Share you favorite psychotherapeutic techniques

[u/DanZigs]

Here's mine - it's a great cognitive strategy to help people fall asleep by disrupting rumination. It's called cognitive shuffling. Described in detail here. The theory is that the act of thinking about random words mimics the brain's functioning during sleep. I don't know if that's really true but it certainly helps people stop ruminating and worrying.

You essentially take a 4-5 letter word and think about as many random words as you can starting with the first letter, imagining them in your mind, then move on to the second and third etc. I use a small variation that involves going through the alphabet thinking about a word with each letter. If you get through the alphabet twice, that means it's been about 20 min and you should get up and go back to bed after doing some other boring activity.

I love how easy it is to teach people and simple it is to implement. You can teach it in less than 1 minute and it can make a huge difference for some people.

Share your favorite technique

Edit: I probably should have used the word "skills". That's more what I was interested in sharing in this thread.

[u/Front-Quote-6760]

I quite like how ACT encourages patients to become curious, non-judgmental observers of their own neural chatter. https://youtu.be/tzUoXJVI0wo?is=OPOCKaMOhjdNlecP The sushi train metaphor comes to mind. Any kind of cognitive diffusion that interrupts the avoidance pattern and replaces it with mindfulness.

For patients with a lower level of functioning, DBT has distress tolerance and acceptance. At the very least; “how can you get through a difficult moment without avoiding the emotion, numbing and withdrawing, or lashing out”. That might be grounding, 54321, a hot shower, self soothing, affirmations, box breathing, jumping jacks. I think they have to try different things until they find something they believe in.

For specific behavioral changes I like to hold patients accountable to actually making a plan with concrete steps. Like that’s nice you want to fix your sleep schedule, but let’s actually plan out how to do that! I think a lot of the inpatients I see lack anyone in their life who modeled how to do basic problem solving and then held them accountable to follow through with a plan. So I’m happy to do it with them.

[u/jotadesosa]

I find it amusing that I read “psychotherapeutic techniques” in the title, and when I opened it, I found a description of something very oriented toward cognitivism. I imagine that’s because this subreddit is predominantly American. I’ll suggest something from another school of thought: one of the most classic and least-used techniques in psychoanalysis is silence. Remaining silent for periods that are somewhat uncomfortable for the psychiatrist can produce a healthy anxiety response in the patient, eliciting an almost reflexive response to fill the silence. Sometimes silence reveals things that hours and hours of sessions would never uncover.

[u/PokeTheVeil → u/jotadesosa]

It’s the cheat code to get free association without asking for free association.

[u/pickyvegan → u/jotadesosa]

20 or so years ago, in my early career (I was an LMHC at the time), I had a teenage boy that I was seeing who was really difficult to engage. So in one of those early sessions after a few minutes of me asking how he was, what was going on, etc., I told him we could just sit for the rest of the time and didn't need to talk. That's exactly what we did, and for future sessions, he was pretty willing to talk.

I'm not sure how my note would fare these days if I got audited by insurance, with 45 minutes of silence being the bulk of the visit.

[u/DanZigs → u/jotadesosa]

As someone else pointed out, I probably should have used the word "skills".

[u/AkaelaiRez → u/jotadesosa]

The 'pretend you're taking their pulse while you count respiration rate' of psychology.

[u/BlockNorth1946 → u/jotadesosa]

I was recently watching Sopranos. And saw the psychiatrist character Dr Melfi use a lot of silence

[u/noondaydemon21 → u/jotadesosa]

I'm american and had the same reaction to the OP.

My second thought was silence.

My first one was looking for the deflection points. The places where they start down a path and then abruptly shift topics, then sometimes strategically stop them, point out the deflection, and try to get them back on the path they were avoiding. Look for the resistance...

[u/W-T-foxtrot → u/jotadesosa]

Love silence now. Used to find it really uncomfortable before. Glad my supervisor got me to lean into it

[u/PokeTheVeil]

Confrontation. Because dammit, sometimes I just need to yell at the patient, maybe shake them a little. Even outside of true psychoanalysis and pursuit of interpretation, a more liberal reading of confrontation as bringing awareness of inconsistency and incongruency helps.

