Psychiatry & Psychotherapy Podcast - Dr. Robert Feinstein Learning Psychotherapy

Episode Date: June 24, 2022

On this episode, Dr. David Puder and Dr. Robert Feinstein discuss the journey of becoming a good psychotherapist and how to increase one's skill in the realm of psychotherapy training through the cognitive apprenticeship model. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Dr. Pudor and Dr. Feinstein have no conflicts of interest to announce. let's start the show. All right, welcome back to the podcast.

I am joined today with Robert Feinstein. He has been on a prior episode with me on personality disorders, and he's coming back today to discuss how to become a therapist, therapy supervision. He has written an article, which I will link in the show notes called Descriptions and Reflections on the Cognitive Apprenticeship Model of Psychotherapy Training and Supervision.

And more than anything, I think he's, he's thought a lot about how do we train future therapists and psychiatrists who want to be therapists, other mental health professionals who are wanting to grow as therapists. And I think he's thought a lot about that. He's built programs around that for different residencies. And so having him come on and talk about what our best practices, how we could best go about doing this. And so welcome to the podcast. Thank you very much. Pleasure to be here again. Yeah. So before we started, we were talking about how you've had some people reach out to you for supervision from Australia. Interestingly, Australia, and shout out to all my Australia listeners.

I feel like it's just a great community out there of very highly interested people and becoming experts and such, so that's awesome. Yeah, so how do you want to begin? Maybe how you got started with interest in this? So I got interested in it because I felt that psychotherapy as a major part of mental health training was on the wayne and for psychiatrists was being was being they were giving it up and being turned over to social workers and psychologists and I felt that all of the mental health professionals should have the skills and ability to do psychotherapy and I wanted to maintain those skills focusing initially on on psychiatrists but eventually focusing on any mental health professional who wanted to be trained.

And I got started on this in about 2013 when I was at the University of Colorado, and we developed a specialized psychotherapy scholars' track within the residency, so that over a four-year period with specialized courses and supervision and communities, residents could come out of training knowing really well how to do two sometimes three sometimes even four different modalities of psychotherapy with patients which is what i think the current practitioners need to be able to treat a wide variety of patients yeah so you were developing a special track and this is something that you know our residency that i've been involved in also we try to do it for all residents so we try not we

don't have like a special track but I'm curious what's been the response like how often do you have residents that get excited about this so it's been interesting that's been yeah that's been really interesting the the initial time when I started it I couldn't get any residents none of them were interested in that when I started back in 2013 and then I coaxed two residents that I was supervising to join the clinic and They joined it. They joined the training for a year, and they loved it. And then in the second year, I had six residents apply. And by the third year of the program, I had all the entire residency interested in it,

which amounted at that point to over 30 residents. And the problem was we couldn't manage that number of people with a model that's this rigorous in terms of supervision. So we offered it to a subgroup who wanted to do it for four years. and then we opened up different components of the program to anybody who wanted to join. So people could join the didactics, people could watch your supervision. The rate limiting step was getting enough supervisors to cover that many residents. Yeah. Yeah, it's hard to find good supervisors. Good supervisors can usually charge quite a bit for supervision.

So it's hard to sort of coax them into the residency sort of capacity of this is how much we can pay you. I don't know if that was. Sure, it was that. It was that. But probably more importantly was that the particular kind of supervision that I was trying to teach was live supervision with residents. And faculty who had experience in group and family therapy had. no problem doing live supervision because they always work with a couple of people and they do a lot of live supervision with trainees anyway. The psychoanalysts initially had a lot of trouble with

this, this idea of live supervision. And folks who were new to supervision also jumped on it and really liked it. So depending on how many years they were supervising and their concerns, only about 30 to 40% of faculty actually expressed interest in this model, in part because when you do live supervision with a resident, they watch and make mistakes. A lot of faculty were concerned that they would lose self-esteem because they didn't feel that they themselves were that good at psychotherapy. They were worried they'd be just.

judged by the residents. And so a lot of faculty steered away from it initially. And then as the groups grew, more and more faculty joined over time. Yeah. Okay. So live supervision. Can you describe what that is? Sure. So it's based on a model that's called the apprenticeship model of psychotherapy, the cognitive apprenticeship model of psychotherapy training and supervision. And I'll just mentioned the four parts of it, and then I will talk a little bit about what live supervision looks like. So if you want to develop a psychotherapy training program in any setting, I think there are four components that I focus on. The first is helping people gain the content knowledge that they need to get. That means they need to learn about the common factors across all

forms of psychotherapy. They may need to learn something about the schools of psychotherapy, CBT versus DBT versus psychodynamic. And within each of those schools, they need to learn about the strategies, tactics, and interventions that they can use that are associated with each school. And that's cognitive knowledge. That's just sort of the didactic part of the training.

