Jonathan Shedler Profile picture
Oct 1, 2020 6 tweets 2 min read Read on X
1/ The PHQ-2 & PHQ-9 are those ubiquitous depression screening questions in medical offices. New article tells us they're "validated" against structured interviews used in research. But... what are those interviews validated against?
It's not the snarky
jamanetwork.com/journals/jama/…
2/ question it may appear to be. Seriously, what were they validated against? The PHQ screeners were designed so non-experts without training in psych could make psych diagnoses by following the instructions. But here's the kicker... the "gold standard" structured interviews
3/ (like SCID) are also nearly always administered by non-experts, typically research assistant or students—not by psychiatrists or psychologists. So the interviews were *also* designed so non-experts could make psych diagnoses by following paint-by-number instructions.
4/ The questions in the PHQ and the structured interviews ask about the same checklist of things. In practice, there's no actual expertise involved in the assessments on either side of "validation" equation. Responses to rote questions administered by non-experts
/5 in one office predict responses to basically same rote questions administered by non-experts in another office. That is literally how it's typically done. Then ppl speak solemnly about "established validity." Few look behind the word "validity."
6/ Researchers will ask, what was questionnaire validated against?" And answer is usually another questionnaire. No asks next question... "And what was THAT validated against?"
Because answer is usually a tautology.

End of today's psychometrics lesson.

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More from @JonathanShedler

Sep 21
1/ There’s a world of difference between sharing painful personal experiences in a close, ongoing personal relationship vs. broadcasting them to strangers on the internet

Sharing a painful emotional experience in a meaningful personal relationship builds emotional intimacy and
2/ connection. Sharing it with unseen strangers *takes the place* of connection—and is often a defense against connection

It reminds me of a case one of my professors described, early in my graduate training. It involved a quite disturbed child, maybe 6 or 7 years old. One of
3/ his weird behaviors was kissing random people in school—teachers, classmates, whomever

The professor said one thing that has stayed with me all these years:

If you go around kissing random strangers, what does it mean when you kiss your mother?
Read 4 tweets
Sep 18
1/ Sixteen psychoanalytic concepts for our time (updated) 🧵

Splitting: Perceiving others in black-and-white categories; seeing them as one-dimensional, as good or bad
2/ Denial: Refusal to acknowledge or accept reality when it does not fit your wishes & preferences
3/ Omnipotent Control: Seeking to control others’ behavior, speech, and even thoughts; insisting that others should think your thoughts instead of their own
Read 17 tweets
Sep 16
1/ I’ve never had a “noncompliant” therapy patient. I don't even find the word helpful. It implies therapist brings an agenda for patient to follow, but that’s not how good therapy works. Good therapy means a “working alliance”—a shared understanding & agreement about the purpose
2/ of therapy and methods used to achieve that purpose. The initial sessions (the “consultation phase”) are devoted to developing that shared understanding

That takes two—it takes collaboration to reach a meeting of minds about the purpose and the methods of therapy
3/ The purpose must fit the therapist’s understanding of what is going on psychologically that’s giving rise to the patient’s difficulties, that is realistically possible to change in psychotherapy, that the patient recognizes (with the therapist’s help) is causing difficulties
Read 11 tweets
Sep 15
1/ “The available data suggest that the majority of carefully selected patients who undergo 16 sessions of cognitive or interpersonal therapy for depression (the treatment length prescribed in the manuals) administered by highly trained and supervised therapists in clinical
2/ trials fails to improve, remains symptomatic at termination, and relapses or seeks further treatment within 18 months. In light of these dismal outcome statistics, and the fact that no one has ever compared these treatments with treatment in the community by expert
3/ practitioners, the assertion that clinicians should start with one of these manuals seems [indefensible]. It is unfortunate that researchers made the collective decision over the last 20 years to study only brief trials of only two treatments for a subset of poorly
Read 4 tweets
Sep 11
1/ Ten “vital signs” of psychotherapy progress* 🧵

1️⃣Greater attachment security / sense of safety in relationships
2️⃣More integrated & coherent experience of self & others
3️⃣Increased sense of personal agency
4️⃣More realistically-grounded & reliable self-esteem

(video at end)
2/ “vital signs” cont'd

5️⃣Greater emotional resilience & capacity for affect regulation
6️⃣Greater ability to reflect on & understand own and others' inner experience (“mentalization”)
7️⃣Increased comfort functioning both independently and interdependently (communally)
3/ “vital signs” cont'd

8️⃣ More robust sense of vitality and aliveness
9️⃣ Enhanced capacity for acceptance, forgiveness, gratitude
🔟 Movement toward more mature and flexible defenses

*adapted from Nancy McWilliams, “Psychoanalytic Supervision,” chapt. 3
Read 4 tweets
Sep 9
1/ Pro tips for therapists🧵

At first appointment with a new patient/client, there are three things you want to find out

1️⃣ What's wrong?
2️⃣ How are they hoping therapy can help?
3️⃣ Why now?

Some elaboration on these 3 things...

➡️ People don't come to therapy for sport. They
2/ come because they’re in pain. Something is wrong. An understanding of what’s wrong is the starting point for any work you will do

➡️ It's crucial to find out their ideas/hopes about how therapy can help them. This is an invitation to start to think together about how things
3/ could be different, what that might look like, and their initial ideas about how therapy might help them get there

The patient’s/client’s ideas about how therapy can help may be realistic or unrealistic. They may be vague or specific. They may have trouble even imagining how
Read 14 tweets

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