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Finding a therapist who you trust and who can offer you proper support can be a complicated process for many people. One of the reasons for this is the confusing and sometimes even misleading terms used in the field of mental health.
Joining me today is research psychologist and medical staff member at the Austen Riggs Center, Dr. Katie C. Lewis. We’ll discuss the differences and similarities between cognitive behavioral therapy (CBT) and psychodynamic therapy, how to determine which treatment modality is right for your unique family, and arm you with the knowledge you need for finding a therapist that will best support your goals and honor your parenting values, whether your seeking treatment for yourself or your child.
Dr. Katie (00:00):
Psychotherapy comes down to, you know, what’s your alliance like with your therapist. Do you feel like you’re kind of locked in and working on goals that you both agree upon, that you both feel are important? Is there a degree of trust and agreement about how you’re working towards those goals?
Dr. Sarah (00:18):
There is a lot of misleading and confusing terms that are used when it comes to mental health and the options that exist. And that can add yet another barrier in the already complicated process of finding a therapist that’s a good fit for you and your family. I am so excited today to welcome my friend, Dr. Katie Lewis to the podcast. Dr. Lewis is a research psychologist and a medical staff member at the Austen Riggs Center. And she’s here to help me cut through the jargon and simplify what your options are when it comes to therapeutic interventions. By the end of this episode, my hope is that you’ll have a basic understanding of the differences between behavioral and psychodynamic therapies and know how to find a provider that is right for you. Whether you’re looking for treatment for yourself, your child, or your family as a whole.
Dr. Sarah (01:10):
Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two in this podcast. I’ve taken all of my clinical experience, current research on brain science and child psychology and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.
Dr. Sarah (01:42):
I am so excited to welcome Katie Lewis to the podcast. Katie, thank you so much for being here.
Dr. Katie (01:48):
Thanks for having me, Sarah.
Dr. Sarah (01:51):
So I should tell you all, cuz Katie and I actually go way, way back. Katie and I were in graduate school together. So Katie and I have been through every possible iteration of like learning to be a psychologist together and even though we’ve moved kind of in different directions in our professional, you know, trajectories, like there’s, I’m just so happy that you’re here. It’s so nice to talk to you. I missed you.
Dr. Katie (02:17):
I know I missed you too, Sarah and, and yeah, there’s a long history, you know, bonding that sort of happens over the course of graduate school and it’s been exciting to kinda follow what, you know, what you’re up to and what we’re up to personal lives, professional lives it’s been yeah, it’s been interesting and exciting.
Dr. Sarah (02:35):
Yeah, it has. And we’re both, you know, moms of two like, it’s, it’s just wonderful. I love having conversations with psychologists, moms. There’s something about that combo. It’s like we get in our own way. We have to really like make sure our hats are on, right?
Dr. Katie (02:51):
Yeah, for sure.
Dr. Sarah (02:53):
But the reason why I really wanted you to come on the podcast today is because there’s this, this thing, it drives me bonkers. And I really wanted someone who could really speak to this for parents and help them make sense of it. And that is this idea that there are, there’s a lot of information about different types of therapies out there for parents. And I don’t know that parents always get the most accurate pictures of what their options are when they’re looking for therapy for their kids or therapy for themselves. And there’s a lot of fancy names thrown about like evidence based. And we’re gonna talk a little bit about what that means today, but I really wanted someone who is a psychologist, a researcher, a mother, to be able to break down for us a little bit of what it means to be an educated consumer of like our psychological options as parents.
Dr. Katie (03:42):
Yeah. I think that’s a really great question. It’s something that definitely, as a parent, I’ve encountered too in trying to make the right decisions for my kids when they need any kind of treatment or intervention or support you always wanna err on the side of really going by you know, best sort of medical guidance, medical judgment. But sometimes it’s really confusing what that is exactly. And so I think it’s really helpful, especially with something you know, like psychotherapy or psychotherapeutic interventions that can be more personal. And I think the terminology gets confusing and it’s, it’s a good thing to demystify as much as we can do that here.
