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Jonathan Shedler Profile picture
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Oct 20 • 4 tweets • 1 min read
People need to understand this
This is why your psychotherapist doesn't take insurance (one reason)
This is how health insurers manufacture a shortage of mental health clinicians
#MentalHealthParity
2/ It's a safe bet their pay scale is shit too (this is the simplest & easiest way insurers circumvent parity laws). Now they're imposing additional hours of unpaid labor, beyond the time they do pay for. Multiply this by all the other patients where this come up, regularly
3/ Then factor in endless intrusions into the therapy relationship which can make it impossible to provide the care the patient actually needs and clinician is trained to provide. Plus crushing, soul destroying bureaucracy & meaningless paperwork. Who wouldn't want such a career?
/4 Dealing with all the intrusions & endless, meaningless paperwork is more unpaid labor, none of it optional. But paying office expenses, malpractice insurance, professional dues, continuing education, etc etc is not optional. The only certainty is the insurance company's profit

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More from @JonathanShedler

Jonathan Shedler Profile picture
Oct 9
1/ Psychotherapy is not a "thing" that exists on its own, independent of complex system comprising therapist, patient & their dynamically changing relationship. In complex systems, all variables reciprocally cause all others. You cannot "isolate" causal effect of any component.
2/ We can say "psychotherapy" is an emergent property of the complex system—not a thing with an independent existence. This is fundamentally different than a drug, which is an actual "thing," with effects that can be experimentally isolated.
If we do psychotherapy research
3/ based on the assumption that therapy models are "things" and their effect can be "isolated" using the same experimental methods used to isolate the effects of "things," we have a fundamental mismatch between the research methods/assumptions and the phenomenon of study.
Read 6 tweets
Jonathan Shedler Profile picture
Oct 7
If you experience a patient as overwhelming, draining, off-putting etc, that's a first-hand window into a) their inner world and b) what's getting in the way of other relationships

This is why they came to therapy. It's inseparable from their other difficulties. This is the work
2/ This is a difference between relational therapies aimed at self-understanding & growth vs. manualized "evidence-based" therapies focused on sx of anxiety/depression/other DSM Dx

Is what's manifested in therapy relationship seen as a distraction from the work, or its purpose?
3/ If therapist feels consistently overwhelmed/ drained/etc & cannot make constructive use of this information (and it is information) to move therapy forward/ facilitate change—it's time to seek clinical consultation from trusted consultant. No one *ever* outgrows need for this.
Read 5 tweets
Jonathan Shedler Profile picture
Oct 5
1/ This is a true story. It happened to someone I know. He was mugged at gunpoint. He handed over his wallet. Then the mugger aimed at his head and pulled the trigger. He was shot in the face. He lived. The mugger was caught and went to jail. But not long after, he received word
2/ the man who shot him would be released. He was told the date.
He tried to wrap his head around it. The person who tried to kill him would walk free. He became obsessed with finding him and killing him. Night and day, he agonized, in rage and anguish.
3/ In desperation, he turned to his sensei, a renowned martial arts master, for advice.
In this martial arts school, character mattered. The ultimate purpose of training was to polish character. A black belt made a commitment to live honorably. It was not a sport.
Read 9 tweets
Jonathan Shedler Profile picture
Oct 2
I do not practice a "type" of psychotherapy. The therapy I provide is based on my case formulation for a specific person. I have never provided the same therapy twice.

It is therapy for that person alone.

This is something outcome researchers seem incapable of grasping.
/2 I also cannot specify my "interventions" in advance because patients are not passive recipient of interventions. I do something & the patient responds. Their response determines what I do next. Each patient teaches me, moment by moment, how to do psychotherapy *for them.*
3/ Causation is reciprocal and bidirectional, not unidirectional. Which is exactly the opposite of how researchers assume therapy works. If our shared goal is self-knowledge and self-understanding (and those are not always goals of therapy), then I primarily monitor one thing:
Read 8 tweets
Jonathan Shedler Profile picture
Sep 29
Many patient cannot conceive of a relationship in which problems are acknowledged, and no one has to be put on trial, blamed, or shamed. They’ve never experienced it prior to the therapy relationship—and cannot bring themselves to believe it when such a relationship is offered.
/2 In therapy, such patients tend to

1️⃣ experience therapist as blaming, regardless of therapist’s words/actions 2️⃣ find reasons to blame therapist
3️⃣ enlist therapist to join them in blaming someone/something else

These seem like different things. A sophisticated therapist
/3 will recognize them as variants of the same relationship (accused and accuser) with the roles simply exchanged.
Read 8 tweets
Jonathan Shedler Profile picture
Sep 21
This is terrible recommendation
-Primary care is not the place for mental health care
-If adequate m.h. care remains inaccessible to most Americans, screening is pointless
-The real problem is insurance companies create impossible obstacles to getting care
nyti.ms/3LtqYwq
2/
 -This will lead to an increase in unnecessary prescriptions—because that's basically all primary care physicians can offer
-Pharma execs are popping champagne bottles now. And strategizing how to shift prescribing patterns to the most expensive on-patent meds.
-None of this
3/
 -is speculation. It's happened before. It's *exactly* how the pharma industry created a vast market for antidepressants in the 90s... just by promoting "screening"in primary care
-And needless to say, almost no one will pay attention to the one treatment that could actually
Read 5 tweets

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