SPEAKER_03 0:03

Hello and welcome back to the Thought Broadcast, the trainee-focused podcast from Australasian Psychiatry. Today's episode will focus on a new topic area for the podcast, the psychotherapy written case. Regular listeners would know that we have previously focused on the scholarly project, amongst other topics. However, the psychotherapy written case is another important centrally administered assessment that can cause particular anxiety for trainees and requires the acquisition of specific theory and skills, which makes it a natural progression for us to discuss on the show. This will be the first of what we intend to eventually be a number of episodes that will discuss the psychotherapy written case or psychodynamic principles more broadly. My name is Michael Waitman and I sit on the editorial committee of Australasian Psychiatry. Joining me today as hosts are two of our regular voices. Firstly, we have Oliver Robertson. Welcome, Ollie.

SPEAKER_01 0:54

Oh, thanks, Michael. It's a pleasure to be here.

SPEAKER_03 0:56

We also have Andrew Amos, Deputy Editor of the Journal. Welcome, Andy.

SPEAKER_02 0:59

Hi G'day, Michael, great to be here.

SPEAKER_03 1:01

So today we're joined by a special guest. We are fortunate to be chatting with Stephen Yates, an experienced psychodynamic psychiatrist and psychotherapy educator from New South Wales. Welcome to the show, Stephen.

SPEAKER_00 1:11

Thank you for having me. Good to be here.

SPEAKER_03 1:13

No, it's great. Stephen, I wonder if maybe you could start by telling us a little bit about yourself, particularly what you're doing professionally at the moment, and also looking back on your own training journey to specialise in psychotherapy.

SPEAKER_00 1:25

Sure. I actually came to medicine from the humanities, which is quite unusual, in that I came from an education in politics and international relations, which, after a little bit of work in a hedge fund for a year of all things, which is a bit of an aside, I went to do medicine at the University of Sydney thinking I would almost certainly do psychiatry. And the pathway from there was that I was introduced to a particular person, I suppose, is where the journey starts at the Royal North Shaw Hospital where I was a student, who was a fairly interesting combination of being both an inpatient psychiatrist of virtually full-time, long-standing full-time director of a unit, who was also had trained as an analyst. And it was probably the influence of that man in my third year of medical school that was the catalyst for training as a psychiatrist. With a brief foray into obstetics and gynecology, I then took up a registrar post, trained mostly at the Royal North Shaw Hospital initially, and then that developed into a position that I took at in Westmead at the Westmead Psychotherapy Service, which is a particular psychodynamic unit specializing in complex traumatic disorders.

SPEAKER_03 2:51

That's great. That's an interesting pathway. And I imagine some of those experiences before medicine as well would be really useful and fruitful in your work as a therapist as well.

SPEAKER_00 3:00

Well, it's the intersection of the humanities. It's that psychotherapy and psychoanalysis in particular have as a long-standing overlap with the social sciences. And it's the idea that, yes, of course, there is, you know, scientific objectivity, of course, which is very important, which you know medicine emphasizes, but dynamic psychiatry in particular starts to think a lot more about the experience of the subject, and particularly through the lens of affect and what it feels like to be alive in a certain way or not alive in a certain way. But the relationship with the social sciences is that it doesn't necessarily lend itself well to um scientific reductionism in its entirety.

SPEAKER_03 3:47

No, absolutely, that's very true. That's I suppose the value of the psychotherapy written case for trainees, which is the subject of our podcast today. So we're looking to expand on your recent article in Australasian psychiatry with the the fantastic title of To See or Not To See? That is the question.

SPEAKER_00 4:05

Do you see where I what I did there?

SPEAKER_03 4:07

Yeah, no, it's a it's a lovely pun. It's it's fantastic.

SPEAKER_00 4:10

About the most obvious quote from uh Shakespeare as I could have come up with, but yeah.

SPEAKER_03 4:17

Obvious ones, often the best ones. But but so where did the idea for this particular paper come from?

