No residency program can fully prepare a trainee in four years to practice
psychotherapy, but it can lay down a bridge the new practitioner may
traverse—with years of study, supervision, and clinical
practice—from hesitancy and doubt to firm conviction about the efficacy
of the "talking
Salman Akhtar, M.D.: As psychiatry residents master psychotherapy, they"
have to live for a long time on borrowed faith. Gradually, from
hesitation through borrowed faith, the resident will come to the doorstep of
Courtesy of AADPRT
That was the message psychiatrist and psychoanalyst Salman Akhtar, M.D.,
brought to training directors at this year's annual meeting of the American
Association of Directors of Psychiatric Residency Training (AADPRT) in San
Akhtar is a professor of psychiatry at Jefferson Medical College and
training and supervising analyst at the Psychoanalytic Center of Philadelphia.
He is the author of numerous articles and papers about psychotherapy and
psychoanalysis, as well as six volumes of poetry. His most recent book is
Freud Along the Ganges: Psychoanalytic Reflections on the People and
Culture of India (Other Press Books, New York, 2005).
At a time when training programs are required by accrediting bodies to have
their residents demonstrate "competency" in psychotherapy,
Akhtar's message was a bracing one about the difficulty of transmitting the
art and science of a special kind of listening and speaking: not everyone can
be a psychotherapist, he said, and even those residents who do demonstrate
promise may not become confident practitioners until many years after
In an address titled "From Hesitant Conjecture Through Borrowed Faith
to Firm Conviction," Akhtar told training directors that he was
practicing for nearly 14 years after residency before he began to feel a sense
of firm conviction about his skills as a therapist and the ability to
alleviate symptoms through listening and talking.
"No residency program, even one that is heavily invested in
psychotherapy, can prepare a resident in four years to be a
psychotherapist," he said. "There should be no fear or shame about
this. We can teach them how to become therapists, but we cannot make them
therapists when they graduate."
With trademark good humor and illuminating anecdotes and examples from his
own clinical practice and supervision of trainees, Akhtar described a process
whereby novice therapists move from "hesitancy" to"
conviction." In making that transition, they have to rely on what
he called a "borrowed faith" in the efficacy of psychotherapy
handed down by institutions and individuals committed to passing on its art
It is this "borrowed faith" that a training program can impart
to its residents. Akhtar outlined nine educational experiences from which
trainees may borrow a faith to last them through their period of
Akhtar said the hesitancy that even the most promising residents bring to
psychotherapy stems, in part, from the fact that what the therapy appears to
consist of—listening and talking—is so commonplace. Inexperienced
residents are prone to either smugness—a sense that they already know
how to do something so commonplace—or cynicism, because they are
skeptical that difficult symptoms can really be resolved through listening and
He said the hesitant novice is liable to be hindered by either a lack of
knowledge, a lack of clarity or assimilation of knowledge, or a lack of
courage. In the first instance, trainees may simply be unaware of the value of
data reported by a patient and its significance to the patient's overall
psychopathology or unaware of how certain aspects of psychotherapy work.
But even knowledge of the working tools of psychotherapy will not help a
novice who has not assimilated it through clinical experience. Here, Akhtar
cited the example of a resident who begs off treating a patient because he
says he "hates" him. When a supervisor reminds the resident about
the nature of countertransference, the resident replies, `No, no, this is not
countertransference. I really hate this patient!'"
Akhtar said, "So the resident has an idea that patients can induce
feelings in us and that we can develop feelings toward patients because of
their particular psychopathology, but he hasn't owned this knowledge and
Finally, the phase of hesitant conjecture can be characterized by a lack of
courage: the trainee may instinctively know what intervention is called for,
but lacks the conviction of his or her instincts, stemming from a fear of
hurting the patient or an overzealous attention to certain learned rules (such
as never making an interpretation before the third visit).
"They will have to live for a long time on borrowed faith,"
Akhtar said. "Gradually, from hesitation through borrowed faith, the
resident will come to the doorstep of conviction." ▪