two things. There are fundamental principles of good psychotherapy that really hold across all modalities of treatment that are effective. Some people call them common factors. I think that's a bit of a misunderstanding.
These core principles derive from the psychoanalytic tradition. The very idea that you could treat symptoms or mental or emotional suffering by talking is a psychoanalytic idea. And it dates to, you know, Freud and the late 19th and early 20th century. The idea that we could address suffering in psychological terms rather than in medical or neurobiological terms derives from psychoanalysis. All of the things that therapists do that we take for granted,
treating people by talking, meeting for regularly scheduled appointments, inviting people to tell us about themselves and helping them to tell us about their experience more fully and deeply, all of these things derive from the psychoanalytic tradition. You know, I think of it as it's like a great tree and right now everybody is pushing or promoting some modality or some brand or some acronym. And it's like people are playing around in the leaves and the branches of a great tree without really an understanding of the trunk and the roots. So, [laughter] you know, one answer is I advocate good psychotherapy and that follows from certain principles we could talk about. The second is I think it's the end of somebody's professional development when they turn a theory or a modality into an identity. Then the question stops being about how can I understand this more deeply? How can I do this better? How can I test what I know and, you know, sort of sift what works and what's helpful from what doesn't. Then it becomes about circling the wagons and protecting our brand which is now intertwined with our identity.
Yeah, and it helps us to feel like we are smart, can help people, are competent because we can stay in what we know and we don't have to deal with the uncomfortability that comes with growth, embracing unknowns, etc.
Yeah, you just said something really important because embracing unknowns, and it sounds glib but I want to unpack it cuz it's really important. The only place real psychological change comes from is from the unknown. Right, it doesn't happen unless patient and that means patient and therapist together enter the unknown. You could think of our difficulties are rooted in what's familiar. We repeat and recreate certain patterns that are very familiar to us. They've often been there from the beginning. They may be invisible to us the way, you know, presumably water is invisible to a fish. Right, we have ways that we know and feel comfortable doing things.
And ultimately what we're doing in therapy is moving from point A to point B. And point A is what's known, familiar, but causing difficulties. Point B is something different, you know, other than what we're already doing. We don't know what point B is when we start out. Right? The only thing that we know for certain is that traversing from point A to point B, the only way to get from one to the other is to traverse into the unknown.
So, one of the problems with, yeah, what I would call descriptive diagnose and prescribe psychiatry and also with prescriptive, you know, therapy brands, modalities, acronyms, worksheets is that they all disregard that truth. That the clinician comes in with an a priori plan about what's supposed to happen. It's not, you know, recognizing existing patterns. Right? Relinquishing those patterns before new and hopefully better patterns are consolidated. Right? So, therapy necessarily moves into a place where therapist and patient are both, you know, uncomfortable and lost. And as soon as you superimpose a, you know, it's like an algorithm or, you know, an agenda-driven therapy, you've actually undercut something that's fundamental to the essence of psychotherapy.
It strikes me how counterintuitive it is that a doctor, a physician would be acting in this way. Cuz I direct a medical student clerkship and so a lot of the students that I teach are not going to be psychiatrists, but they have to make it through their psychiatry clerkship because that's sort of the system that we've set up. I can't imagine going to an orthopedic surgeon and my ankle is broken and they say...
Yeah, and that's because the analogy breaks down, and the practice of psychiatry generally, but the practice of psychotherapy in particular doesn't fit that model. And we keep pretending that it fits, and we try to keep trying to, you know, like shove a square peg into a round hole.
I taught, I still teach, I taught psychiatry residents as a full-time faculty member and an attending doctor in a psychiatry outpatient clinic. I taught psychiatry residents for years. And one of the biggest hurdles in teaching them to think psychologically and teaching them to do psychotherapy is that they really had to unlearn a lot of things. [laughter] And they had to unlearn what they had learned about how to be a doctor. This is true at the most fundamental level. So, we would like to create a relationship if we're doing psychotherapy, and I would even say if we're even if we're doing, you know, psychopharmacology, but doing it skillfully and sensitively. We would like to create a relationship where the patient is an active participant, where, you know, the work is a partnership where it's not... Right. Right.