Dr. Sarah (04:18):
Yeah. And so maybe, could you talk a little bit about the difference. So there’s kinda like two camps basically, if you wanna really get like over simplify it, there’s kinda like two camps of therapeutic interventions. They’re the behavioral interventions like cognitive behavioral therapy, dialectical behavioral therapy. And then there are the more psychodynamic or relational based interventions, which are slightly more holistic. They take a more like wide angle lens view at the individual look at how past early experiences impact the present. And so I wanna give people who are listening, some sort of we’ve been, you know, it’s hard for you and me. We can get into this and get very psychological. But like for most people who are listening, they’re like what’s CBT what’s DBT what’s psychodynamic psychotherapy. So like, can we break them down a bit and also talk a little bit about like what a person might go into therapy for, for these different modalities.
Dr. Katie (05:21):
It’s a, it’s a good question. I’ll do my best to kind of summarize although, you know, there’s a lot of nuances and Sarah, as you know, there’s like a million different forms of these cognitive behavioral treatments that each target and take slightly different approaches to different outcomes. So, but I think, you know, the general characterization would be that CBT or, or behavioral approaches they’re most focused on like problematic thought patterns or problematic behaviors that are interfering with someone’s ability to kind of function in their daily life. So in some cases you know, the kind of, the most classic one that kind of comes to mind is what a cognitive behavioral therapeutic approach would be to depression. Where what, you know, the focus of therapy is sort of trying to break down the thought patterns of you know, what’s our thinking is driving the depression symptoms. Is it a self critical stance that involves sort of faulty beliefs about the self is bad? The self is unworthy of love, these sorts of things, and then trying to work with the patient to challenge those assumptions or those beliefs and to sort of recognize them I think recognizing them when they emerge and feeling some sense of mastery over them is a big first step. So sort of trying to gradually, you know, identify isolate and then break down where these problematic thoughts are coming from. And it extends out into the environment, you know, if you’re using these approaches to try to manage like suicidal urges or substance use impulses or things like that, you also look at like environmental cues and context that might be leading someone to be, you know, to have greater temptation to drink or you know, feeling more more dysregulated, more suicidal, and, you know, when you’re with certain people or feeling a certain way. Um so, so I think it’s really looking to try to track down the thoughts and the things that are under your behavioral control, like where you are, who you’re with, how you’re acting and, and to sort of be able to build in some coping skills that compliment that. So if you’re feeling suicidal, you know, who can you call, what can you do to distract yourself? So it’s, it’s really a, you know, there’s a level of insight and understanding that you’re aiming to get, but really you’re trying to be much more proactive about problem solving and you know, and resolving things and giving a person a sense of mastery and greater agency over their experiences. So, you know, these treatment, I hope that’s a fair characterization. I think it captures sort of the main points and I think that these treatments get people get referred to these forms of treatment for things like depression and anxiety, because I think the coping skills are really, have shown to be really effective for those symptoms. And so that’s sort of the broad you know, the broad focus on the behavioral treatments. I’m not sure if there’s something I’m missing Sarah, that you might wanna add in about those from your experience.
Dr. Sarah (08:24):
Right. I mean, I think, well, I mean, obviously you use research suicidality, so that’s like a very central way that like, you’re gonna think about applying these things. But like, I’m also thinking about like on a much less intensive scale like we use DBT and CBT to treat emotion regulation, like difficulty with emotion regulation. Right. I have lots of my teenage patients who do DBT skills group to help them to learn to ask for what they need in a way that other people can hear them. In a way to think about the feelings that they’re having in the moment and build a little space between, I have a feeling I have an urge to act as a result of that feeling, and I might immediately act, how do I build space between the urge and the behavior, right. So it’s like impulse control, impulse regulation, impulse awareness. So, you know, I’m trying to translate some of the work that you do into something that’s a little more ubiquitous for a lot of families that might be listening, like you know, there are, there’s a lot of value to cognitive behavioral and dialectical behavioral skills. Um and I think they’re often used with anxiety. Like, if you are always having worry, OCD, obsessive compulsive disorder. If you’re having a lot of intrusive thoughts or compulsive urges, you can use the kind of awareness building and skill building from a cognitive behavioral approach or a dialectical behavioral approach. Dialectical behavioral was more for impulse control and executive functioning stuff. And you know, emotion, regulation and interpersonal effectiveness skills. Really, those are the four things that we teach in DBT skills are mindfulness, distress, tolerance, emotion regulation, and interpersonal effectiveness skills. The thing though, and here is the thing. These are all fantastic skills to have, and I want to integrate those things into my treatment. I’m very integrative in my approach to therapy. I use skills all the time, but I think for me, where the behavioral approach in isolation falls a bit short for me is that I wanna know the context of where these behaviors came from to begin with