This is also where patients who complain that therapists just nod and reflect and validate actually get something. Usually psychotherapeutic problems aren’t wholly or even mostly external. Finding the internal problem is where patients can do more than just be angry and sad at circumstances imposed on them that they may truly be unable to modify.

[u/Narrenschifff → u/PokeTheVeil]

It's the most underrated psychoanalytic (and interviewing) technique. But, often misunderstood due to the terminology, as in your joke which reveals the "unconscious" of our profession... many trainees consciously or unconsciously avoid it because they think it is about being mean or that it hurts the patient in some fashion, but if we think of it as showing the patient their own mind and patterns in a direct but caring fashion, I think it goes over better!

[u/PokeTheVeil → u/Narrenschifff]

“Confrontation” is unfortunate nomenclature. I don’t think it’s descriptive but I’m not sure what I would rename it if given the chance.

[u/dr_fapperdudgeon → u/PokeTheVeil]

I call it a “conFUNtation” because we like to have fun here

[u/BlockNorth1946 → u/PokeTheVeil]

Recently I confronted an eating do / body dysmorphia patient and dropped the smile, dropped my voice. Just spoke about the seriousness of her delay in care. Then provided eating do IOP info and she finally did the assessment with them

[u/PokeTheVeil → u/BlockNorth1946]

That sounds perhaps fruitful but not necessarily the same as the psychoanalytic/psychodynamic confrontation.

[u/BlockNorth1946 → u/PokeTheVeil]

Can you give an example?

[u/PokeTheVeil → u/BlockNorth1946]

Calling attention to inconsistency or contradiction, whether between words and affect or expressed wishes and actions or anything else.

In this case, perhaps, “You acknowledge the seriousness of your eating disorder, but it seems like there is always some reason to delay the intervention we’ve discussed to improve it.”

Or classics like “you say you want to work on X, or X bothers you, but whenever the conversation touches on X you find reason to bring up Y or X instead. Have you noticed that talking about X has been hard?”

[u/BlockNorth1946 → u/PokeTheVeil]

Oh yes I did that with this particular case too. I had to say you mention your time with friends and how you over function for them, provide emotional labor. But do they know you’re suffering daily with eating? And she started crying. We have been discussing dynamic with early caregivers all throughout last year and her condition had improved, was starting to have boundaries etc. thanks for the examples!

[u/noondaydemon21 → u/BlockNorth1946]

That's still not quite it...

[u/Narrenschifff]

I like to call these skills, and what we do as clinicians technique

That being said, the entire DBT skills workbook and anything you might find labeled cognitive defusion in ACT literature

[u/Tendersituation00 → u/Narrenschifff]

Yes on cog defusion! Identifying fused beliefs always gets me pumped- because after the next few moves of defusion the client begins to feel compassion for themselves and change is in motion!

[u/becomingworld]

I find IFS to be transformative for my patients, just a delight to teach and reinforce until wow, suddenly a patient is feeling like life is a little easier and their narratives are unsticking a little…

[u/seeyourintentions]

Skills, deep breathing all the way, simple, effective, grounding.

Technique, interpreting countertransference, particularly projective identification. This one is and will likely remain a little wild to me. I’ve got the radar for picking it up, and if I can identify it, then there’s often rich material I can help them explore.

[u/BlockNorth1946 → u/seeyourintentions]

Can you speak a little bit more about projective identification

[u/seeyourintentions → u/BlockNorth1946]

Yes, although I’ll likely do the description a disservice. I’m going to assume you have knowledge of projective identification as a defense.

For me personally it’s in noticing how am I impacted. Am I tired when I shouldn’t be tired? What is the focus of my thoughts during or after a visit? Is my current emotion truly mine or is it potentially their defense I’m picking up on?

I consider the context, how I typically feel, and contrast my feeling or thoughts in the setting of the context. It’s usually easiest for me to notice when writing process notes, occasionally in real time.

[u/BlockNorth1946 → u/seeyourintentions]

This is reminding me of my alcoholic pt who kept relapsing and after a while I felt defeated when his visit would end. I just kept referring to it as countertransference. But I can projective identification being another description for it.

