Good old fashioned psychotherapy is SO MANY DIFFERENT THINGS. Some of the following overlap a little, but what interests me is making a list of *mutually irreducible therapeutic endeavours*. If you think I've left out truly irreducible other such acts, might you add them below?🧵 1. Sometimes I'm 'just' a trustworthy recognition-affording ear. My patient's thoughts & feelings spontaneously up-well, self-organise, firm up in my presence. Her subjectivity then blooms; now she can grow as a person. It can feel to me like I'm "just listening" while she's...

Is an interpretation just a guess / hypothesis about what's going on for a patient? Well, yes and no. It is that. But it's delivered in a particular manner in a particular context, and this makes it what it is. The therapist is uniquely doing 2 things at once. 🧵 1. Trying to apprehend 'speaker's meaning' - listening to what the patient is trying to say, and having ordinary empathic responses to that. 2. Listening for what we could call 'psychological meaning' - what the patient's words and other responses themselves say about the ...

A serious vice of psychodynamic therapy, in practice if not in theory, is apophenia: a tendency to over-narrate & see meaningful connections where none obtain. There's an interesting 'tell' for this visible in low-quality supervision groups... 1/7 A supervising clinician who's never met the patient will, on the basis of your descriptions of the patient and of a session or two, quickly start to theorise the unconscious dynamics at play (not in you who is actually in front of them, but) in the patient. The ordinary 2/7

Depression, it's sometimes said, is not illness but a functional withdrawal response to dismal life situations. Like immune responses: they can feel bad, but are to a good end, so let's not pathologise them or get in their way. But then again, such responses can be excessive... (allergies, asthma, eczema) causing true illness. And might not the psychological equivalent be precisely what we call depression the illness (not mere depressed mood)? Or a metaphorical auto-immune response: the mind now reacting to its own products as if to foreign bodies?

So I'm reading this book by Christopher Jamison OSB. He's talking about how our earliest experiences are often of the withdrawal of love, ie of #loneliness. In it he references an interview by Kirsty Young of @TomHanks (). 1/11 bbc.co.uk/programmes/b07…
At 11:38 he offers her this Beatles song:
"There's a place
Where I can go
When I feel low
When I feel blue
And it's my mind
And there's no time
When I'm alone
I think of you
And things you do
Go round my head
The things you said
Like I love only you" 2/11

Psychoanalysis: Straightening the Crooked Path🧵

When you're by yourself you're probably spending a good part of your time in imagined conversation. Much of what we call 'thinking' is in fact internalised, self-readying, chat. You try out conversational moves, shore up your defences against being misunderstood, judged unfairly, accused of pride, etc. This is, all at once, an intellectual and an emotionally charged affair. It can all be like an earworm you don't even realise is inwardly playing.

Psychotherapy sessions can sometimes settle into a pattern of a patient talking a good deal about their week, their struggles and successes. I think it easy for clinicians to be dismissive of such a use of therapy. 1/9 Perhaps we think:
i) Talking to a friend would be as good.
ii) This isn’t working on a problem; there’s no clinical focus.
iii) It’s a defensively-driven evasion of the real emotional issues. 2/9

Read books on either child development or psychotherapy and you’ll typically get the impression that what the child mainly needs is the m/other’s accurate reading and reflection of their affects, and their successful containment of such affects as are overwhelming. 1/5 This kind of picture is exactly what you get when you mistakenly think that psychological rather than ethical discourse provides the essential disclosure of humanity. It gives us, in effect, a psychologised notion of recognition. 2/5

two forgivenesses (and the mourning of hope): 🧵

Two forms of forgiveness are alive in our moral lives, forms which must be understood separately. We call them both ‘forgiveness’ because they both involve putting down resentment. But the resemblances do not proliferate. 1/7 1. Interpersonal: You wrong your friend but later, realising the selfishness of your ways, come back contrite. You own and confess your sin. You ask what you can do, and attempt, to put it right; you ask your friend if they might give you another chance. *They do just that*. 2/7

Therapeutic wisdom - a🧵

1. Integrity as the lynchpin of integration: We hear lots about punitive hence disintegrative superegos, & too little about the integrative power of conscience. Keep your word, avoid hypocrisy, shoot straight: your heart now stands a chance of wholeness. 2. Get on good terms with yr true conscience and ordinary shame. Too many struggle to own their bad, repent, tolerate shame. So they project, deny, self-punish - & create interpersonal & intrapsychic misery. Instead: bear with your guilt & shame... & try to put things right.

Out today! - my “On Madness” - available in pb hb & ebook from Bloomsbury: bloomsbury.com/uk/on-madness-… Herewith a🧵 detailing some of its key notions. OM is unapologetically philosophical, yet keeps its eye on the psychotic subject’s intolerable predicament. Philosophy here is tasked not with fancy theorising but with diagnosing and stemming psychological theorists’ tendencies to evade rather than bear with psychotic suffering.