What's the model for almost any other kind of, you know, medical exam, diagnosis, disposition? You know, the patient comes in, they provide us with information. You know, their job is to give us information, and we collect information. You know, we take a history, we do an examination, you know, we record signs and symptoms, we order lab tests. We gather this information, and then we come up with an answer. So, the patient is in a sort of a passive role, you know, beyond providing information and history. You know, they're in a passive role once we have it, it's up to us to solve it and come up with an answer. And the patient receives this treatment, all right? It's something we do to the patient.
I mean, ideally with their, you know, [laughter] consent, active consent and collaboration, but it's done to. That whole model of taking a... If you start a psychological or psychiatric treatment by taking a history, you are already reinforcing a model of how this relationship is supposed to work that follows this sort of doctor-patient, you know, format. That's antithetical to what the work is, because what the work is is when we come in to do what I would call meaningful psychotherapy, our stance is very different. Our stance is, you know, you don't know what's wrong with you. If the patient don't know what's wrong and how to solve it, if you did, you wouldn't be here, right? That's a given.
I don't know what's wrong and how to solve it, because I'm not inside your mind, right? I'm a different person. I can observe, I can infer, I can speculate, but I can't know your experience. So, you don't know how to solve it, and I don't know how to solve it. But, we can do something here. We can put our heads together, and maybe we can figure out a way to understand it and find a way through it together. So, it's the difference between being the expert in the room who already has the answers versus joining with the patient, right? Not doing something to the patient, but doing something together with the patient to discover something really that's never been discovered before, because this person is not like any other person, right? There's certain patterns and configurations. It's not like we're flying blind, and we, you know, like we come into the room and know nothing, right? We, I mean, we have pattern recognition going on. We understand that, you know, mental health concerns tend to fall into certain patterns. We have the, you know, sort of broad guidelines of, you know, a map from a bird's eye view. But how it's going to unfold and play out with the specific person, there is nobody else like that person. So, part of what I say when psychiatrists have to unlearn that, you know, sort of medical history taking, you know, diagnose and disposition approach, part of what I mean is this.
There's so much humility associated with this approach, and humility is so uncomfortable, I think, especially for doctors. I wonder if this is something, if embracing this uncertainty and embracing this role of unknowing with the patient and exploring with the patient as a partner, as opposed to an all-knowing sort of trip director. I wonder if it's easier with more clinical experience, because I think for young therapists, for therapists that are in training, just starting out, it's so reassuring to be able to cling to a manual.
Yeah, of course it is. A manual, an algorithm, a prescription pad, among other things, serve the function of helping to manage the clinician's anxiety. Right? So, we can think of, you know, theory or treatment models as, you know, they're serving a function for the clinician.
And we have to learn the treatment models, right? We need a knowledge base. But the goal of training, you know, isn't to follow a treatment model more formulaically. The goal of the training is to internalize it and, you know, know it so well, understand the principles so well, that when we sit in the room with the patient, we can be fully present with the patient, let go of our models, right? So, people talk about, you know, you have to get to the point where you can throw away the book. I would modify that and say, yes, that's true. But you need to own the book before you can throw it away. The problem is, this is why trainees gravitate toward manualized treatments or gravitate toward a diagnose and prescribe approach, the promise of people never come out of that. They never move beyond it. And it takes three things to be able to move beyond it. One is we really should be selecting people for the field who have the aptitude for doing the work.
And in many cases that's no longer true.
Second, when you select people with the aptitude, how do we overcome the anxiety of our own uncertainty? Right, right, how do we sit in a room and communicate to the patient that, you know, I don't know the answers. I do know a method for finding out answers. And even though neither of us know yet exactly where this method is leading, I actually have hope and confidence. And I believe that it is leading somewhere, and it will lead somewhere to a solution to your problems. So, I don't know what the solution is, but I believe we can find one. Right, what does it take for somebody to, it's not even necessarily in words, but to communicate that attitude and that view? Well, for one thing, it takes our own in-depth personal psychotherapy or psychoanalysis. We need to have the experience ourselves, not as a doctor, but as a struggling patient, right, this method works. We start off, we don't know where we're heading, but there's a method to, you know, how we go about doing it. Things happen that we can't anticipate or foresee, and those things are very beneficial. But, it can't just be intellectual knowledge or book learning. We have to really, you know, know it in our bones. That comes from personal treatment for the clinician.