the behaviors we’re trying to change. I wanna know their roots. I wanna understand the intergenerational transmissions of trauma that, that put these roots in the person in the first place. Right. I want to know how, if I’m triggered by my child, when they’re really, really, you know, defiant . If I, as a parent find that to be enraging, I, as the therapist really wanna know, where does that rage stem from? What unmet need did you have when you were a child potentially that is leading to this particular defiance to be very triggering for you when you were defiant or expressed anger to your parents, did they shut that down? Did they, did they separate from you? Did they send you to your room and tell you you’re not allowed to be a part of this space until you turn that off? And now when your child does the same thing, does that activate in you a part of you that says, oh, that’s not a safe behavior. I recognize that one. Not safe. Gotta turn that off. And so we’re, that’s I think where the difference between a cognitive behavioral solo, solely behavioral approach to a more dynamic relational approach differs is that I might wanna do some of those skills. I wanna help a parent say, I’m noticing I’m feeling angry, and I wanna take deep breaths, or I wanna buy some time and some space, or I wanna say this thing to myself to help myself calm down. Those are all skills. Those are fantastic. But at the end of the day, I can’t just give someone a million skills and send them off and expect them to not repeat these patterns over and over and over again. Like, you gotta gain, you gotta get the blueprint, you gotta understand where the blueprint comes in. And that I think is where the relational and dynamic work really shines.
Dr. Katie (12:44):
Yeah. Yep. I would agree. 100%. In that way, the two sort of treatment camps are very complimentary. You know, sort the cognitive behavioral approaches give you the skills to kind of manage you know, manage the situation that you’re in, but the relational psychodynamic approaches give you that kind of deeper understanding and validation, I think too. If you sort of recognize that there is a longer history you know, to these experiences that might have been adaptive at one point in your life, but have, are no longer serving you in your current life context. I think that there’s validation that comes from that and a sense of you know, less defensiveness and thinking about how to change and challenge and less of a sense of self is kind of like, oh, I’m bad and I need to get a handle on this. It’s more of like a, oh, I’m learning, I’m in a process of learning and adapting.
Dr. Sarah (13:42):
Yeah. And so maybe, could you talk a little bit about the more psychodynamic or relational based interventions? It’s a little fuzzy, it’s a little harder to put your finger on exactly what it is that’s working in that treatment. And so, as a result, I think the behavioral treatments have kind of taken on this sort of representation of, we are the treatments that are easy to study. We’re very straightforward, it’s very clear and transparent what’s happening. We can measure what’s going on really well. And so they’ve kind of taken on this name evidence-based. And I’m wondering, could you explain a little bit about what that means and how we might be interpreting or misinterpreting it collectively as like a sort of lay society?
Dr. Katie (14:29):
Yeah, for sure. And I think, you know, it is all of this is very complicated and you know, you’ll hear different perspectives depending on who you, who you talk to. The term evidence based treatment actually has kind of an interesting history. It started out in the field of medicine, where there was such a focus on science that other factors that might be relevant to picking the right treatment. Things like like patient culture or patient values tended to be regarded as being less important. And so the move to evidence-based treatment was meant to move the field into a more holistic approach to choosing medical interventions that included things outside of just you know, what sort of you know, control trials were showing was most effective and to take into account things like clinical judgment and patient values, cultures, characteristics, and things like that. Um this idea was sort of picked up in the field of psychology with with psychotherapy but was sort of the opposite approach where it was meant as a term that sort of emphasized what you know, what the scientific literature was showing to be most effective. And we can talk about what most effective means, maybe in a second. But the idea of a treatment is considered to be an evidence based treatment. If it’s something that if it’s an approach that has some evidence of being effective based on empirical study, based on psychotherapy trials, things like that, if there’s clinical expertise or consensus that it’s a helpful treatment. So this might be you know, things that fall outside of strict randomized control trials or, you know, the more strict research approach. You know, if there’s a substantial clinical literature on it, where experts are writing about it, it’s been shown to be effective in you know, in outpatient clinics where research might not typically be done. Um and a psychotherapy approach is considered to be evidence based treatment if it also is responsive to patient values, patient culture you know, basically things that are most meaningful to patients. So it has sort of three parts to it that all together kind of contribute to this idea that a treatment is evidence based. And it’s really separate from another term, which often gets used, which is called evidence, supported treatments, evidence supported treatments are the treatments that are, that have more of a history of being evaluated in like psychotherapy trials or long term research studies. And that’s really just one component of evidence based treatment, but it tends to be, I think the idea that people assume is meant when people talk about evidence based treatments. I think they’re really grounding it thinking it’s more about the science when really it’s a broader concept.