Does anyone here really think mental illness *isn’t* essentially *self-maintaining*? (I’m talking necessary not sufficient conditions.) I often see Twitter discussions which reframe MI as situationally-driven suffering. This always just seems odd to me. 1/6 What I see in the therapy clinic are paradigmatic MIs which qua MIs *always* involve a mind becoming unmoored from reality and instead, thru a reality-short-circuiting feedback loop, becoming rooted in and reactive to its own fearful/dismal fantasy. Sure, we can often see… 2/6

I was once helped greatly by a therapist who, when asked by me “ok I get it, why I keep feeling that, but what should I *do* about it?” said “what, other than understand yourself?” I want to explain why he was right - ie why understanding is often enough for change by itself. 1/4 We’re talking here not only about psychological understanding *had of* us, but also of such understanding as is *shown to* us. This is moral understanding. It’s intrinsically de-shaming. We feel accepted by it. And because of that it permits integration.

For Rogers the task of ‘becoming a person’ was about self-actualisation and self-worth. These are important, but that task more fundamentally requires the inculcation of the virtues - dignity, courage, conscience, love, prudence, etc. These are regulative ideals, developed over 1000s of years, for the living of functional, inwardly balanced, truthful, human lives. Therapy without them breeds narcissism - which in turn makes for instability, unconscious guilt, and unrewarding relationships.

People often ask “Isn’t psychotherapy a difficult job, all that suffering you’re having to vibe with all day?” And I say “No, conscious suffering is fine; it’s only having shame or guilt projected into me that wears me down”. Yet that’s not quite right. For what also gets… 1/4 … my spiritual goat is bearing unvoiced witness to the patient’s unconscious suffering. The silent, literally unbearable, sorrows of mankind are vast. Whether it’s the unknownly unlived life resulting from pain’s reflexive evasion. Or the blankness that takes its place. …2/4

Mental health ideologies perpetuate through the unwitting overgeneralisation from particular instances. (Wittgenstein: our “craving for generality”.) Certain patients, doctors, predicaments, contexts, become the model for all. On any occasion might we best seek: Inner work or inner acceptance?
Inner or environmental causes?
Change thru understanding or thru doing and experiencing?
Disability, illness, or problem in living?
Growth or recovery?
Working in past, present, or future? …

Dogmatic proclamation: Unless you, your patient, and your work together, are fundamentally motivated by an orientation to *the good and the true*, there’ll be no worthwhile therapeutic result. The only true, ongoing, therapeutic motor is a love-derived conscience. The right question is ‘how *ought* I to be treating myself and others?’ … Of course there’s toxic superego ‘oughts’ to defuse along the therapeutic way. But it’s corrupt to think the scope of moral obligation to self and other exhausted by superego edicts.

Let’s discuss what psychoanalytic therapy really is by first talking about what transference (T) is.

Look up definitions of T and you find they straightway go beyond what’s immediately encounterable. They talk of the repetition in the present of earlier forms of relationship. The idea is that your current tacit experience-shaping expectations of how you’ll be treated by others stem from your earliest relationships.

Well, no doubt they often do. But IMO we’re here already off on quite the wrong foot.

In his Salpêtrière consulting room, Pierre Janet gets the devil lodged in his somnambulistic patient Achille to bow to his commands. Here’s this devil’s petulant automatic writing. /1 The case of possessed Achille can be found in ch10 of Janet’s Névroses Et Idées Fixes. hansen-hypnose.com/cas-de-possess…

Achille: a 33 year old Parisian, with a grandfather prone to fugue, married at 22 and had a daughter. 10 years later he comes back distracted from a business trip. /2

On appeal to biological explanation in psychiatry. A 🧵.

It’s tempting to think that reference to (neuro)biological factors in psychopathological explanation is only warranted when there’s positive evidence for the contribution of such factors. (Think epilepsy.)

This is wrong. Now, to get it out the way: there is of course the relevance of biology for all (disturbed and non-disturbed) thought. You can’t have any kind of thought without having a brain that has this and that going on within itself. But, well, who cares about that.

Some of my own thinking…

OCD presents in semi-psychotic forms.
The distinction between thought and action gets blurred.
Unlike phobias the patient may well utterly lose a sense of the irrationality of their preoccupations. /1

https://twitter.com/drgipps/status/1471100967605186562

CBT models can underestimate pathology when they, say, articulate the issue as merely ‘mistaking a fear for a wish’ (as if it’s even clear what that means anyway) or focus mainly on inner hypervigilance. /2