And the third element is really good high-quality supervision, clinical supervision, which is happening less and less now both in psychiatry and in other non-medical therapy professions. The field has succumbed to so much external pressure from healthcare systems, from health insurers, from economic factors. Though the field in the last decades watched it happen. It has really gotten distorted in ways that are beyond recognition and so the function of clinical supervision was always a mentorship relationship and a teaching and training relationship with somebody who was a senior expert clinician who could fulfill the role of teacher and mentor. But, you know, now the role of supervisor is often reduced, you know, basically to an administrative function.
And so people don't have the emotional and psychological support to grow in the way they need to through their own therapy or through their own supervision. There are all these pressures, you know, which almost always come down to, you know, seeing more patients in less time, and all of these different forces are really pushing people not just away from doing what I call meaningful therapy, but even from ever being exposed to what it is. So we don't know what we don't know. That's...
That's exactly right. You can't be it if you can't see it. You can't even imagine it really. I think on number three, I feel that personally. We provide supervision for our psychiatry residents. We block out essentially an hour a week to do that. Most of us, some of us have more supervisees where we block out more time than that. That time's not reimbursed. That's just lost income. It's just lost patient time. And there the system, the incentives do not support this model that you're suggesting.
The incentives are absolutely broken and people hate when I say I've taken so much flak from colleagues, including colleagues I respect and look up to for saying this. But it's incredibly difficult to get meaningful psychotherapy or, you know, really good quality psychiatric care within an institutional setting. It's not impossible, but it's really, really difficult because there is so much external intrusion and impingement on the clinician-patient relationship. It's constantly an uphill battle. And often you get into the situation you just described. If the clinician really wants to do good work, you know, they're often working on a volunteer basis, you know, putting in time that they didn't get paid for. And of course, that's really not a fair thing to ask of clinicians. We didn't go into the field to become martyrs.
Right, which is not to say that if you're looking for a therapist, you have to find someone that's not at an institution or that people who are not at an institution are by definition practicing more meaningful psychotherapy because on the other hand, at least an institution does have some supervision and some oversight even if it is administrative, right? I think we have these training programs now that don't offer these maybe these three things that you just described. And so you can hang up a shingle and provide private practice pretty low quality psychotherapy.
Right, right. Finding someone in private practice is no way a guarantee that you're going to find a, you know, genuinely skilled clinician. But if you do it in an institutional setting, you might need to recognize that the deck is stacked against it before you even walk in. You know, you may walk into an institutional setting where the norm is, well, eight to 12 session manualized therapy. Well, if you know the research literature and if you practiced clinically for long enough, you know that meaningful therapy, right? Not the kind that's a balm or a salve or first aid for a symptom, the kind that actually creates meaningful psychological change that, you know, that shifts the course of somebody's life, right? That can't happen in 12 sessions. It doesn't even start in 12 sessions, and research shows it. Right? So, what research actually shows, not my research, but published research, is, you know, on average, obviously everyone is different, but meaningful change in therapy begins around 6 months. Begins.
In most of the institutions where, you know, people go for treatment, the norm and the expectation is that treatment will be over long before that. Right? So, you know, we have to understand that. And then once you go down that, if you're a clinician working in that system, if you take on supervisory or administrative responsibilities, which you'll be asked to do as you get more senior if you're any good at it, it's very, very hard for clinicians to live with that dissonance. The dissonance is, I know I'm not really doing right by my patients. I know I could do better by them, and I'm going to do this anyway cuz I'm compromising because these are the institutional requirements that I'm compromising with. Very few people can live with that. So, it becomes, I'm not doing right by my patients, that morphs, right? Cognitive dissonance kicks in, and it becomes, 'Well, it's good enough for most patients.' It actually morphs into, 'It's better than nothing.' And then it becomes, 'Well, no, it's really good enough for most patients.' And then that morphs into, 'Oh, you know, this is really the standard of care. This is right.' Right? And at that point we professionals can betray ourselves.