Dr. Sarah (17:16):
Okay. And so it’s sort of been a bit co-opted from that original, like that original understanding though. Would you say?
Dr. Katie (17:26):
Yeah, I think so. I, I think it’s been sort of taken from, from the field of medicine and sort of treated in a different way than it was originally intended, although it’s still a useful concept in a lot of ways.
Dr. Sarah (17:38):
Yeah. Cause my here’s my thing about evidence based. And I think if we take evidence based as the way you’ve described it, it’s got empirical validation, we’ve done studies on it. That show it works, it takes into account patient values and their culture and this sort of holistic picture. Like that sounds amazing. Like, sign me up. Right. But I think the problem is like, there’s been what feels almost like a game of telephone tag or something where like, you start off with one, like you have a field that sort of says we’re evidence based. And then over time that message gets passed around so many different times and so many different iterations that now, like it kind of become, it means something else now.
Dr. Katie (18:21):
Yeah.
Dr. Sarah (18:22):
And I feel like, yeah, like basically like full disclosure, Katie and I are trained in psychodynamic relational psychotherapy. That is like the basis of the way that we’ve done most of our training. We’ve both subsequently been trained in many behavioral treatments. So we kind of know both worlds. But I think the field of like relational and psychodynamic and like attachment based therapies has been sort of set aside and the behavioral based treatments have sort of claimed evidence based as their own, with the implication that psychodynamic or relational treatments are not evidence based. And that is, that is where I get a little concern because I think it can confuse people, consumers of therapy to not understand what they’re signing up for when they sign up for something that when someone is waving an evidence based flag, maybe it drives people away from a treatment that might actually be quite, you know, valid and empirically valid.
Dr. Katie (19:32):
Yeah. Yeah. I think that’s right. And, and again, I think that’s where the efforts to kind of demystify all of this are really helpful. Just to kind of go back to what you had said earlier about these kind of two camps. So there’s the relational psychodynamic camp, and then there’s more of the behavioral or cognitive behavioral camp. You know, even that Sarah, like, as you had said, there’s a lot of overlap between the two camps. The boundaries are very fuzzy. And I think, you know, in regards to what we’re talking about today, my guess is that patient experiences, like in the consultation room with their therapist you know, it’s not so dissimilar, the approaches are, you know, they are definitely distinct, there’s different points of emphasis. You know, but ultimately, you know, the sort of common factors research around psychotherapy comes down to, you know, what, what’s your alliance like with your therapist? Do you feel like like you’re kind of locked in and working on goals that you both agree upon, that you both feel are important? Is there a degree of trust and agreement about how you’re working towards those goals? You know, those are things that really cut across different psychotherapeutic approaches and really where the difference comes down to between these two camps that you described has to do with what are the outcomes that are being studied. And with behavioral and cognitive behavioral approaches kind of broadly speaking, they’re really very focused on symptom reduction. So, you know, have your, have your depressive symptoms and anxiety symptoms gone down, you know, a certain number of points on a self-report questionnaire or something like that. You know, they’re really focused on that, which is, you know, I’m not gonna be the person that argues that that’s not important. I think it is important to, you know, to have your symptoms reduced, but the focus of more psychodynamic or relational approaches is a little bit broader and less specific to symptom reduction. It has to do more with Sarah, like what you were saying, like attachment, you know, the quality of your relationships your sense of self and identity and agency. So it has you know, it has sort of a broader focus that in the past has been really hard to nail down in terms of how to measure these things. You know, how do you measure you know, like this podcast, how do you measure secure attachment? And we have ways, but they’re, they’re very involved. They involve sort of these long interview processes and you know, trying not to oversimplify the idea which is not great for research and research. You sort of want things to be very simple, straightforward, streamlined. So it’s a long way of saying that this is really where like the cognitive behavioral approaches have had, had an easier time establishing a research evidence base you know, to really say like, we can show that this CBT treatment for anxiety reduces anxiety symptoms. And, and that’s the story. It’s a very nice clean story. Relational psychodynamic approaches might also reduce anxiety symptoms, but they’re also doing a bunch of other things too. They’re improving sense of identity relationships in addition to all the rest of it. And so it’s just been a little bit harder to, to study those things. And I think that’s where the, it’s more of a compelling argument that behavioral and cognitive behavioral approaches have a larger evidence base. It’s really because they have this kind of they have a longer history of researching and a cleaner story with their research results, but psychodynamic treatments also at this point, definitely have a large research base. They absolutely would qualify as evidence based treatments. But it’s just it’s a more complicated process to get there.