And then there's the supervision, which I'll go into a little bit more. And there's a model of supervision that I think really helps supervisors and we can talk about it in more detail, but just to run it down, I think when you're modeling live supervision, you want to model it with a student, you want to coach them,

you want to be asking a ton of questions about what you did and what they did and why they did it. You want to have them reflect on the process and you want to try to have them explore different kinds of interventions and different kinds of therapy with different kinds of patients over a period of time. So that's sort of the second component of the model.

The third component of the model is how do you sequence the training across number of years? Whether they learn first, what do they learn second, whether they learn third. And this is an area of much controversy. I think most of us would agree that people should start learning the common factors across all psychotherapy. But then you hit the issue of, what are the kinds of therapy that you should teach in what sequence? So should you teach CBT first?

Should you teach psychodynamic? Should you teach empathy forms of therapy first? So it gets into those questions, what modalities to treat. And then there's also the issue of patient complexity. I think in many programs we give trainees patients that are just too complicated to start. So we do better if we gave them a patient who had one problem like depression or one problem like anxiety instead of what typically happens, which is they get patients who have bipolar disorder, personality disorder, panic attacks, and an eating disorder.

And we ask them to treat them too complicated for trainees to begin. And then you want to think about whether you want your training to be a few patients that they spend a lot of time with or a lot of patients that they see over shorter periods of time. That's a depth versus breadth conversation. And then, of course, thinking about special populations and special kinds of training, so eating disorder patients or alcoholics or other patients who are in special populations may need specialized psychotherapy training. And the last part of a comprehensive program is really the learning environment that you

set up. And you want to make sure that where you're teaching psychotherapy fits with the learning environment. For example, you don't really want to be teaching psychodynamic psychotherapy on an inpatient service where the length of stay is five to ten days. That doesn't make sense. You don't want to be teaching, you might want to be teaching short-term brief interventions if you're on a consultation liaison service. So really match the learning environment to the kind of psychotherapy that you're trying to teach becomes really important. And also, it's really important to have a community of practice. And that's where you're working with a bunch of people who all are doing and learning psychotherapy. And that community of practice includes supervisors and trainees

and a program that you're in. And then mostly you want to foster a lot of peer learning in peer supervision groups where people who are learning psychotherapy can teach. their peers and vice versa and those are sort of the four core elements I think of a of a top flight psychotherapy training program yeah that's good no it's good I um I think I've I've thought about these things as well you know it's like what what do you teach first I tend to start with the empathy we teach a lot of like therapeutic alliance stuff the core common factors What's the first thing that you guys teach, what psychotherapy sequencing do you guys use? So we emphasize the common factors because when you look at common factors,

they account for about 90% of the outcomes. And I think trainees get caught on, I don't know how to do CBT, I don't know how to do DBT, I don't know how to do psychodynamic. And it turns out that the specific school that you use, only accounts for 12% of the outcomes of psychotherapy. So it's the common factors that account for 90% of your effectiveness as psychotherapy. And when you teach the common factors, this is very reassuring to trainees because many are the common factors they already know how to do.

These are such things as teaching them about giving patient hope, setting positive expectations that they can make change. patients can change, doing something, learning about something that's called the Horthon effect, which is that people do better when you observe them, even if you don't say anything. Just the process of observation makes people do better. Again, a common factor.