SPEAKER_00 4:22

From working as a psychotherapy educator and also from my own experience doing the case, but also in my work as a you know full-time or near-to-full-time dynamic therapist, I started to make the observation about how different the patient population was that you encounter in the private sector as distinct from those who you encounter as a registrar. So the sort of core observation was that you have this completely paradoxical situation where paradoxical is actually the wrong word. It's counterintuitive, is probably the better way of putting it, that registrars are engaged in, for the most part, managing the sickest patients. You know, there's people detained under the terms of the act, severe disturbances in mood and thought form, and major disruptions in behavior. This is not everybody, of course, but it's it's a good deal of it. And very little exposure to what you know might be called either high prevalence disorders or disorders that you much more commonly encounter in the community. So, for example, when I left training, I had done a number of psychotherapy cases, but as a registrar, so when I left psychiatric training, that is, and I remember remarking to somebody that I had never seen a patient in psychotherapy who had not attempted suicide. Whereas you go into the community, and this is common to not see patients who have an attempted suicide. Now, as a measure of severity, that's really striking. So the observation was that you're training on the most difficult patients often. I also then made the observation that there was this inherent tension between the need to finish the case, get a punter, as it were, and to also make sure that this was a case that had a reasonable chance of continuing and succeeding. So it came out of my own being struck by this contrast in the difficulty of patients and my wish to kind of impart some of my thinking around this because the area of assessment is a very vexed one in the literature, and people are not so inclined to make declarations, and I guess some might criticize me for making the declarations that I do.

SPEAKER_03 6:28

Just to jump in there, Steve, what do you mean by assessment in terms of the psychotherapy written case? Is this sort of the write-up portion of it, or are you referring to something else?

SPEAKER_00 6:35

No, I'm not referring specifically to the case as far as the college is concerned. I mean assessment in dynamic therapy. There is a whole literature on so-called analysability and on who can be treated with dynamic therapy. It's in quite a deep literature. Whole books about how to begin, for example, and who you might begin with, and chapter after chapter of textbooks dedicated to it. It came out of an observation that there was a deficit in the literature on it specifically for the long case, that nobody had written, I don't think, maybe there are out there that I didn't find, that on that question about who should be seen for the long case.

SPEAKER_03 7:10

Yeah, it certainly makes it a very useful topic. Just on the literature more broadly, I mean, in your article you referenced Glenn Gabbard's Psychodynamic Psychiatry and Clinical Practice, which is a text that registrars will often turn to as their introductory text for the case. Is that the go-to one that you would suggest? Or are there other ones that um would be of value for novice trainees in this area?

SPEAKER_00 7:33

There's a book called Essential Psychodynamic Psychotherapy, I think is named by Terry Quatman, Q-U-A-T-M-A-M, which I think is very clear. There's also I think it's called an Introductory Text for Psychodynamic Psychotherapy by Alessandra Lemmer. The title I'm less clear on, but the the author is definitely Alessandra Lemmer. Both, I think, are very clear texts. I guess it also helps to elaborate that with what one shouldn't read, you know, and I think what isn't particularly helpful are huge amounts of primary sources of early theorists. Um, in my analytic training, we read Freud over many, many months, you know, and a lot of historical context that needs to be understood in order to make use of that. You need something that's been synthesized. I think whatever it is, it's got to have been synthesized.

SPEAKER_02 8:26

I think the best description of Freud is that he was a great novelist but a lousy scientist.

SPEAKER_00 8:30

Oh yeah, and I mean that's an interesting way of putting it. And I've certainly come to enjoy the writing much more as I went in to read it, and some amazingly prescient things, you know, things that are still true to this day. So, you know, the one that comes to mind is the in one of the technical papers, he says, Oh, you know, beware the patient who wishes to start at some distant point in the future. You know, that comes somebody comes in and says, Oh, yeah, I can't start now, but I'll I want to start in in September after after my dog's been spayed or whatever. He said, These patients never turn up. And this is actually the observation, both as a supervisor and as a clinician, that this is amazing how predictable that is. And good on him. I mean, he made some incredible observations.

SPEAKER_02 9:16

Maybe jumping ahead a little bit, we were going to talk about this down the track. One of the things that has changed, obviously, in being a psychiatrist is that it used to be expected that you would go through your own course of analysis before you became a psychiatrist. We don't do that anymore. I was reflecting when you were talking about the most difficult patients being the population that we select from for our case. We also don't really start from a position of good self-understanding. And I was wondering if you had any thoughts about that.