We have to convince ourselves of that to avoid that moral injury.
Yeah, and I think it happens all around. Just, you know, go into any established, prestigious, especially training institution and look around.
Let's stick with the structure here for a little bit. We're talking about structural factors. One thing that I've always kind of wondered in reading your work is do you think there's a minimum dose required to achieve the type of goal that you're talking about? So, you know, for meaningful life-changing, I don't know what we were wanting to use for changing someone's self-understanding, schema, belief of themself in addition to just symptoms. 6 months is when it typically begins. Probably no one-size-fits-all, but is it even possible to do good therapy at a frequency of less than let's say 50 minutes once per week?
I don't think it is because there's not enough continuity to get beyond the surface of things. I think meeting once a week is a bare minimum. It's actually incredibly difficult to do therapy once a week. It takes much, much more skill on the part of the therapist to do therapy once a week than to do therapy with the same person, you know, twice a week or even three times a week.
What happens is a few things happen. One is it's very, very difficult to get beyond the weekly catch-up and, you know, the review of symptoms. How am I doing? How am I feeling? So, therapy tends to stay at that level and then that shifts the entire purpose of therapy away from changing the person's underlying psychology toward symptom management. And then we say, 'Oh, you know, well, look, the patient's score on the PHQ-9, you know, has improved.' It says therapy is successful, but I would say we're not doing psychotherapy. See, there's a weird thing that happens in mental health that's different from any other area of medicine. In every other area of medicine, absolutely everybody is clear on the difference between medical treatment versus first aid. Right? I mean, we need first aid.
But there's a difference between first aid and ongoing treatment for an underlying medical condition. In mental health and only in mental health, we're not clear on the distinction and we do two things. We sell first aid to patients and we tell them it's treatment. And they believe it. Why wouldn't they? Like, you know... But then worse than that, we sell that to the clinicians, to the providers, and many of them also start to believe it, especially if they've never been exposed to an alternative.
Sure, the blind leading the blind, so to speak. I want to go back to the initial question here and ask about one thing you mentioned. You mentioned that you have some objections with the language of common factors. If I followed you correctly, you're basically saying because these are actually psychoanalytic factors that we've then taken and applied to other forms of therapy. Is that a fair enough understanding?
Well, all of the other forms of therapy, whether they want to acknowledge it or not. I mean, there's a very, very few exceptions, but generally speaking all of the other forms of therapy are derived from psychoanalytic treatment, are renaming or repackaging time-honored psychoanalytic concepts often pretending they're new discoveries or their reactions against aspects of psychoanalysis, but while preserving the general structure. You know, let me give you an example. It's a bit of a pet peeve of mine. They say the working alliance is a predictor of outcome, a strong predictor of outcome. And in research, that's true. So, it's like, oh, well, that's a common factor, it's the working alliance. But let's really think about what that means. Let's unpack that.
So, a working alliance has three elements. It means there's connection or attachment. It means there's a shared understanding about the purpose of the work, right? We're in agreement or on the same page about what we're doing here. It means there's a shared understanding and commitment to the methods, how we're going to go about it. Now, if you take a pretty, you know, healthy, functioning person who's generally functioning well in the world, who's capable of secure attachments, who's capable of, you know, interpersonal trust and, you know, decent interpersonal relations, who generally trusts the, you know, good intentions of other people, especially, you know, professionals, well, it's a piece of cake to develop that relationship. So, what? Anyone could do it. I mean, you know, a sort of high school student with social skills can create a working alliance. So, now it looks like working alliance is a predictor of outcome.