And then other things that we focus on are what are therapist characteristics that lead to good outcomes and what are patient characteristics that lead to good outcomes. And then the alliance, really focusing on the alliance, which accounts for about 35% of outcomes of psychotherapy. And the one that people don't think about very much is what we call life effects on psychotherapy. So there's a lot of patients who get better while we're doing psychotherapy, but not because of anything we do, but because of important life events. So for example, if you're treating somebody and they get married, while you're treating them, their life may get better. Is it because you're doing psychotherapy or is it because they got married? And the same thing

happens in the reverse. Some patients do very poorly, not because of anything we've done or not done, but because life events drag them down. So you want to be thinking about that so you don't take too much responsibility for outcome because some of it is determined by these common factors, but some of it is determined randomly by the events in your patient's life as you're treating them. Yeah, yeah, that's good. I think, yeah, so we start with common. Therapeutic Alliance, we kind of group that into common factors. I think some of the common factors kind of play out in there for me a little bit more,

like or how I define therapeutic alliance. A lot of the common factors sort of maybe go into there. Like how do you create meaning? How do you hope or how do you look? look at your own transference or countertransters, how do you work through negative feelings? Okay, so that's where you start. And interestingly, so one of the things that I got from a resident one year is that, you know, go through this whole therapeutic alliance common factor sort of curriculum, which is like,

for us, it's the first year. It's the first like eight two-hour blocks of the year. So once a week for two hours, we talk about these things. get to the end and this resident says to me like man i wish we learned about specific psychotherapies more like i feel like i would have really been helped by that and i kind of had this like fist to the head moment of like wait a minute like don't you get like how many times do i have to try to explain that like 80 90 percent of outcomes are these common factors that we're just we just went over this you know but like i feel like sometimes residents they really want like this like

give just give me like the CBT manual Dr. Peter like just teach me how to do like this specific type of therapy so I can feel confident that I know how to do something you know I don't know do do you come up against that at all absolutely absolutely so they they it seems too simple you know that they know the common factors so they want the more advanced the more advanced features but it turns out that it takes some practice to use common factors how do you instill hope how do you set, especially when cases are difficult and patients aren't better, how do you get them home? How do you set expectations that they are going to get better? I mean, I take the position when I'm training, but also with all patients, that there is no patient, I can't help,

but I have to define very carefully what health means. So for some patient, help means get them into a day program. And for other patient, help means resolve a conflict. And for other patients, help means figure out how to negotiate things with their family. But philosophically, I take a position that there's no patient we can't help. You just have to define what help means. And I know that you can add something to every patient's life, sometimes really small things and sometimes very big things. Yeah.

Yeah. So it's like what is the biggest win for this particular person at this particular time, right? Yeah. And it looks, it's, it's, that is often very intuitive and it's, you know, sometimes I'm telling people things that I've never told anyone else, right? It's like, like, okay, your biggest goal is friendships. Like, how do you establish some friendships? Okay, what's getting in the way of that? Or where do you find these people? Let's find that. That was a recent, that was a patient this morning. Okay, so we have, we have the sequencing. I'm curious, like, what has been, do you think the biggest win with, with rolling out this. program for you? For me, it's watching the trainees light up as they feel their learning. I mean, live supervision is a wonderful experience for residents. I have had many a resident after a round of 20 sessions with them, seeing a patient together,

have them say that it changed their whole idea of what psychotherapy was. and also really help them develop a sense of competence. So it's really been the supervision with residents, and the way it's changed the trajectory of their careers because many of them thought they were only going to prescribe and do neuropsychiatric things. And now all of a sudden they light up and they say, wow, psychotherapy is really important,

and it's something I can learn. And that's been the most gratified. find part of it and part of my mission is to keep psychotherapy alive and well in training programs and available to the patients because that's a lot of what patients want. They really want to talk out their problems. It's not all about medication, although medication is real useful. Yeah. So what would you say to like a resident who says to you like, well, why do I need to even understand this? I'm just going to prescribe medication or I'm just going to, you know, this isn't something I'm going to do ever in my career.