Dr. Sarah (23:08):
Yeah. And I think this is the thing that I is so important about understanding to be an educated consumer of psychology services is to understand kind of what you’re saying. Like it’s not really about anybody kind of everything that we do in this field is pretty evidence based from, you know, from what you’re saying. Like, but it sounds like you have to understand, like, what is your goal when you’re entering into treatment? Right. If you want to reduce symptoms, if you have a very specific goal, that’s different, there’s a different type of treatment that would be most applicable to that. And if you are looking for a more internal shift, a more interpersonal shift, if you want the quality of your relationships and the way you relate to yourself to have this sort of transformation. Or if you are in a family system and you need to have the relationships within the family shift in a way that makes, the quality of the family feel more harmonious and more comfortable. Then you’re not probably looking at symptom reduction and a CBT, or a, you know, a more behavioral based treatment might not meet your needs. So it’s certainly not to say that CBT or DBT. I mean, I use CBT and DBT all the time in my work with families, and kids, but I think you have to know what you’re trying to accomplish and you wanna make sure you’re working with someone who can understand the nuance of those different modalities and know what to be using when, for what, or for what end.
Dr. Katie (24:48):
Yeah, absolutely. I actually that’s usually part of my you know, initial meeting with a new patient is sort of a discussion and disclosure about the approaches that I take as a therapist. You know, where I sort of feel like the value of psychotherapy really is and how I think it helps people so that so that new patients really have a sense of my approach. And I, you know, we have discussions about other treatment approaches. Like if what someone is looking for is to develop emotion regulation skills you know, or something that’s very kind of concrete or mindfulness skills, things like that. Those are things that I can integrate a bit into my treatment, but they’re certainly not my areas of expertise and they might want that and wanna work with somebody else. And in contrast, I have patients that come in after years of more skills based interventions, and they feel like what they really want is to do more of a deep dive exploration into their history and their relationships. And the more implicit stuff that’s hard to articulate until you really have a chance to get deeper into a more intensive treatment. So people need different things at different points in their life. They find you know, different points of resonance with different therapists. Sometimes it has to do with the intervention approach. Sometimes it doesn’t you know, this is again, really where we’re, we’re quite different from medicine. Not that those factors aren’t important in, you know, relationships with medical providers as well. But with psychotherapy, it it’s a relationship and you have to, there has to be some alignment and adjusting to each other that that happens and frank discussions about you know, what pathway seems to be best to get to where the patient wants to go.
Dr. Sarah (26:31):
Yeah. And I remember even, I think it was in grad school, we wrote some studies on like alliance, like therapeutic alliance. And it was this idea, there was quite a bit of research that shows that it’s not actually the modality that often predicts outcome as much as it is the alliance with the therapist that predicts outcome. And that you can’t really, you could, you could do a fantastic, like a fantastic treatment, but if you don’t trust your therapist and you don’t come in, cuz with that trust comes the vulnerability, the openness, the willingness to kind of put yourself in a place where a change can happen. Yeah. If you don’t have that safety with your therapist, then that changes harder to get to because you’re coming in guarded, you’re showing them a part of yourself, not all of yourself. And so, you know, maybe that part of yourself that you’re showing up in therapy with is gonna change, but the rest of you doesn’t really do much changing. And so like, you’ve gotta feel safe with your therapist. You have to trust them. And I always tell people, honestly, one of my friends, you know, I get friends who are like, I want a therapist. Can you help me find someone? And I always say to people, one of my top advice my top tips for my friends is think of it like a job interviewer or a first date. Like you might wanna go on a couple before you decide this is the one for me. Like make a couple different intake appointments with a couple different providers and see who feels best to you. Right. That that’s okay to do that. You’re allowed to do that. And sometimes when people are coming to me and they’re a little unsure and they’re a little ambivalent about treatment, I often recommend, I was like, why don’t you, you know, check in with a couple other providers too, and see what feels good to you. Because if you don’t have that willingness to connect and trust your therapist, it’s going to make for a tricky treatment.