But, what if actually working alliance is a proxy for the level of health versus the level of personality functioning of the patient? You get into the character pathology realm or now the, you know, personality disorder realm. Now, the therapist's actual skill comes into play. Right? I mean, a high school student could create a good working alliance with somebody with good object relations, healthy attachment, secure attachment, benevolent worldview. That's not why people come to psychotherapy. They come because they can't do those things. So, there's like, okay, so the first pillar of an alliance is attachment, connection, right? Attachment, trust, and security. The person comes in because they're not capable of those things. Now, we're getting into the realm where developing an alliance requires actual expertise, right? Actual clinical expertise.
So, it's not the working alliance. The working alliance is the common factor, but it's a proxy for something else. What is our professional expertise in navigating a relationship with somebody who is there largely because they cannot have healthy functioning relationships? And how do we learn those skills? Well, you know, now we're back to our own personal psychotherapy or psychoanalysis and our own intensive in-depth therapeutically meaningful supervision. So, to answer your question, you say, 'Why do I say I have some trouble with the concept of common factors?' Well, there's one common factor front and center, but to develop that skill takes the kind of training that has always been part of this therapy tradition.
Sticking with that thought, when I reviewed your work prior to this episode, I felt like one takeaway was that there are no shortcuts to good psychotherapy. And we just went over that, right? I mean, even I really appreciate the direct answer to the question of how much time does this take, right? Yes, you have to spend time with someone to understand them and build this relationship.
And let me sharpen the question. Are we doing first aid? Somebody comes in in acute distress. Can we do something to, you know, relieve their distress in the short term? I would call that first aid. Are we trying to do something to change the underlying psychology that creates the vulnerability to that kind of distress?
You're not saying, 'Let's not talk about your panic attack. We need to be talking about your attachment style.' You're saying we can offer some first aid, but we can't stop there.
Yeah. And the answer to what... So, when I say meaningful psychological change begins at around 6 months, I'm talking about psychological change, not just, you know, some symptom relief. And what we do now often, especially in, you know, health care institutional settings, is, you know, we go for symptom relief and then consider the job done and take the victory lap knowing full, if we're good clinicians we should know this, knowing full well those symptoms are going to return again at some point down the road. You know, that's the typical course when people, for the relative minority of people with major depression who have a good meaningful response to antidepressants, right? We put them on antidepressants, they get symptom relief, they're better, but it's so common, and then the patient comes back a year later, maybe two years later, and they don't say, 'I'm depressed again,' because we never dealt with the underlying psychology. They come in and say, 'My antidepressants pooped out.' That's the word, and then begins the chase. Oh, you know, we'll switch antidepressants, we'll change the dose, we'll augment it with something else, and there, you know, so begins this, you know, revolving door of treatments that never ends.
I agree with your first two sort of factors that you think are required to train reasonably competent therapists which would be selecting the right people for the field and selecting people who are willing to admit what they don't know, get into the unknown, embrace the discomfort with the patient.
And I agree with your statement that basically if we took a high schooler with good social skills they would be able to develop a connection with a patient. I think that the second part of that productive relationship which is a shared understanding of what your problem is and what we are going to do to fix the problem, maybe this is happening like in 1% of competent therapists because I think there's such a misunderstanding even amongst the most highly trained, right? Psychiatrists have eight years of post undergrad training.
And most of it is devoted to things that have nothing to do with the practice of psychotherapy.
Right. I couldn't agree more, right? Because what is depression, right? How do we understand what depression is? Is this a chemical imbalance? Is this just a label? Is it a set of symptoms? And the ACGME and the ABPN have a lot of requirements about things that we need to learn in psychiatry residency, but this sort of philosophical understanding of are we speaking the same language? Do we have the same goal?
Speaking the same language at all. And that's the difficulty with this confusion of tongues. You mentioned depression as an example. You know, what is it? Is it a neurochemical issue? Is it irrational thoughts? Let me offer an alternative.
So, depression is the psychic equivalent of fever. What is fever? Fever is a non-specific physiological response to an enormous range of possible underlying medical conditions, you know, from the common cold to Ebola, you know, right? Fever, the same fever could be a, you know, go home, get some rest, drink fluids, you know, call me in a couple days if things don't, you know, take a turn for the better, to this is a medical emergency and you need to be, you know, hospitalized in an intensive care right now or you're going to die. But the symptom is the same, it's fever, right? Non-specific.