So I'd make the case that to be a good medicate, a good pharmacologist, you have to know something about psychotherapy. Because the patients won't take the medication if they don't have a good relationship with you. They won't weather the side effects if you can't explain the process. and they won't settle into accepting help unless they feel that you care for them. And the only way to do that is to learn the empathy and the communication strategies that are embedded in psychotherapy. So even folks who, the best psychopharmacologists are the ones who know how to do supportive

psychotherapy and meds. Those are the best psychopharmacologists, the ones who just prescribe and are in and out in 10 minutes you know, they don't work that well and the patients don't get side effects and they don't have someone who they feel understood by. So to me, you can't do any other part of psychiatry without having psychotherapy at least a part of it. It doesn't have to be the primary part of it, but at least a part of every interaction with every patient. Yeah, and I say to residents, like, don't wait to practice psychotherapy until you're in your third or fourth year. if you, you know, like every patient interaction, you meet with someone in the ER, like,

can they feel heard and seen and understood in a way that they might not have been before? Or like, if they share any emotion, can you empathize with that emotion? So we do like continuous case conference all year round. So we watch videos of the residents doing therapy. We do this once a week. And I've been doing this for like 10 years now or so, you know. And so we watched them do. these interactions. And as third years, just starting out, like, sometimes I can watch 10 minutes

without any empathy, which you would imagine, like, most people think of themselves as, like, I'm empathic, right? But then when they get to their fourth year, because I think I've drilled it in and they're annoyed by how much I drill it in, you know, by the fourth year, it's like maybe every minute you can hear something empathic coming from their mouth. You know, even if they're doing CBT or if they're doing psychodynamic or if they're doing some more like DBT type stuff. Like you can still hear the empathy come through more and more often and more consistently. So I think first thing that I'd like to convince people of is that just because they think that they're empathic doesn't mean that a patient will share an emotion in a situation and then

they might not, the patient might actually not get anything empathic back. And so that's one thing that like I feel at the at the bare minimum I want every resident to walk away with it's like how do you read people more accurately and apathically respond to them I don't know any thoughts on that yeah I mean I think when you do live supervision so here's this here's a story that happened I had a resident who was seeing a patient and the patient took a history and the patient started to talk about the fact that his mother died. And the resident was feeling some time pressure and the patient got a little teary. And then the resident moved on and asked about sleep questions. How are you sleeping? And did, went down the DSM checklist. And because it was live supervision, I could say to the resident,

could you back up a minute? Did you notice that the patient was crying? And could you back up to that minute and ask about that. Now, are you in the room? Are you, or are you, like, texting the person? I'm physically in the room with the patient. I can't get the sound physically in the room with the patient. It's the three of us, or since COVID physically in the virtual room, the three of us in a virtual. Right, right, right. Since COVID. And that does exactly what you're talking about, but it does it in the moment. In the moment, yeah, I like that. Where there's a patient there, and you can watch the patient be transformed from what they were doing and now being heard, and then the whole relationship warms.

So it has an immediacy. Yeah. Yeah. So we do that every like Wednesday. We have like, or we try. I think it's about for the residence third and fourth years. It's like two afternoons a week, basically. They'll have the attending come in.

Usually it's only for like 10 to 15 minutes of the session. So it's not the whole session. So you're saying you're in there for the whole 50 minutes doing co-therapy? I'm in there for the whole treat. Okay. Let me describe that a little bit. So you can use this model for any form of psychotherapy. And here's the general idea.

And I do this as part of an hour a week supervision. So when I'm doing it, this is my supervision. Life supervision is the one hour a week I meet the company. So it's not extra time. it's just changing how you use your one hour of supervision. And here's the way it works. There are three parts. I say to a resident, first find us a patient that you'd like to see together.

It can be a brand new patient that you've never seen before. Or it can be a patient that you're struggling with where it's not going well, either of those. And sometimes I help them with personality disorder patients because they're really difficult group of patients. And then I ask them to explain to the patient that I'm going to join that a professional that a supervisor, a senior person in psychotherapy, is going to join the sessions, and that we're going to meet anywhere from 10 to 20 sessions. That's what the patient is told.

And is it okay with you if the supervisor joins? And sometimes the residents say, well, no, I really, I mean, the patients say, I really don't want that. But then I have the resident described that, you know, I do have a supervisor, and I talk with my supervisor about you every week. you might as well meet them. And this usually convinces the patients to accept this as a voluntary treatment. And they're also told that if they want to stop it at any time, they can. So it's totally voluntary and it's patient consent. Then when we get into the sessions, the sessions are there, if you think about, say, 10 sessions is an example. It's divided into thirds. So the first third of the