SPEAKER_00 9:46

Well, I mean, it's got an enormous number of thoughts about it. I mean, personal analytic experience, personal therapy is still central to most postgraduate psychotherapy trainings. So it's certainly a big part of psychoanalytic training, it's a big part of some of the trainings that emphasize lower intensity treatments as well, which there are a number. The whole idea is that if you look at the you know what might be the four or five central elements to training as a therapist, it's personal therapy, supervised clinical work, some sort of a theoretical framework, some knowledge of theory, infant observation, and the group experience. Now that the last one is that trainings are often done in groups because you need to sort of work out where you are in a group. This is the one that sort of takes the longest to get your head around, that by being in a group process, there's something that's brought out about that. Um, but I mean you're absolutely right. The individual therapy is still such an important dimension because your development as a therapist is broadly congruent with your development as a person. I've not I've not been able to find a better way of putting it. As unsatisfactory as that is, I I haven't been able to put it any better.

SPEAKER_03 10:56

Just going back to the challenge of finding suitable patients in the public training system. I'm just curious, with your own practice, Stephen, where do you get referrals or or patients finding you from?

SPEAKER_00 11:06

How do people Mostly other psychiatrists? An occasional person contacts one directly from your presence on some sort of directory, whether it be a directory of therapists or a directory of psychiatrists or something, but mostly from other psychiatrists. And it's unusual to get a referral from general practice, at least in my experience. And I think that's because psychodynamic therapy is, in my view, wrongly often seen as some sort of treatment of last resort. I think this is a sort of general comment, it should be employed broadly earlier in most people's disease trajectory to rather than something that you get to after sort of everything else has failed, which is one of the issues with referral pathways, I think.

SPEAKER_02 11:50

Do you think that that treatment of last resort might be a misunderstanding of what the nature of psychoanalytic psychotherapy actually is? It seems to me that a lot of uh what we think of in the acute and public setting is emergency treatment, really, and anything that we can refer someone to that takes them another step down the track, that's what we're going to use, whether or not it's indicated. But psychoanalytic psychotherapy, that's not really the purpose. What what would you say is the purpose of a course of psychoanalytic psychotherapy?

SPEAKER_00 12:20

Broadly speaking, to assess issues in development. So dynamic therapy's key indication is in issues of development that there is an alongside patient motivation to explore their own development and their inner life, which may be ambivalent at first but hopefully increases in the course of treatment, is to develop some sort of understanding and modification, transformation of the emotional processes that took place in early life. There's also a role for issues that are currently taking place. One might think of something like a workplace issue, and the observation is that these are often able to be linked with something that has gone on in early life and reminiscent of some problem. So it is also the observation that trauma tends to be more prevalent amongst people with a disrupted attachment. It's so later traumas are experienced differently, and that that's observable, and also that the role for dynamic therapy is can be in addressing the intersection of those factors.

SPEAKER_01 13:25

Stephen, I'm I'm thinking this is a good point to jump in and I suppose bringing it back to the article that you've written, which is really, I think, fantastic from a trainee perspective. The psychotherapy written case, and look, I'm paraphrasing and giving my own interpretation, but for trainees to have experience in a in a longer form of therapy and get some practical understanding or engagement with those issues of development so then they can apply them to their broader work wherever that might be within the broad umbrella that we all sit within. I think your article is going to assist a lot of trainees in ensuring that or maximizing the chance that that psychotherapy written case is a productive experience and not something that ends up being either too difficult or sort of falls apart and becomes really tricky from there on in. I'm interested, can you tell us a bit more about what you would define as, say, an unsuitable versus a possibly suitable patient?

