Key moments, in order
Psychiatry was fundamentally not about medications, which barely existed for psychiatry until the 1960s. It is about formulation and giving patients explanations that are adaptive.
Psychodynamic and psychoanalytic concepts get abused in short bursts during psychiatric appointments.
Review moments in your own interviews. You may notice times you acted outside the treatment frame just because you were curious or afraid of a bad outcome.
When anxious, novice therapists feel pulled to explain what they are thinking or doing, to escape the discomfort of silence, instead of letting the process unfold.
Frame and alliance are techniques, not only concepts: notice when you or the patient step out of the frame or the alliance ruptures, and know how to repair it.
Follow the affect. Be emotion focused in many ways, not just cognitively but interpersonally in your exam.
Teach patients explicitly that emotions, while unpleasant, are not in themselves dangerous.
Affect can be too hot, a patient coming on very strong, or too cold, someone describing the death of a loved one with little feeling.
Track the affect while you interview. Dysregulation and plain dissociation are easy to miss if you are not following it, dysregulation can look subtle (freezing rather than agitation), and a dysregulated patient does not give good information anyway.
Unless someone is flowing with narrative and emotion, you may be missing information. They are not withholding it on purpose; they may be too closed off from themselves to access it.
Do what emergency medicine teaches: in a crisis, first take your own pulse.
The physiological sigh (a full breath in, another pull at the top, then a slow full exhale) is a subtle way for the clinician to activate the parasympathetic system mid-session.
You do not have to know a technique well. Search box breathing on YouTube and do it with the patient at the same time.
When a patient starts to dissociate, name it and orient them: "I notice you're getting a little different there; this seems like a lot for you." Then ask simple present-moment questions: your name, where you are, who I am, the color of the chair.
Give assurance only in ways that are true and that everyone knows are true: we are here together right now, you are feeling awful, but you are not in physical danger.
In therapy, name it: 'I notice you are talking about something quite painful, but you don't seem to be feeling much emotion as you talk about it. Do you notice that?'
The goal is for technique to become so ordinary to you that you can deploy it at will.
Picture the levels as a reverse pyramid, with what you do most at the top. That is level zero: the supportive elements, including frame, boundaries, psychoeducation, safety, the alliance and technical containment. Level one is empathic mirroring.
The goal is to help elaborate someone's emotional experiences and understand them better, in the hope of giving them more degrees of freedom in their life.
Therapy does not work by giving answers. Hand a patient a diagnosis or formulation, even a 100% accurate one, and it might as well look like black magic to them.
There is no use giving a diagnosis the patient does not understand or cannot explain in their own words from what has happened in their life.
It comes from Bion's theory of thinking: humans cannot inherently form thinkable thoughts. Before experience becomes words, it is undifferentiated, and the caretaker, physician or therapist perceives that internal process happening in the other person.
Some people cannot name emotions or put experience into words because of a lack of development: they were never given the tools or the chance to self-reflect.
A diagnosis can be a container. For a patient frightened by OCD obsessions, the concept of intrusive thoughts explains what is going on so the thoughts no longer feel wild and unexplainable, and they feel much better.
Step one is to observe and hear what the patient is saying and doing in front of you, what they are not saying and doing, and what ordinary people might experience in their place.
If you are not doing some containment, you are not really having a conversation; you are both just talking at the same time.
To learn it, watch Carl Rogers work on YouTube. His client-centered technique was essentially only containment: only reflective statements.
Do not be afraid to simply reflect back. It may underlie the whole development of thinking and emotion regulation, especially in traumatized people, and at minimum it proves you are listening.
Many therapies offer unconditional support for whatever the person is experiencing instead of curiosity and a wish to expand and understand it.
Used judiciously in a diagnostic interview, containment bolsters the patient's ability to elaborate, builds rapport and gets you more information.
The actual core of motivational interviewing is technical containment, Rogerian mirroring, which lets patients notice discrepancies in themselves they would not otherwise notice.
This work is often described as narcissistically depleting. It is not hot and sexy, thinking up complex interpretations.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.