session, of the sessions, so three sessions about, I take the lead. I do the, I do the, the initial intake on the patient. I'll work through a case formulation. I'll discuss treatment options, and I will begin the psychotherapy. And I'll do this with the resident in the room with me. And I say to the resident, if you would like, you join in at any time in the conversation. But I asked them to follow my lead. So this is sort of the part of the treatment where I'm modeling for them one way to do this, one attending. Because I think what residents don't see is how we work. They see us supervise them, but they don't get to watch people who've been doing this

for years with different styles and stuff. So that's the first sort of third of sessions. I tell the resident that in the middle third, this is going to switch around. And now the resident takes over the psychotherapy. And I'm quiet. I sit there with the resident, I listen, and if I think there's something I can help the resident with in a session, I may make one or two, maybe maximum three comments to redirect the therapy if it needs to be, to just draw their awareness to a dynamic that's happening, draw their

awareness to something the patient said that was missed, draw their awareness to patient affect, whatever it is, I may do that. But really small so that the resident really feels like the resident is running the case, soup to notes. And then what happens in this, and each of these sessions with the patients run about 45 minutes. What happens in the last 15 minutes is we get to go over the session in detail. And during that 15 minutes, when I'm leading the sessions, I ask the resident, I tell the residents what I was thinking why I did what I did what strategies I used what

techniques I was using and I allow the resident to ask me any questions about my thinking in the opening part of that and that's what that's not what the patient is gone at that point is that you know right 45 minutes with the patient this is 15 minutes with the knee and me alone and then when the resident is leading the sessions in the middle part at the end of this session with the 15 minutes at the end where the patient is not present. I asked the resident, how did it go? What do you think went well?

Was there an area that was difficult? Was there an area where you didn't know what to do? And the resident will describe that. And then we'll do an active role play. I'll be the patient for them. And I let them redo it with some supervision along the way of how they could have negotiated anything that was problematic for them. So it's really a demonstration and a role play and a feedback.

that comes in the last 15 minutes of every session to handle any problems they had or things they didn't think go well or just things they wanted to do better. So that's sort of the way that the sessions work. And then in the last third of say 10 sessions, the last three, I leave that up to the training. I can be present and continue the same thing I did in the middle three. I talk even less at this point. Or if they want, I agree that I will step out and observe them on video. and give them feedback after the session in a more traditional way of feedback post a session. And I leave that up to the resident

to choose which way they want to go. So that's the format for the live superview. I think that's great. I think it's, I'm just imagining there's going to be people who are listening to that being like, man, I wish I had Robert Feinstein to like, like do some co-therapy with you know it's like oh man because it's it's i feel like yeah just like you said it's hard to find probably the amount of supervisors necessary for the interest that's there

and the thing that's cool about it is that it's not extra time you know usually we typically save an hour to review a case with the resident so while i'm doing live supervision that is that that is the one hour a week that I give. It's not extra time. It fits in the same structure that most programs have, which is an hour of supervision a week with each training. Yeah. Yeah, that's good.

Yeah, so I was looking through the kind of the four dimensions of this cognitive apprenticeship model. And one of them is acquiring content knowledge. And so is there certain books that you recommend? or is it mostly handouts? Or what do you do for that portion? I use a combination of books and handouts. So Deborah Kavanaugh has a wonderful book

on psychodynamic psychotherapy that I use. I guess the different people come at this in different ways. I, in part because I'm an analyst, but I actually think that teaching psychodynamic psychotherapy as the base treatment is the best way to go. because it encompasses all of the common factors in a way that CBT, for example, does not easily address all the common factors. So I'll typically start with the basics of psychodynamic psychotherapy.

Not so much the theory, but a lot more of the technique of that. Theory comes later, but a lot of the, a lot more of the techniques is typically how I'll start. are other programs who teach empathy-based emotional regulation, emotional-based treatments first, because those tend to focus on patient affect and focus on the alliance and focus on empathy and mentalization. And that's another way to go. The McMaster's program in Canada begins that way with sort of a focus on emotion as their opening part. So I think it depends. a little bit on the teacher and where you are theoretically. So that's kind of where I would start.

Yeah, okay. Well, I think I imagine, you know, as there's going to be some residents who are people applying to residency, one of the things I'll sometimes ask them if they're really into wanting to learn psychotherapy is like, have you talk to the program about how they teach psychotherapy? And it's interesting in the comments I get back. from people as they go on these, you know, interviews, these programs, how they teach psychotherapy, what they do, what they don't do.

