1/ “The patient in psychotherapy, like the young child, may have an impossible time knowing his internal states—or even knowing that he has internal states that can be known—until these are recognized by another”
—David Wallin

This is why therapists who respond to patients only 2/ as hurt, vulnerable victims do them a disservice. Yes, we must recognize our patients’ hurt, vulnerable states so they can come to know these states. But we must also recognize and respond to their states of rage, spite, hate, envy, cruelty, destructiveness—and the entire rest

What expert therapists understand that others do not:

“What the patient does with the therapist in the room always holds a key to what caused her problem, what has kept it going, and what has made it difficult for her to benefit from previous efforts to treat it”
—Mary Jo Peebles 2/ Another way of saying it: expert psychotherapists do not rely on patients to *tell* us what is wrong. They do not know and cannot tell us (because unconscious mental life is real). We know they will *show* us

They have just entered a new relationship with a new and unknown

1/ Possibly 90% of arguments/disagreement about "diagnosis" in MH professions would disappear if people clarified whether they mean

1️⃣trying to trace & identify the source(s) of a problem (like my auto mechanic diagnosed the rattling noise) or

2️⃣using the DSM diagnostic manual 2/ If you intend to offer meaningful help for any problem, then you are necessarily in the business of "diagnosis" in the former sense of the word—working to understand what's wrong so you have a realistic chance of helping

For problems we typically address via psychotherapy,

1/ In Kernberg’s object relations model

1️⃣pathological narcissism
2️⃣malignant narcissism &
3️⃣psychopathy

form a continuum. Here’s my “Cliffs notes”

Pathological narcissism rests on the defense of splitting. The person identifies with the good parts of self and projects the bad 2/ parts onto others. In this way, they maintain a perception of self as good and righteous while seeing others as bad and inferior

In malignant narcissism, the projected badness is infused with hate & aggression. Others are not just seen as lesser but will be treated in cruel,

1/ from In Treatment season 1

Why do you think you had that particular memory the other night?
-Dr Paul Weston

Perhaps there’s a reason you had that particular memory the other night
-me (imagining I'm his consultant)

Two ways to invite reflection. Perhaps one is more inviting /2 This is a matter of therapy technique

Many therapists default to question-asking, intending to elicit the patient’s curiosity and self-reflection

But there are more refined ways to accomplish this

1/ Here's a two-question test to determine if you're getting meaningful, in-depth psychotherapy (part 1)

1️⃣ Think of a time you were upset with your therapist. Did you tell them? y/n

no = you are not working in depth
yes = you may be working in depth 2/ (part 2)

2️⃣ Did your therapist respond with non-defensive curiosity and genuine interest in hearing and further exploring your thoughts, feelings, and experience of them? y/n

no = you are not working in depth
yes = you may be working in depth

1/ A sure sign of bad therapy is that the client or patient leaves therapy sessions feeling better—but continues living their life the same way, repeating the same self-defeating patterns and getting the same unhappy outcomes

Real psychotherapy is not meant to be a feel-good 2/ balm or salve. It’s purpose is not to leave sessions in a better mood, or feeling calmer. It’s purpose is to help us understand how we unknowingly contribute to our own difficulties—and change that

Make no mistake, this entails difficult, painful work

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

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

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

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

1/ Ten “vital signs” of psychotherapy progress* 🧵

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)

“The problem you see on the surface is rarely the problem psychotherapy needs to address”

(from my workshop, “Personality styles in psychotherapy: a roadmap for deep and lasting change” hosted by @PCPSIreland) 2/ Here are some bonus slides...

1/ Pro tips for therapists🧵

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

In every successful therapy, there is a period when the patient feels more lost than ever. They are relinquishing old ways of being & have not yet consolidated new ways

We are changing life patterns. There is no path from point A to point B that does not pass through the unknown 2/ Real transformation occurs when patient and therapist embrace the unknown

But this is also the point when inexperienced therapists get anxious & want to rush in with solutions—instead of continuing the shared work of exploration, and accompanying the patient into the unknown

1/ “A strikingly cyclical effort to sanitize speech has contributed to widespread misunderstanding of psychoanalytic tradition. Over time, whatever the original intentions of those people who coined any specific psychological term, labels for certain conditions ineluctably come /2 to have a negative connotation. Language that was invented to be simply descriptive—in fact, invented to replace previous value-laden words—develops an evaluative cast and is applied, especially by lay people, in ways that pathologize.  Certain topics seem inherently

There’s a huge difference between “obsessing” and “ruminating” vs. discussion aimed at insight and self-understanding leading to CHANGE

Maybe people who don’t know the difference should not represent themselves as experts on anything having to do with psychology or psychotherapy

https://twitter.com/ScottAdamsSays/status/1828044200249896995

2/ When a person uses therapy sessions to replay the same loop over and over, we are seeing massive defenses at work.* The patient is, in fact, working (not necessarily consciously) to shut out new & different thoughts, feelings, perceptions, experiences, and understandings

Training in psychotherapy begins in earnest when it finally sinks in that giving advice doesn't help

And it sinks in that common-sense solutions haven’t helped and won’t help now

Meaningful psychotherapy is not an extension of common sense. It is something else entirely. 2/ It’s fair to ask WHY advice and commonsense solutions don't help

There’s a lot to say about his, but ONE crucial reason (among many others) is that the problem you see on the surface is rarely the problem that therapy needs to address

There is the *surface* problem or the

1/ Lot’s of people commented on this article showing that providing DBT in schools HARMED teens’ mental health

But no one seemed to notice the highlighted sentence. DBT worsened depression with an effect size >2

That number is utterly implausible
sciencedirect.com/science/articl…
2/ There are no interventions in psychology or psychiatry with effect sizes that large or anywhere close

What could account for it?

👉One possibility is computational error
👉Another is that we are seeing what researchers long ago termed the “screw you effect.” If you piss off

1/ Listening non-judgmentally is not something therapists learn from a book or class. It takes years of work

We can listen without judging because we have examined the dark corners of our own souls in personal psychotherapy. What you think shocking, we know to be simply human 2/ Therapists who have not done the hard work of in-depth personal treatment over an extended time do not and cannot listen non-judgmentally

They can tell themselves they do, they can play the role of what they think it is—but it is performative and patients can feel it

1/ Masochism is a key psychoanalytic concept

One form is victim entitlement—insistence one is entitled to special compensation in proportion to suffering & victimhood. Thus the need to *amplify* suffering in all ways

Without treatment, suffering/victimhood becomes a way of life 2/ A big therapy challenge is the patient's deeply-rooted (not necessarily conscious) conviction that if only they suffer enough & make their case convincingly enough, all past wrongs will be righted & made up to them. Relinquishing suffering is therefore tantamount to giving up