Dr. Katie (28:23):
Yep. I agree. A hundred percent. I take the same approach. And you know, if I have people asking for recommendations, I will never send just one name, one person I will send a bunch and I will say, and if you need more, you know, a month from now after you reach out, let me know. Because it is you know, that initial match is very important. And I think if I remembering correctly, I think the alliance research says something like by the third session, you know, if there’s a strong alliance, then, then you know that you know, it’s, it’s more predictive of good psychotherapy outcome. If there’s, if you’re kind of still disjointed at the third session, I think it’s a harder path to kind of climb your way back to a good treatment trajectory. But I try not to think about that too much when I’m meeting with new patients, if it’s a tough start.
Dr. Sarah (29:10):
Yeah. But I, but I think as a therapist, like going into that, having that same mentality, cause I think there are a therapist that also listened to this podcast too. Like, you know, I think as therapists, you know, if we can kind of remind ourselves that like, Hey, it’s okay if this isn’t the right fit and there’s no pressure to keep this patient here. Then there’s this openness at the beginning of the treatment where it’s like, Hey, let’s see where this goes. Let’s have this sort of trial period where we say, let’s make sure we’re checking in and seeing how this feels. And I think this is true for when I work with individual adults, like when I’m working with parents, but also when I’m working with a child, I want the parents to end the child to have an opportunity to get to know me. Like I often tell parents, like when I work kids, it takes a little while till we actually get to like the therapy, the real, the real meat of the therapy. Because my goal, when I’m working with a young child is in the beginning simply to become a safe person for them. Yeah. And that takes a minute. And that’s more important that establishing that alliance with that child is more important than immediately jumping in with therapeutic interventions.
Dr. Katie (30:17):
Yeah. I think, and, and it is a therapeutic intervention. I mean, just to establish that trust in the beginning, that is you know, again, this is where I think the psychodynamic thinking around therapy is a little bit different with CBT or DBT, there’s more sort of a structure. You know, even if they’re not going strictly by manualized approach, there’s more structure to the sessions where there’s a definition of, you know, what is the therapy, what isn’t the therapy you know, what sort of counts where’s the boundary. And with more relational or psychodynamic approaches, it’s sort of like everything, you know, a voicemail left to reschedule is grist for the mill for the next, the next session. Um so no matter what you’re doing, you’re doing something and, and there’s tremendous emphasis on the relationship right, right from the start. And I, I think that that’s it’s another place where the two different treatment camps are, are more distinct and it’s a little bit harder to nail down in terms of like measurement what’s happening in the relational psychodynamic treatment approaches, even though it feels when you’re in it, you can really tell you know, there’s trust building. There’s, you know, there’s really something there’s really traction in the relationship, right. From the first contact.
Dr. Sarah (31:30):
Yeah.
Dr. Katie (31:33):
I also think what relational and psychodynamic approaches do well, I don’t know that they emphasize this enough. There’s more, I think with cognitive behavioral approaches, there’s an assumption that people are kind of rational and, and want to be rational. And in psychodynamic approaches, there’s a recognition that people are really ambivalent and conflicted and can want two very different things at the same time. And that causes all kinds of mischief in our day to day functioning. And to kind of simplify it and say like, no, no, no, here’s the blueprint to rational thought. Sometimes people just don’t want, they might think they want that, but they don’t really want that. You know, for example like depression, you know, depression is not just bad. There are things that come with that. There, you know, there’s maybe care taking from others that meets an unmet emotional need. Um you know, there’s sort of symptoms, you know, can have different meanings and, and raise different things. And it’s important to kind of recognize that ambivalence and develop a degree of tolerance for it. So I always, hold that in mind too, and try to point it out to my patients when I feel like they’re struggling, you know, when they feel like they should be able to do something differently, but they just keep getting stuck a lot of times it’s because there’s something else going on that’s competing and they just have to kind of recognize that and learn to live with it. But I think otherwise, yeah, that you’ve kind of laid out the way, you know, in a similar way to my thinking what the two approaches are really looking to accomplish how they can work together and what parents might wanna be thinking about. You know, if they’re looking at different options.
