1/ Legit therapist don't act "like therapists" on twitter. We're therapists in our offices, in context of a professional therapy relationship. Not on twitter.

Steer clear of anyone who respond "like a therapist" on twitter. They're already showing their lack of understanding &
2/ lack of professional boundaries.
Think about it. What would you think of an attorney who gave legal advice to a stranger based on a 280 character tweet? An MD who made diagnoses/wrote prescriptions based on a tweet? Most people would understand it's a screaming red flag.
/3 Yet some seem to think psychiatrists/ psychologists/therapists should engage with everyone on twitter as if they were our patients/clients.

No. It doesn't work that way & can't. If you think that's what "therapists" should do, it's time to seriously rethink your assumptions.
/4 Case in point: if a patient were rude or antagonistic, I'd likely get curious with them about their thoughts, feelings, & experience, including their perceptions & experience of me. I'd hold as an open question whether I had done something that hurt or offended, or whether
/5 their experience & reaction in the moment was being colored by a past experience or relationship with someone else, or perhaps some of both. This would happen in the context of an ongoing therapy relationship in which some trust had been established, and in which there was
6/ mutual understanding and agreement that this kind of inquiry and exploration would be and part of our relationship, as well as understanding of why and how this kind of exploration & inquiry could ultimately help them with the difficulties that brought them to therapy and for
7/ which they were seeking help. The relationship would also be one in which I give the person my full, undivided attention for the duration of our sessions, hold in mind why they've come for help, & use my clinical expertise to the best of my ability to provide that help. And
8/ I'd be getting paid to provide that very specific kind of attention and expertise.
NONE of these things is the case when a random person with whom I do not have a relationship addresses me in a rude or antagonistic way on twitter. Here, you'll get ignored or blocked.
9/ Or, depending on my mood, if you say something particularly irritating, you may get an irritated response back. And that's how it should be.
Twitter is not your therapy. Real psychiatrists/ psychologists/ therapists are not going to act like your therapist on twitter.

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More from @JonathanShedler

14 Sep
Patients recreate their problematic relationship patterns in therapy relationship & draw therapist into them as participant. True in ALL therapy relationships.

Recognizing/understanding the patterns is central to psychoanalytic therapy—and makes it possible to rework them.
/2 When treatments get stuck or reach an impasse, often because unrecognized relationship patterns are being reenacted in the therapy rather than being recognized/understood. For example, therapist can end up feeling just as helpless & ineffective as the patient feels but cannot
3/ express in words. Or as helpless and ineffective as the patient's parent had been. Or as confused. Or as enraged. Or as indifferent. Therapists who do not understand how relationship patterns are recreated in therapy will experience experience countertransference without
Read 4 tweets
13 Sep
1/ Narcissism & depression

"People with narcissistic personality are inherently vulnerable to depression. One source of vulnerability is a chronic gap between grandiose expectations and what the world affords. Rewards that come the person’s way fall short of those to which they
2/ feel entitled and are therefore devalued. Instead of feeling satisfaction & pleasure, the person ends up feeling disappointed & aggrieved. The gap between expectation and reality never closes, leading to dejection, hopelessness, and despair.
There is likewise a chronic gap
3/ between self-expectations & capabilities. The narcissistic person fantasizes about unlimited success, power, beauty, or talent. Instead of experiencing satisfaction and pride in legitimate accomplishments— which could provide a basis for realistic self-esteem— they perpetually
Read 7 tweets
12 Sep
1/ Interesting how a few psych terms suddenly get trendy on social media & become wastebasket explanations for anything/everything.

"Narcissist" used indiscriminately for toxic behavior, but most descriptions sound like psychopathic or borderline personality or a mix of them.
2/ "Trauma" used indiscriminately as catch-all explanation for any/all emotional pain, as if no other psychological explanation could exist. Term has specific meaning to experts, but in popular culture, now means everything & nothing.

Weirdest thing is how "therapists" with
3/ minimal training now adopt the language of social media & come to use the terms with the same (lack of) sophistication/understanding as found on social media.

So social media usage shapes the (mis)understanding of these "professionals," and these professionals" in turn shape
Read 4 tweets
11 Sep
1/ Clinical case formulation

"Clinical case formulations articulate cause and effect. For example, the person with depressive personality defends against anger, which finds indirect expression through self-criticism and self-punitiveness. The person with narcissistic personality Image
2/ inflates themselves to ward off underlying feelings of inadequacy and emptiness, but their defensively constructed self-image cuts off authentic connection with self and others. The person with borderline-dysregulated personality cannot reconcile contradictory perceptions and
3/ feeling states, and so gyrates between them. The person with paranoid personality sees their own projected hostility everywhere they look, and so experiences the world as cold and cruel.
Such statements describe cause-and-effect relationships that can form the nucleus of
Read 5 tweets
11 Sep
1/ Inexperienced therapists often confuse therapy goals with life goals. They're different. The goal of psychotherapy is *psychological change.*

“Treatment goals include areas that are influenceable by work on the self; life goals depend heavily on factors outside one's control.
2/ Therapy goals thus might include reducing perfectionism, increasing realistic self-esteem, resolving an internal conflict, making a difficult choice, mourning a painful loss, and so on.
Life goals include, for example, finding a partner or or spouse, getting a good job,
3/ becoming a parent. They may be attained more easily when therapy goals have met, but they are not themselves treatment goals. Clinicians cannot promise that at the end of the therapy there will be a partner, a job, or a baby; for those aspirations, too much depends on external
Read 4 tweets
9 Sep
Good question. In my view, there are no relevant quantitative data because that would presuppose academic researchers are measuring psychological change in therapy in meaningful ways. But they almost never considers "outcome" as anything beyond symptoms lists/questionnaires. [1]
Impossible to see what you've never even bothered look for.
Beyond that fatal flaw, the most widely-cited studies that claim to examine relation between therapist experience & outcome don't actually include therapists with meaningful experience, patient samples in which [2]
patients with serious & ingrained psychological problems are represented, or therapies of long enough duration for meaningful psychological change to take place. Anyone who reasons from these methods/findings to conclusion therapist training & experience doesn't matter is [3]
Read 4 tweets

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