SPEAKER_00 14:19

Uh here I am, this has to have a little caveat. I'm not making a declaration about suitability for these patients in some general sense. I'm making it as a declaration for the long case. So that hopefully that's clear in the article that call me old-fashioned, but I think you should start on easier cases. The more straightforward case increases the probability of a good experience. That's my argument. The cases that I would say are unsuitable, if you want to make an umbrella comment and then break it down, those who have either a sort of fundamental deficit in thinking, so somebody's acutely psychotic, somebody who has such a severe disturbance of mood that they have almost no capacity to exercise executive function or judgment, somebody who's so severely on the autistic spectrum that it becomes impossible to engage them in an exchange that's sort of prototypical of dynamic therapy, and patients who are so prone to acting out that they can't participate in the exercise. So the necessary conditions for dynamic therapy are the frame, which has to be built and maintained by the clinician, in this case the registrar, and creating the conditions for thinking, uh, you know, creating the conditions for the management of development of new affect states, new new thoughts, new feelings, new ways of being. So when I make my claim in the in the paper that I say that patients who are severely acting out in some sort of forensic way, who are predatory or pose some sort of risk to the clinician, shouldn't be seen as a long case. It's a question about whether there's a literature of doing it in some other setting. Leave that aside. Patients who are intoxicated, by definition having some sort of impairment in their capacity to exercise frontal functions. And this comes from the premise that what is a dynamic therapy? Well, it's about creating more extensive and sophisticated links between frontal systems, basically the frontal architecture, the architecture for thinking, expression, language, and judgment and so on, and emotional systems which are subcortical. So the bit that's above the cortex starts to interact. Some of my colleagues have said in conversation with, that's fine with me, you know, in conversation with affect systems. It's not about intellectual understanding, it has to reach affect, it has to reach an experience in some sort of emotional contact, but it then also has to be integrated with other frontal ideas. This is why you hear bandied about in dynamic circles notions like insight and so on as being very important. And it's that the idea is that there's been some capacity to express an emotional state in a framed environment. So those who are not suitable at all can prospectively be assessed to be highly improbable to be able to participate because they either act out too much or they're not in a state of mind that means that they could possibly think.

SPEAKER_01 17:24

Yeah, no, absolutely. And then I suppose the second part or the backup question would be what defines a likely suitable long case in your opinion?

SPEAKER_00 17:32

In my opinion, a likely suitable long case is an individual who has some functional capacities, so they have been able to participate in work social functions, such as they might have been able to have a successful relationship, for example, or do some sort of higher education, and notwithstanding having symptomatology of some sort, which almost certainly is why that brings them to therapy, and has the capacity to adhere to a frame. And now what is work? Work is a frame, what is school? School is a frame, what is uni? Uni is a frame. What is marriage? Marriage is a frame. You see where I'm going with this. I I only have one drum, you know, and I just keep sort of saying that all these are frames, and what do they mean? Well, they mean that there's a capacity to participate socially, and the dynamic therapy exists in manifest reality insofar as somebody has to rock up to sessions and has to be aware that there's a thing called a clock. And now, not that there won't be tensions around these things, there often are, and that's normal, but that there is a sort of basic acceptance of this sort of social trade-off that goes with it. That that has to be existing, I think, that capacity. And the therapy can expand it.

SPEAKER_03 18:49

You mentioned about using the global assessment of functioning uh as part of that assessment for suitability in the paper. For registrars who are not so familiar with DSM4, can you tell us a little bit about how you use that particular tool?

SPEAKER_00 19:01

Yeah, the reason I picked this tool is because one of the items under Medicare that specifies the indication for certain intensity of psychotherapy uses the global assessment of functioning as one of its metrics. That's the history of that. So I picked it. Now, people criticize this tool, of course, and fair enough. I picked it because I happen to think that function is a very good measure of suitability. And the global assessment of functioning makes basically a zero to one hundred scale that has, I don't know, some sort of superhuman at 100 and sort of people with increasing levels of difficulty in their global functioning all the way down to something like acute psychosis or or whatever the psychic equivalent of being moribund is, and everything in between. And the observation is that somewhere around 50, we sort of make the intuitive judgment that an individual is sort of more functioning than not, insofar as they have some relationships, have some job, some sort of participation in the external world. That might be a retired person who does a bit of charity work and managed to remain through their life but had really major difficulties in their early life, they still have reasonable functioning in some global way. And the claim is that an individual who has almost no other ancillary capacities, so they don't do anything, or have such impairments in their social or occupational functioning, will be too hard for a registrar. Not that they're again, I'm not making a claim here about whether they're too hard in general, that's a different argument. For if it were my registrar, I would say I don't want you to spend your life that way trying to convince somebody to come to sessions or you know have to have such a sophisticated technique that you're trying to remove the impediments to coming to sessions, for example. And that's too tough.