Dr. Sarah (33:07):
Yeah. And I think, you know, parents are consumers of therapy, both for themselves and for their children. So it’s very, like they really have to, there’s a lot, there’s a lot that’s on their shoulders. Like figuring out what is the right treatment for me, what’s the right treatment for my child. I think there’s a tendency sometimes when we look at treatment for children to lean more towards the behavioral. And I think that this is rooted in a long history of our culture and our society of thinking about children in terms of their behavior and sort of reducing them a bit to their behavior. My job as a parent is to change my child’s behavior. My job as a parent is to make my child behave well, my child, my job as a parent is to raise a child who can behave. And so we look, we’re so trained to look at our children from this behavioral lens. And so then we automatically sort of tend to lean towards treatments that address behaviors. Right. And I understand that completely. But I do think, and this is the, you know, this is where I differ in big ways from working with kids is I don’t come at working with children from a behavioral approach, again, I might weave in some skills. But I look at the family entirely as a system and look at the child as a interconnected part of that system with the parents. And I think for any child work to be effective, we have to understand the relationship between the parents and the child and how that parent child relationship, that attachment relationship, the safety and the trust and the capacity for tolerance of this child’s emotional experience and understanding of this child’s emotional experience beyond the behaviors can help us to, can help us to inform what we do in that treatment, so that I’m not, I’m not looking at behaviors by themselves in isolation and looking at ways to just change a behavior. Underneath that behavior is some driving force, some emotional or interpersonal force. And we have to understand that that’s actually how we shift the behaviors, but we can’t just focus on behaviors. And so I think having a more integrative approach, having a more, having at least part of the treatment be relational, and dynamic looking at the dynamics between the people in the family is critical.
Dr. Katie (35:36):
I think too, I, you know, a lot of what we try to do and, you know, mainly I work with adult patients and a lot of what I try to do is to you know, help them develop a curiosity about their own mind and their own emotions, so that they’re not sort of doing that reductionist approach to themselves. And Sarah, I imagine what a lot of what you’re doing in your work with children with families is trying to model that a bit for the parents so that the parents learn, like you’re saying not to just sort of focus on the behavioral problem, but to, to have curiosity about what’s going on for the child and what their emotional state and experiences are. You know, where are the things sort of underneath the behavior that might be contributing to it might help us develop more of an understanding. And to the extent that parents sort of pick that up from you and learn to do that themselves, it can really be a game changer. You know, I find it just to kind of draw on our own like parenting experiences. My younger daughter is three years old now. So, you know, full context, she’s been, you know, living in a pandemic world for two thirds of her life at this point. You know, but she’s really the one that’s sort of bouncing off the walls and you know, very sweet, very, very energetic, but you know, I’d say that sort of, we butt heads more than with my older daughters, just pure personality wise. It’s gonna be great, you know, someday when she’s older, it’s tough now that she’s three. But but we sort of have this I don’t know if it’s, I don’t know what you’d call it, but, you know, if there’s a day where she’s really been having trouble kind of, you know, following rules or listening, you know, if we ask her to do something or to stop doing something you know, where really, there’s just a, you know, a sense of a showdown, you know, what I’ll say to her is you know, it’ll reach a point where I kind of look at her and say, do you feel like you’re having a rough day? And that usually just diffuses the situation where she learns you know, that that’s a point where she’ll run up to me and just kind of climb into my arms. And we have this moment of recognizing that you know, what could be construed as just a behavioral problem, you know, something like you know, her being overly stubborn, comes down to just, there’s a recognition that she has this feeling, that things are just not going her way. She doesn’t have control. She feels kind of, you know, helpless in a way. And that’s okay, and that we can still hit pause and kind of snuggle and just recognize that she still will have to, you know, clean up her toys or do whatever the showdown was about. But I think she, you know, it helps her feel like she’s seen, and it helps me put myself in check and sort of say like, this is a kid that’s having a rough day and that’s okay. And we can kind of, you know, find a different way to connect. So it’s a small thing. I wouldn’t, you know, it’s not necessarily as an intervention, I would say, like to a parent, you know, Hey, try saying this to your kid.