Depression is a non-specific psychic response to an enormous range of underlying difficulties. And right, the idea that I'm treating depression and that's the job is to me a profound misunderstanding. Because we have to say, 'Okay, but if we're going to be real clinicians, right, the job isn't to deliver aspirin. The job is, can we figure out what the cause of the fever is?' So, now to come back to your question, do we have an agreement about the purpose of the work? If it's the kind of therapy I'm talking about, the purpose of the work is to change something about oneself for the patient, right? Real psychological change. To change something about oneself that's either causing difficulties or limitations that the person desires to change about themselves and that psychotherapy could realistically help them to change, cuz I...
See people, you know, embarking on therapy all the time to address things that aren't actually psychological issues. Like, we don't know that on session one. So, you don't come up with a treatment plan on session one. What we what we need is a case formulation. And you know, what's a case formulation? It's making the link between, you know, the surface difficulties, like the fever, and what's going on, you know, under the surface that's creating the vulnerability to that. And that takes time and that takes real expertise.
And the patient doesn't come in and they're on board with that change. They don't even know, you know, where the area of change should be. Neither does the clinician. Like, so it takes some time to begin to formulate a case and basically say to the patient, not as a conclusion, but as a hypothesis, "Here's what I'm seeing. Here's what I think I'm understanding. I think this has everything to do with why you get depressed. I think if we could address this in therapy, it would make things different for you." Like, and the clinician is going to tell the patient something that likely they've never considered before. So, it's not it's not a conclusion. It's a hypothesis for mutual discussion. And now what I want is for the patient to engage with it. And it maybe it resonates with the patient and they go, "Oh my god, that's right. I never thought about it like that. I do I do do these things. Why do Why do Why do I do that?" So, like, yeah, well, I don't know why, but we could answer that together in therapy if that's what you'd like to do. So, what we want from the patient is they really take it in, they think about it, it feels like it fits, they elaborate on it and provide more information, and then we hone and refine the formulation. Or the patient says, "No, that doesn't fit. That's not my experience."
And just as good, certainly.
And we want them to, right? And then, you know, what we want is for the patient to correct us and say that's not it and elaborate on what their experience is. So, we're starting in a cyclical iterative process of offering hypotheses in very very personal experience near language and thinking about it together with the patient and the process repeats iteratively until we can home in on an understanding that neither person had when they came in. And that becomes the purpose of the therapy.
The case formulation is not a secret little expert-level series of fancy words that the psychiatrist can use to sort of put the patient in a little box and say, "This is for me. Now I understand you because I'm so smart." It's something that, A, the patient's always going to read it now in the age of open notes, but really the utility in it is that we are going to put it out in the open. We're going to shine the sunlight on it and we're going to develop it over time and we're going to see what sticks and what doesn't.
And and it's not hypothetical and intellectual. It's rooted in data, but not the kind of data we usually talk about. It's a different kind of data. Because what we're trying to do is identify psychological recurring psychological patterns, right? Sort of ingrained or, you know, well-worn grooves in the patient's functioning that are causing difficulty.
It's not a game of speculation. It's those patterns are unfolding in the session with us. Right? We're not hearing about their difficulties that are happening in another time and another place with someone else. We are an observer and a participant in those difficulties. So, there are the facts of our, you know, actual experience, interpersonal experience in the therapy room. So, you know, when the therapist says, "Here's what I see," it's not hypothetical. It's a shared lived experience. And the patient says, if you get to the character character disorder range, the patient might say, no, that's not true. I didn't, you know, that's not that's not what happened. So, well, that was your experience of it, but let me tell you what I just observed. This this this, but what happened in the room? Right? It has to tie to something that concrete.
