1/ "Beginning in the mid-1990s, [depression] screening tools were developed specifically for primary care, and research projects (generally funded by pharmaceutical companies marketing antidepressants) were conducted with the aim of promoting their routine use. The results of
2/ these research projects were nearly always the same: reports in prestigious medical journals documented the validity of the screening tools but failed to mention that medical providers used the screening tools only for the duration of the research projects, while they
3/ received external support and incentives. When external support and incentives ended, providers stopped using the tools, essentially 'voting with their feet' regarding their perceived utility in day-to-day practice."
—J Shedler, 2017
4/ "The primary care physicians felt that tools that screened for depression alone had limited utility because they did not provide enough information to guide treatment decisions. The physicians were, in fact, correct.
Comorbidity of psychiatric disorders is the norm
and cases
5/ of depression alone are relatively rare. Epidemiologically, 78.5% of cases (12-month prevalence) of major depressive disorder (MDD) have additional psychiatric comorbidity, 'with MDD only rarely primary.' In practice , this means that physicians see depression accompanied by
6/ generalized anxiety, substance abuse, trauma, panic disorder, or any number of other configurations of symptoms & disorders which have different implications for treatment. For a substantial percentage of patients who screen positive for 'depression,' treating depression
7 per se may not be the correct treatment decision.
From the perspective of primary care providers,
screening for depression alone amounts to opening
Pandora's box without providing actionable information for treatment decisions."

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More from @JonathanShedler

20 Jul
Term "empathy" rampantly misused in therapy professions to refer only to patient's nicer, needier feelings—so therapist can play caretaker role.

Empathy has to apply to full spectrum of emotional experience including aggression, hostility, competitiveness, selfishness, etc. /1
Therapists who have empathy only for patients "nice" feelings signal that other parts of patient are unwelcome in therapy relationship and must go unheard/unacknowledged.

That's not therapy & it's ultimately destructive. For many patients, it simply reenacts early patterns /2
with caretakers that required child to distort himself to fit their image, negated & disavowed huge swaths of child's experience, & demanded self-estrangement as a condition of love and care. That's what did damage in the first place & set the stage for pt's current problems. /3
Read 4 tweets
18 Jul
1/ "Psychotherapist, psychoanalyst, therapist, hypnotherapist & counsellor are unprotected terms in the UK where there is no regulation. You can legally call yourself any of these titles without training."
"Anyone can call themselves a psychologist."
2/ So let's see... there are people with mental health problems, many desperate for help. And there are people with titles that sound legitimate/professional—that in fact mean *nothing.*
What could possibly go wrong?
Things are little better in the U.S.
3/ There are *huge* differences in training between mental health "professionals." There are ppl w doctorate degrees & decades of rigorous training, ppl with correspondence school degrees, ppl w mail-order degrees, & people w no legitimate training whatever. Public has no clue.
Read 5 tweets
15 Jul
1/ The term psychoanalytic (or psychodynamic) refers to three things: 1) a body of knowledge 2) a way of thinking about & understanding mind & behavior 3) a range of therapies (plural) based on this knowledge and understanding.
To speak of "psychodynamic" as if it were only a
2/ a modality of therapy betrays a profound misunderstanding of what it is & offers.
As an attending doctor in a psychiatry dept., I supervised psychiatry residents providing CBT, DBT, schema therapy, hospital C/L, ER crisis intervention, psychopharm, etc. When they got
3/ overwhelmed or stuck, it was virtually always a psychoanalytic lens that helped them navigate the impasse and find a way to be helpful to the patient.
Transference & countertransference, defense, rupture & repair in the therapy relationship, working alliance, & unconscious
Read 7 tweets
11 Jul
Narcissism is a thief of
-capacity to accept realities that can't be changed
-capacity to apologize
2/ Let's unpack this and consider why.
-There's little gratitude because there's a chronic gap between grandiose expectations vs. what reality affords. Rewards that come the person's way fall short of what they feel entitled and are therefore devalued. Instead of satisfaction
3/ and pleasure, the person ends up feeling disappointed and aggrieved.*
-There's little acceptance, because the person cannot relinquish their insistence on how things *should* be (vs. how they are). Reality should bend to the person's will, not vice versa. Acceptance would
Read 5 tweets
26 Jun
1/ "Personality is not about what disorders you have but about who you are. It refers to a person’s characteristic patterns of thought, feeling, behavior, motivation, defense, interpersonal functioning, and ways of experiencing self and others. All people have personalities and
2/ personality styles.
While there are as many personalities as people, clinical knowledge accrued over generations has given rise to a taxonomy of familiar personality styles or types. Most people, whether healthy or troubled, fit somewhere in the taxonomy. Empirical research
3/ over the past two decades has confirmed the major personality types & their core features.
Most theorists do not view the personality types as inherently disordered. They are generally discussed in the clinical literature as personality types or styles—not 'disorders.' Each
Read 11 tweets
17 Jun
1/ "I will generally use the term patient rather than client. In truth, both words are problematic, but patient seems to me the lesser of evils. The etymology of the word patient is 'one who suffers.' But for some, the word has come to imply a hierarchical power relationship,
2/ or conjures up images of authoritarian doctors performing procedures on disempowered recipients. These connotations are troublesome because psychoanalytic therapy is a shared, collaborative endeavor between two human beings, neither of whom has privileged access to truth.
3/ On the other hand, the term client does not seem to do justice to the dire, sometimes life-and-death seriousness of psychotherapy or the enormity of the responsibility therapists assume. My hairdresser, accountant, and yoga teacher have 'clients' but none to my knowledge
Read 6 tweets

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