I'm BAFFLED by therapists spending hours catching up on "notes." What in god's name are you writing? Who do you think they're for? Hint: Chart notes are NOT for your benefit—or your patient's (just the opposite). They should meet letter of the law & NOTHING MORE. Here's example:
2/ Chart notes are legal requirement, not part of your clinical work as a therapist. Communicate with your patient *in session*. If you're writing for your personal clinical purposes, write private process notes & never let them near patient chart. If you need to share info with
3/ a colleague, get permission & *speak to the colleague.* Chart notes are not for any of these thing. They're for regulators/health insurers/lawyers. Not—never—for clinical purposes. Nothing in chart note will ever help your patient. They can only be used against them (and you).
4/ And on a purely personal note, it would give me a special kind of yucky feeling if I thought my own therapist or analyst was writing extensive, detailed notes about what I said in sessions. Among other things, I’d wonder who he was writing to, or imagined he was writing to…
5/ and how and why this imaginary other had intruded into our relationship and had come to take up so much space. Is he really in the relationship with me? Or is the relationship really with his notepad, keyboard, or imaginary interlocutor?
• • •
Missing some Tweet in this thread? You can try to
force a refresh
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?
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
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
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
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
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