And and of course, that's what we discuss in terms of transference. The transference is a fancy way of saying the human condition is we live out certain relationship patterns that are formed we form these patterns very very early early on in life through our earliest attachments. We continue to live them out for better or worse for the rest of our lives. We bring them into all of our other relationships. Real psychotherapy is a relationship. So, the patient brings their relational patterns into the psychotherapy relationship where we call it transference. That's where we have direct access where we can see and recognize and begin to understand those patterns. So, you know, in one way, especially for physician non-psychiatric physicians or or psychiatrists who aren't trained in therapy, it sounds very abstract and philosophical and esoteric. On the other hand, it's actually very very rooted in immediate real data.
It's very concrete in that way. I think that's a really good segue into our next section when you talked about the patient having one experience of something and the clinician having another experience of that same thing. We're going to go to break and when we come back, we're going to talk about different forms of therapy speak. I think in this case the example would be this is my truth and we'll talk about maybe how that is helpful or at times unhelpful. Stand by.
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Welcome back. I want to make one follow-up comment on the fever. I think a corollary of what you mentioned about depression being a non-specific symptom like a fever, and depression being a signal to us of changes that might need to happen in a person's life.
Same for anxiety. Also a non-specific symptom like fever.
Absolutely. And I think we could probably go down the list there. I, having experienced this myself, and I will say if I had not had that so-called fever, I would not have made meaningful changes in my psychological life, and I certainly wouldn't be the person who I am today. I think a corollary is the fever is not the enemy, right? The goal of treatment is not fever bad, fever whack-a-mole. You're having this problem, you're you're this discomfort. It's more like, what is the fever telling us, right? Is the fever unimportant? Should we even get rid of the fever? Have we done what we need to do with it yet?
And and thank you, you just gave me an opportunity to mention something that I would have otherwise forgotten. So, the thing is, patients actually understand this at some level, but a paper just came out just last year in Lancet, you know, the most prestigious medical journal of all. There was a survey several I don't have the numbers at my fingertips, but it was several hundred studies, several thousand patients, therapy patients, and it asked the patients, "What are the things that you wanted out of therapy? What are the things that you got from therapy that were most important, that were the most value to you?" And, you know, they had a a list of the things that were mentioned most most frequently. And these were qualitative. We didn't say to the patient, "Here are the things you could get out of, you know, treatment. Was it A, B, C, or D?" Right? That would just confirm the researcher's starting assumptions. It was just asking the patient, "What was of most value to you?" And recording responses and coding them according to categories.
So, they came up with quite a long list of things that patients valued. Number one on the list was insight and self-understanding, self-awareness. I think symptom remission or symptom reduction was like number seven or eight on the list. It was way far down of what patients said they, you know, valued most in therapy. So, then think about that. There's a real mismatch between expert clinicians are trying to do, what real-world patients really want from therapy, and what we study as outcomes in research, where it's like apples and oranges. We do this research and we get our findings and we pretend that we've demonstrated the benefits of therapy, and we're not even measuring the benefits that real patients want and expert clinicians are trying to provide.
Right. I think when we're critiquing this nebulous idea of kind of therapy as it is in vivo in the world around us, a medical student listening might say, "Well, yeah, that's bad psychotherapy. That's not evidence-based psychotherapy." And you are indicting that whole the whole argument of "Well, we have to be doing things that are evidence-based" because you're saying garbage in, garbage out, right? What does evidence-based even mean?
Yeah, and and this is science, right? What What's I mean, real science. Real science is not an RCT. Hey, that's that's a map. That's a tool. I mean, real science is I think I might know something. How do I find out if what I think I know is right or wrong? What do I need to do? And any research method we bring rests on certain assumptions that are baked into the research method. If the assumptions are false or indefensible, the research findings are meaningless. And you know, I would say real working scientists in the in the basic sciences or in the natural sciences, everybody understands this.
What we have in mental health, unfortunately, is we have all of these assumptions baked in and nobody examines them. Nobody says, "Hey, wait a minute. All of your findings rest on the assumption that the purpose of therapy is to lower your score on a Hamilton Depression Rating Scale." Well, that's not what the clinicians think is the purpose and that's not what the patients think is the purpose. So, in what parallel universe are you operating? In your parallel universe, these assumptions hold. In the real world with real patients, these assumptions don't hold. Maybe we're not doing this right.
