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Jonathan Shedler Profile picture
@JonathanShedler
Feb 8, 2020 • 3 tweets • 2 min read • Read on X
1/ JAMA: "High nonresponse & dropout rates suggest mismatch between complex clinical reality of military-related PTSD and one size-fits-all treatment approaches in VA"
"...do not effectively manage PTSD in large % of patients" #cbtworks #somepsych #psysci
jamanetwork.com/journals/jama/…
2/ Talking point emailed from VA central office: "Disseminating [same one-size treatments] through national training initiatives is appropriate given that these treatments have the most robust evidence of effectiveness."

Someone invested in "alternative facts."
JAMA or VA?
3/ Therapies in question were NEVER tested against relationship-based talk therapy as practiced by most psychotherapists.

How can a treatment have "most robust evidence" when never compared to psychotherapy as practiced in real world by most psychotherapists?

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More from @JonathanShedler

Jonathan Shedler Profile picture
Jun 29
1/ I see right-leaning accounts saying mental suffering is a weakness/character flaw

and left-leaning accounts saying mental illness doesn't exist, it’s all trauma inflicted by an inequitable and oppressive society

They think they’re different—but have the exact same mentality
2/ These superficially opposite camps both view mental suffering through the same judging, condemning, shaming, 𝘮𝘰𝘳𝘢𝘭𝘪𝘻𝘪𝘯𝘨 lens

They differ only in where they want to point the self-righteous, moralizing, blaming, shaming finger—at the individual or at society
3/ But neither camp can transcend their self-righteous moralizing. Someone or something must be 𝘣𝘭𝘢𝘮𝘦𝘥

There’s no interest on either side in listening, hearing, understanding, or grappling with the profound complexity of mental suffering

There is no possibility of that,
Read 9 tweets
Jonathan Shedler Profile picture
Jun 23
1/ We are the “authors” of all our thoughts & actions. We claim ownership of some of our thoughts and actions and disclaim ownership of others

When we claim ownership, we tend to use the word “I.” I did this. I said that

When we disclaim ownership, we tend to use the word “it”
2/ For example: I didn't mean it. The devil made me do it. It wasn’t me, it was the the alcohol. It wasn't me, that's not who I am. It just happened

Freud observed this & used exactly these words, “I” & “it,” to describe thoughts & actions that we claim & disclaim, respectively:
3/ “Das Is und Das Es.” I and it

The words were unfortunately mistranslated as ego & id, by a translator who thought he needed to make it sound more science-y. Unfortunate, because the original words were experience-near & intuitive to anyone. The simple starting observation of
Read 16 tweets
Jonathan Shedler Profile picture
Jun 10
They’re discussing psychoanalytic object relations. Mental representations of self & other are are formed through relational experiences & internalized as part of our inner world. The representations become templates/schemas for subsequent relationships & the patterns get relived
/2 Psychotherapy is also a relationship and in one way or another, these relational templates are recreated in the therapy relationship too. The dividing line between meaningful psychotherapy vs. 'something else' is that in meaningful therapy, the relational patterns will be
3/ recognized over time, discussed over time, explored, understood, and ideally, reworked. Thus the therapy relationship becomes, simultaneously, a vehicle for self-understanding and insight, and a template for a new and different kind of relationship with other people
Read 4 tweets
Jonathan Shedler Profile picture
Jun 9
1/ “These three roles [the abuser, the victim & the omnipotent rescuer] can appear in any particular order or sequence. A common sequence is for the therapist to start out in the role of rescuer (a role to which therapists are naturally inclined), while the patient begins in the
2/ role of victim. The therapist may become involved in an effort to be the perfect parent who will repair all the damage done by the real parent. This role is doomed to failure because the therapist is not a parent and will never be able to fulfill all of the patient's [needs]
3/ The therapist who tries to be an all-good parent starts running the extra mile by extending hours, not collecting the fee, taking repeated late-night calls and hugging the patient. Demands by the patient may escalate until the therapist begins to feel tormented, as though
Read 6 tweets
Jonathan Shedler Profile picture
Jun 2
1/ The “evidence-based therapy” game—explained with 🥞

I have a pancake recipe. I do randomized controlled trials (RCTs) showing that people like my 🥞 better than getting no breakfast at all

My🥞are now “evidence-based” & yours aren’t. I start telling everyone my🥞are superior
2/ I do more RCTs and compare my🥞to a fake🥞recipe. No one makes🥞with this fake recipe, I just made it up to be my “control group”—and left out key ingredients

I now have RCTs with an “active comparator” condition. My🥞 are empirically proven. They’re “the gold standard”
/3 I tell everyone my🥞are proven and your🥞 are scientifically discredited. No one should ever eat them

This seems a little unfair to you, so you start doing RCTs too—to study your🥞using the same research methods

Guess what? It turns out people like your🥞just as much as my🥞
Read 19 tweets
Jonathan Shedler Profile picture
May 30
1/ “The term ‘support’ has positive connotations to many therapists. It implies they are being helpful & help is what therapists intend to offer. It is consequently easy for therapists to overlook the very real limitations of supportive, helping interventions. For example, rather
2/ than solving a problem for a patient, the therapist can work to build the patient’s capacity to solve problems autonomously. In other words, there is another route available to therapists. Supportive interventions can be enormously useful at a given time for certain patients,
3/ when applied in a conscious, planned manner, with understanding and skill. However, very often supportive interventions are entered into almost reflexively and without much thought. Supportive interventions applied in this fashion often represent [dysfunctional relationship
Read 4 tweets

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