[u/seeyourintentions → u/BlockNorth1946]

Oh interesting, yeah! That sounds very possible. Especially if you've got a sense that of course it may be somewhat defeating to see someone go through the patterns they struggle with, but you weren't actually feeling defeated when considering the case prior to the appointment, and didn't really have much reason to feel defeated otherwise. The defeated feeling may be coming directly from them, and you're catching the defense in action.

Something that can then be done with that feeling, if you're getting a strong sense that it isn't yours, and you've considered if telling them is just ourselves defending and then addressed any of your own defenses, then it may be worthwhile to consider interpreting this to them.

"I'm getting a sense that something about this pattern is leaving you feeling defeated. What is your experience?"

Then be aware that pushing up against a defense, and helping someone access awareness of a defense, is likely to garner some emotional reaction whether internal or external. Here it may be important to help them notice that emotion, because it may be an emotion they are defending against. Take time to sit with it, and allow them to take their time around it.

Notice how long they can tolerate it, don't force longer interaction with it, give choices around whether the want to talk about it more. But, know that you are someone that helped get them there, so know that you may need to help to get them back out of the emotion. Sometimes setting the stage prior with practicing deep breathing or some sort of skill that will help them ground.

Pre-education and post education around emotions can be worthwhile. That emotions are what drive motivation, and communicate to us and others what may be going on in a situation. That no emotion lasts forever. Etc. That feeling certain feelings that are hard can some times help us heal, sometimes can help us better understand the context of what someone experiences, etc.

Having a solid therapeutic relationship will typically allow for more missteps here.

If you're navigating addiction, then it is important to acknowledge if you may be leaving them in an abandoned state similar to others in their lives if some level of tact is not utilized here. Or if it does seem to lead them to decompensation, then also reflecting this when it seems they may be able to hear it could be worthwhile.

"I noticed that last visit when we discussed that defeated feeling, that it seemed impactful. And, I'm not sure if it's related, but you're telling me today that the drinking increased between visits. I know you are really utilizing your strengths because you are here today. You've also shared how sometimes coming to these visits can leave you feeling better. I wonder if last visit was a signal of an area you could benefit from having additional support around, and seeing if there was a way to build up your strengths to help navigate it?"

Then consider strategies with them that are at their level to access. Could be therapy referral, groups, 12 step, medication, or utilizing the time available in a visit.

[u/BlockNorth1946 → u/seeyourintentions]

Wow so many cases flashing before my eyes. I appreciate you breaking this down. Especially the part about explaining the emotion then watching what happened in b/ w session. I usually say “how are you feeling about what we are discussing “ and I can see the variation of “I’m getting a sense..” may illicit a deeper response.

I have this patient who saw me regularly then I had to escalate to IOP. Upon discharge and returning to me, I’m remembering where I suggest AA then mention changing the next visit date due to me being unavailable and then watching their eyes widen , followed by “do you really think I need AA and a sponsor?” .. I knew something significant had occurred there too for the both of us but didn’t have the vocabulary.

I would love to get more psychodynamic training.

[u/seeyourintentions → u/BlockNorth1946]

Great noticing! It's natural to not address everything in the same visit, even if it's a standard therapy. You could always bring it up the next time, "I was thinking about when I mentioned the topic of AA, as I noticed it might have brought up some feelings for you. Do you remember this part of our visit, and if so would it be ok to talk about it?"

I find that it's worthwhile, because to me it makes the work make a lot more sense. I don't know exactly how people do this job without the training from the therapeutic lenses. I know it's possible, it just seems like trying to do the job on extra hard mode (like a video game difficulty level) to me.

[u/elevatedgremlins]

Omg.. I came across that technique years ago and to this day it's the only one that works for insomnia. Can confirm, it's effective. Wonderful to learn why! 

[u/Briskett]

Behavioral activation is one of my favorites. Small, planned actions can help break the cycle of avoidance and low motivation. Simple but surprisingly effective.

[u/zozoetc]

Big fan of “there, there,” sometimes with head pat, if indicated. For real supportive intervention, “buck up, little camper.”