Yeah. My experience with that has been it's a little bit driven by the way their schedules are set up. For example, one program that I'm aware of has residents in their second year after they've done in-patients on a lot of specialty services. So they do eating disorders. They do a CO group with HIV patients. And then they try to teach psychotherapy in those settings. That's way too hard to do.

You can't start working with an eating disorder patient in a specialty clinic before you know the basics of psychotherapy. So that's an example where there's sort of a mismatch between the service and the thing we're trying to teach. So you really want to be careful to match the kind of therapy you're doing with the service that the patients are. So a lot of my listeners are probably out in practice, or they're maybe, you know,

they didn't have the formal psychotherapy training. They didn't go to a great residency, like where they had all of that, but they still want to learn. How can we take some of the sort of knowledge that you have to think about how they might sort of make their own psychotherapy training program? So I would say,

Start with some really good books. One book, a couple of books that I really like are the Deborah Kavanaugh's book on psychodynamic psychotherapy. There's another wonderful book that's called Beginnings. It's also terrific by Mary Joe Pebbles Cleger. It's just, I think it's Mary Joe Peoples right now, a wonderful book on beginning psychotherapy. Those are great books to start off with because they give a broad overview of all aspects of psychotherapy. I particularly like the beginnings book

because that book is trans-theoretical. So it's really thinking about how to start all forms of psychotherapy and what are all forms of psychotherapy have in common and it's beautifully written. So that's a place to start is with a couple of good books and those are two that I recommend.

And then I would say the next thing to do is to get a supervisor. You can do that in a couple of ways. You can do that. You can look for peer groups that are doing peer supervision. So a lot of the professional organizations have these groups. So you can join up during COVID. The American Psychological Association had peer supervision groups.

And this is where there are six to eight people in the group. Somebody presents a difficult case. and the group helps that person with the difficult case. So peer supervision is another thing to look for in your communities if you can find it, or attached to organizations or attached to any of the psychological organizations. I imagine social work and Maryland family therapy and certainly psychiatry and psychology have these kinds of peer groups. And then an extension of that, which I've suggested to some of the residents who want to do this on their own,

is to start a reading group. So you can start a peer reading group where you get together with one or two peers. You can pick a curriculum off the internet of the different forms of psychotherapy and do an article a week and discuss it with peers. So you're in a peer supervision,

a peer didactic group. So you can tell what I'm modeling is the core elements, right? What are the content information that you need to have, the didactic information you need to have. What's the experience you need to have? That means picking up patients, right? And maybe even videotaping yourself. Now on Zoom with patient permission, you can videotape yourself and review yourself. And then certainly the last part is being in supervision and getting some specific help with supervision. Yeah. I think those are great. And I think the, you know, cost effectiveness of some of those sort of peer supervision groups and the collegial bonds that form the, you know, friendship, that's fantastic.

I was in a peer supervision group for 17 years. Okay. Wow. And I, long after I had graduated and after I had been in practice for five years and was feeling that I was a little stale. not wanting to enroll in an institute again. And so I joined a peer supervision group. There were nine of us. And we presented our difficult cases, met once a month for 17 years.

And it was just fantastic. That's awesome. Yeah. And I think I keep telling people like financially, when you're going to get out and you're going to be making more money, put some money away for good supervision. I took a job at the university I did. There was some offers that I got for almost double or more than double what I was going to make at this university. I took the university job because I knew I was going to get to hang out with Dr. Tar five hours a week.

We were going to co-teach all these psychotherapy classes. And I knew that at the time, like I was not an expert psychotherapist, but I was going to get to teach it. And there's something about teaching, you know, that kind of solidifies your knowledge as well. but I was going to get to co-teach, which is, which was prices. I've coached a couple attendings when they were getting out and they had the opportunity to teach. And they were like, I don't know if I could teach psychotherapy. They want me to teach psychotherapy. I don't know if I'm ready to.