SPEAKER_01 21:01

I was gonna ask Stephen on that point. Um do you think it's worth when a registrar is preparing to commence their case, do you think they need uh supervision to begin before a patient sort of comes on the radar and and an assessment is done? Or do you think a registrar could go out of their own volition and find a patient, assess them and then seek supervision? Would you would you make a recommendation around that?

SPEAKER_00 21:25

Supervision beforehand. I think if you can, and you know, there there are certain things that are don't respond very well to didactic teaching, and there are things that do, and one of them that does is some sort of instruction on the technical aspect of how actually to do it. So, you know, I I would say that it's it's of substantial importance how you find the patient, what your first type of interaction is with them, how you make the phone call or initiate the contact. And some of the people that I've taught have needed some education about. Why to be relatively socially constrained or socially restrained in some of your interactions with patients and what the purpose of that is. It might not be clear in the first instance why using smiley faces in an email might not be all that helpful for your course. There's nothing wrong with a smiley face in other settings, but it's a sort of a time and a place kind of a question. And I think that could be taught in the abstract.

SPEAKER_01 22:24

Yeah, look, it's certainly my experience was that having supervision before the assessment phase was very helpful. I I assessed at least one patient and did not proceed with the therapy, and I think that was the right decision, but I may not have made that decision without the supervisor's influence. So certainly from my own point of view, it was it was helpful.

SPEAKER_00 22:43

I should also say to your previous question that of the patients who present, because the the the very antisocial patients or severely narcissistic patients quite that don't necessarily present very often, but of the patients who present who are the least likely to be able to be helped by dynamic therapy in the immediate term, but still present with difficulties that look on the surface of it to be dynamic in origin, are those with addictions. So my experience is that it's very, very common for somebody with an alcohol use disorder or something to have a developmental problem, but it is nigh on impossible to treat in dynamic therapy somebody who's got an active addiction. It's attempted, there would be people who would disagree with me about that, of course, and they'd have a point. I've certainly tried it, but there's the observation is that you have so much influence from the change in the mental state, from the presence of some sort of substance and the total disruption of the reward-firing pathways that it is very difficult to execute that. A past history of addiction, different question. That's my possibly suitable category. Maybe, you know, it's somebody long-term sober, a history ten years ago of you know heroin dependence or something. I'd be more open to those questions. But that's the group most likely to present.

SPEAKER_03 24:02

Yeah, and we haven't talked so much about that possibly suitable category yet. What is it that would likely sway you one side to another in terms of suitability for current functioning?

SPEAKER_00 24:12

Current adherence to social frames.

SPEAKER_03 24:15

Is this preferably over course of years, or is there a particular length of stability that you're looking for?

SPEAKER_00 24:20

Case dependent, and I think you're only that I don't think there is a metric for that. I think it's intuitive. Uh, but I'm thinking of these are sort of a composite case, if I have to put a number of different ones together to sort of give you an example, that is somebody who had, you know, a lot of severe acting out in early life sort of a couple of decades ago presents for therapy in their 50s, but probably would have satisfied criteria for an addictive disorder of some sort and a you know borderline disorder in their twenties, I would put that in the in the possibly suitable. Because it the on the face of it, lots of acting out and addiction one might say is unsuitable initially, but the shift into the middle category with a case-dependent examination of the circumstances will tip you in favour of being more open to it.

SPEAKER_03 25:10

I guess that speaks to the value of supervision as well, having someone who these issues can be discussed with and getting that counsel from someone who's done it many times before.

SPEAKER_00 25:18

There's no substitute, and it's not a need that goes away either. That it probably becomes less intense the need from early on, but supervision has a role for established clinicians, and it gets to the idea that sort of everybody needs another mind at some point that you don't neither aim to become nor do you get some sort of perfectly integrated. I'm thinking of a kind of isolated brain in a bottle or something. You don't become a kind of perfectly self-reliant unit. There are always things that you miss, and that you miss them by definition, because the the nature of things that you miss are missable, and that this is why that need is ongoing. It just diminishes in its intensity.