Dr. Sarah (38:36):
I might!
Dr. Katie (38:38):
But it’s, it’s an example, I think of a moment. It’s surprisingly helpful in, in our household and to the point where I try to hold that in mind and sort of ask myself, you know, do I need to sort of ask them how they’re doing and sort of just put it, put some words to it in a way that’s gonna be helpful for both of us.
Dr. Sarah (38:54):
Yeah. And I think that really honors yourself, your child’s self and all of these bigger factors that are so much more salient than a particular behavior. Like you could have easily focused on the fact that she wasn’t picking up her toys and think about all the ways you could get her to pick up her toys. But you’d be missing out on this much more important piece, which is, she’s feeling something. And she can’t articulate it. And so you articulated it for her held space for it helped her move through that feeling, and then you can go address the behaviors, like yes, of course the behaviors get addressed, but not first.
Dr. Katie (39:35):
Right, right.
Dr. Sarah (39:36):
Maybe not even second or third or fourth, eventually. But the first stuff is more, is more, has more value. Oh, I could talk to you about this for hours. I feel like we could really have this conversation for like hours. But I wanna give parents like a kind of nitty gritty, like nuts and bolts of what they can do when they are, when they’re feeling like they need some support or they’re thinking their child might need some support. What are a few really straightforward things that parents can do in addition to kind of shopping around for clinicians and trying to make sure we have that connection, what are some other things we can do to make sure that we’re getting high quality care that’s gonna meet our particular needs?
Dr. Katie (40:15):
I think that, I think parents, first of all, you know, I do think the point of don’t just sort of go to the first person that you get a referral for, you know, make sure you get a list of a few people that you feel empowered to reach out, to empowered, to meet with and ask direct questions about their approach to, to working with people. Whether it be children for your own treatment, just ask ask directly, like, what’s your philosophy of how people get better? You know, how should I expect our sessions to go? You know, where do you think the value is in psychotherapy and how does that translate into what we’ll be doing in our meetings. And go by your own sense of whether it feels like it’s gonna match up. If it’s somebody that seems to be saying they’re gonna come in with a lot of structure and that doesn’t feel quite right. If you’re sort of looking to get into something that might involve more sort of uncovering, exploring past patterns go with your instinct and, you know, and meet with other people and see if there’s an approach that feels better or the opposite. If you feel like there’s no structure in what you’re looking for, some practical skills, then, you know, you can ask about that, you know, can we focus on skills? But again, go with your gut in how the therapist will be speaking to you and planning to work with you. And, and again, you know, to the point of, of, you know, our earlier discussion, be wary of the term evidence based treatment, not because it’s not an important thing to take into consideration, but just make sure that if someone is arguing that what they do is evidence based that they’re not placing so much emphasis just on this research history, which you know, is one small component. Um you know, you don’t want someone that’s gonna so rigidly stick to a, you know, a manualized treatment that’s from a research study and not be responsive to what you need in the here and now, or have the ability to be flexible. Most people, most therapists are gonna be operating in, you know, somewhere in between. They’ll use evidence based approaches, but not be so strict. But just make sure that the way that they’re thinking about evidence based treatment, if that’s what they say that they’re doing, make sure they’re thinking about it from all perspectives, including what’s gonna be valuable to you as a patient.
Dr. Sarah (42:35):
Yeah. Oh, I think those are such great strategies. Thank you so much for coming on. And it was just so good talking to you and yeah, I think this is really, really insightful and interesting.
Dr. Sarah (42:51):I hope that gave you a better understanding of your options, whether parenting advice or therapeutic interventions, it’s always my goal to help you become an educated consumer so you can make the best decisions for you and your family. If you’re interested in additional resources, head over to my website, drsarahbren.com, we’ll find free guides to help support you in your parenting. From planning for your postpartum, to fostering resilience in your child, and to creating a successful toddler bedtime routine, all of these are on my website. And you can check out my newest free guide, Reduced Tantrums Before They Even Begin, in which I equip you with an understanding of what happens in your child’s brain and body when they have a tantrum so you’re able to most effectively help them. Plus five fun and simple games that strengthen their emotion regulation ability to prevent tantrums from happening in the first place. Go to drsarahbren.com to download this and many other guides and workbooks. And until next week, don’t be a stranger.
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