And I'm like, you absolutely can, but find someone in the community to co-teach with you, someone who's in their like 60s or 70s who has that generativity, you know, mindset. And just to rub shoulders with them. priceless, absolutely priceless. I also did a two-year psychoanalytic institute when I got out. It wasn't as intense as like the full psychoanalyst, you know, you're going to be, which with my family structure I just couldn't have done at the time, you know, weekly or a daily therapy for myself just wasn't an option. But I did like a two-year psychoanalytic institute, which was really good. A lot of really high-quality supervisors. This was in Santa Monica at the new center for psychoanalysis.

And the best part about it was I was in a group of colleagues with like a really good therapist. You know, these were the therapists that were good enough to do, run a good cash pay practice and then have some generativity to give their time to the institute. And, you know, it was good. So, yeah, any thoughts? Yeah. I mean, I think, you know, the whole, the whole,

idea of apprenticeship is really the way you learn how to do this. You have to apprenticeship, you have to learn with someone who has more experience than you do. What's hard to find, though, is some training that you can get that teaches more than one modality. You can get into a training for psychodynamic for two years. You can get into a DBT training course, which runs a year. You can get into any other forms of therapy. But the problem with each of them, I think, is they only teach a single modality. It's really hard to get access to multiple modalities because we have some patients who

really need CBT and that's the treatment of choice. And we have other patients who need DBT and that's the treatment of choice. And we have other patients who need trauma-focused treatment or other patients who need psychodynamically focused treatments. And if you want to be well trained, you have to know more than one form of therapy because there isn't one form of therapy that works for every problem and every patient. And that's a problem. So it's not easy to access that. One of the best way that I would try to do that, which is sort of a run that I've been on on, is you can take seminars in different areas that run for like three days. So recently I took an update.

on mentalization-based treatment at McLean's, which was wonderful. It was a three-day training. And you can do that. You can do three days of a specialized training in CBT and three days of specialized training in DBT and do it that way. And that gives you what I think you need are tools from multiple different forms of therapy,

not just tools from one. But it is useful to stay on a theme. So the way my training went is I initially learned how to do family therapy, and I stayed with that for a few years. And then after that, I learned how to do psychodynamic psychotherapy, and I stayed with that for five years. And after that, I learned how to do motivational interviewing in CBT while I was working in primary care, because that worked very well. So you can also just think about your training sequentially, and that'll keep you interested and have you adding skill. over the span of a career. I think the one thing that all therapists suffer from

is that when we stop training, actually our skills deteriorate. And that's been shown in study after study that people think, well, I'm finished with my training and now I'm done. And of course, if that's the approach you take, you never learn the mistakes you're making. You make the same mistakes over and over again

and you can't progress your skills. And that's because most people don't actually track the outcomes of their treatments. You know, they do the treatments, the patient's better, and then that's where they stop. So I think you need to figure out a way to be continuously learning different forms of psychotherapy across your careers. Yeah. I think two things with that is the, one is the supervision, like the quality of the supervision that you get. One of the reasons why I made the connection index was to look at like the

connection that was going on in the supervision, looking at the psychological safety of the supervisor and the empathy. And I think that that can give you a clue if it's a good match. So I'll link that in the notes. The other thing I was thinking about is with... Say a little more about the connection. So it's, so I've done an episode on this recently, but I'll just kind of break this down. The idea is that the connection. you have with your supervisor is, I think, as important as the connection between, like, a patient and the physician, you know, sort of the patient of the provider. So you're going to have better outcomes. And I think you're going to absorb, I think a lot of, a lot of becoming a therapist

is absorbing the empathy or absorbing, you know, more than the content, right? So different aspects of connection are like empathy, you know, do I feel? heard and understood, like, does your supervisor hear and understand you? Psychological safety, you know, do you feel safe disagreeing with them? Or if you don't understand something, do you feel safe asking a question? There's feedback, you know, do you feel like you get feedback based on specifics, not on generalizations, based on observations, not hearsay? And then, education alliance, you know, which is kind of a therapeutic alliance.

So do you feel like you can connect with this person? You have gratitude towards the work that you're doing. Right. So what we found in my initial study on this and in the later study that we've done on this is that the most connected supervisor actually decreases the trainee's burnout by a considerable amount, almost by one unit which would make you answer on a burnout scale from like, I'm burned out every day to a few days. days a week, you know, or like that kind of level of change of burnout.