SPEAKER_02 26:02

I don't know, this may not be a brief one, but I worked as a director of training for a number of years, and a particular patient group that seemed to cause problems were patients with dependent trays. And the angst, of course, didn't come until the end of therapy when we were trying to separate, and this caused quite a bit of distress. Do you think that this is a bit of a siren song? A dependent patient comes in, and you know they're going to turn up for that 40 sessions, but of course they're going to want 80 or 120.

SPEAKER_00 26:31

Yes. You know, I read The Economist, and I hope your listeners don't switch it off right now just because of that. But I read The Economist, and they have this section on style, and in that they say, um short sentences are best. It's a quote from one of the writers. And I often think to myself, well, what would I say in dynamic therapy? Separations are resisted. This is something that happens, you know, and it's it's not exclusive to dependent trades. I mean, there are all sorts of separation resistant behaviours that happen. Anytime you try and leave a telco or get foxtel disconnected, you'll be aware of separation resistance from large organizations. We we don't like this process. It's sort of inherently wired up to be in groups and to to resist it, saying bye a million times before you hang up the phone. And there is a group of patients, of course, this is really hypertrophy. That's what you're describing, that there's a you know an intense need for a certain emotional and social contact, which there's also usually a concomitant fear that it's that that nobody will ever want the patient, or that there's something that's sort of a terrible anxiety that will never be quelled, or something. And my first general comment is that separations will always pose a difficulty. Endings are rarely easy if there's been some sort of a real contact made. So if you manage to slide by without making any real contact, it might be relatively unremarkable. The second part of that is in those patients who are very separation sensitive, it has to be handled over a longer period and it has to be paid, a lot more attention paid to the nature of the separation, the so-called termination phase and how that's handled, awareness that it's going to be have an effect on the patient. And then we need to realize that it's also difficult for clinicians to end sometimes. It can give rise to things like guilt and to lots of feelings around stopping. But to answer your initial question, no, I don't think we shouldn't treat these patients because often some of the most tractable insofar as they get something out of the therapy by having an interaction that does extend a little bit longer. So I would say, no, it's not a it's not a category I would exclude because the anticipation of a difficult ending, I would get better at managing endings. How does that go as far as far as answering that?

SPEAKER_02 28:53

Oh no, ideal, yes, you have to be thinking about the end at the beginning. And this is where this is where having a good relationship with a supervisor comes in. I would just add to what you said about supervision that you should have it before you start looking for a patient. The most successful programs I've seen actually had group sessions as well where you get got to see other people consider patients who that they might see and hear other people's assessments and so on.

SPEAKER_00 29:19

Yeah, most of the um postgraduate psychotherapy trainings, you know, the Institute of Psychoanalysis, for example, or or the other equivalent bodies in the various states, they they all have a group process that starts very early. You know, there's more than one reason for that. Seeing other work is one part of it. It's also getting to know who you are in a group, which is something we alluded to at the beginning. But yeah, I I I agree with you. And that that you seeing other work is tremendously helpful, both what to do and what not to do.

SPEAKER_03 29:48

Absolutely. So, speaking of endings and separations, this is probably a good time to wrap up our conversation for today. So, Stephen, thank you so much for joining us and giving us your time and wisdom on this really important training topic.

SPEAKER_00 29:59

It's my pleasure. It was lovely.

SPEAKER_03 30:01

Absolutely, and it would have been really useful for myself back when I was studying my case to have access to your article. So I'm sure it would be very useful for trainees who are getting to that point of their training journey currently.

SPEAKER_00 30:12

Yes, I can't send it back to myself either. To my great chagrin.

SPEAKER_03 30:20

And big thanks also to both Ollie and Andrew for joining me as hosts today. Yeah, thanks, Michael.

SPEAKER_00 30:26

Yes, thanks for helping interviewing.

SPEAKER_01 30:27

Yeah. Oh, it's been a pleasure. Thanks so much.

SPEAKER_03 30:30

We'd also like to acknowledge David Beale and Nishda Kuma from the college who give us so much support in producing the show. Lastly, we thank Australasian Psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shady Day for our music. We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrars or supervisors. We always love getting feedback or suggestions for further episodes. Please get in touch by email at thethoughtbroadcast.podcast at ranzcp.org. That's all for now. My name is Michael Waiteman. Thanks for listening. We'll catch you next time.