Largely, I think, because of the meaning and the purposefulness and the connection and how connection reduces stress and how, you know, it increases confidence and meaning and, you know, so all those things kind of go into play. But also, we know that, of course, bad supervision leads to bad outcomes, right? So we found this out. And a lot of this stuff shouldn't be a huge surprise, but it can help you sort of understand, like, if you're in a bad supervision context, it might give you like, oh, maybe I should consider, you know, what might be going on between me and my supervisor, actually. You know, like there's an interpersonal, there's a third space, there's transference going on, there's countertransference. You know, I imagine my listeners have transference towards me.

you know, it's like impossible not to have transfer. It's going on whether you know it or not, you know. So that's interesting because that's sort of the drawing the analogy between the alliance with the patient and the supervisory alliance is really what you're talking about, is what's your alliance with your supervisor, and how does that enable your learning, which is great, just the thing you want to do.

Yeah, so I think knowing that that's important, but also I think what you were saying of like having some feedback of your approach with your patients. So one thing that I like to do is I like to do the OQ45.2 with my patients at the very beginning. And then if I feel like I'm getting stuck with the patient, I'll have them redo it. Or if I feel like I'm not making progress, I may have them do it like once a month. Or if my patients don't feel like they're making progress, we'll redo it once a month.

To see like, hey, we're making some, we are making changes here. And so we can feel confident. that, you know, the average therapist, I think, lowers the OQ, like one point per session. So you kind of have like a, okay, this is the slope that's normal. Okay, I'm going at half the rate of that, but this person has pretty severe personality disorder. That's probably normal. Or I'm a little bit above one, but I still feel like I'm not making progress. So maybe you could feel confident that you are making progress.

Sure. Great to do some measures of whatever process you're doing. to see how things are, so you can correct your course. Yeah, that makes a lot of sense. So, okay, what would be like your hope from this episode? Like, what would be your hope for people listening that they would take away? So I hope that people will know what to look for when you pick a supervisor, understand the importance of that.

And, you know, understand that there are multiple different kinds of, kinds of supervision you can get. So I'll just review that briefly. So a lot of people do what we call case supervision. That's where somebody will just present a case. And then there's a discussion. What was your thinking? What was the diagnosis? What did you do? What did you work? Case supervision can be really very useful. Then there's the kind of supervision that you can do, which is sort of video supervision, right? And that's where you actually can review the video, stop, at a moment and say you did that. Did you see what happened with the patient?

What's your alternative? And video and audio are similar that way. And then if you want to tap your own psychological processes with the patient, then it's useful to do process notes in your process note supervision with a supervisor. And that's where you take down detailed notes of what went on in the session. And I've sort of evolved permutation of. this that I find very useful to bring out the transferences, the countertransference or difficulties in the treatment. And the way I do process notes is I'll suggest in one session with the patient,

write down everything you say, but don't write down anything that the patient says. And then after the session, from memory, write down what you think the patient said. And this then allows you're unconscious to be introduced in the session. And then the next time you do a supervision session, do it the reverse. Take down everything the patient says. Don't write anything about what you say. And then after the session, fill in what you think you said or what you wished you had said. And this is a way that you can, because when you do it that way,

then your unconscious processes enter into your understanding of the patient. because you're doing it from memory and you have to fill it in and none of our memories are that perfect that we can do it like video. So that's important. And then, of course, there's the option for live supervision. And I think when you're looking for a supervisor, you want a supervisor who will use more than one style of supervision

because you get something different from each of them. You get something different from case supervision. You get something different from audio and video, and you get something different from live supervision. And supervisors who can span multiple forms of supervision with you will make it an enriched experience. So when you're looking for a supervisor, those are the kinds of things I would ask about. And usually most people can do two or three of these. Some can do all of them. But that would be the advice I would give if you were trying to find a supervisor.

And obviously, your point, even before that, is, do you feel safe with the supervisor? Is this someone you think you can learn from? And is it someone that has the expertise that you're trying to acquire? Good. Yeah. Very good. Well, if you are interested in reading more about the cognitive apprenticeship model, I will put some links on the article that will go with this and the books that were recommended.

And hopefully this has been helpful for you if you're thinking about learning psychotherapy and wanting to improve as a therapist. So thank you so much for coming on and educating our audience. It's always fun to be with you, David. Thanks so much for having you.