Professor, psychologist, author. Tweets about psychology, psychiatry, psychotherapy.
I say the quiet part out loud.
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Jun 29 • 9 tweets • 2 min read
1/ I see right-leaning accounts saying mental suffering is a weakness/character flaw
and left-leaning accounts saying mental illness doesn't exist, it’s all trauma inflicted by an inequitable and oppressive society
They think they’re different—but have the exact same mentality
2/ These superficially opposite camps both view mental suffering through the same judging, condemning, shaming, 𝘮𝘰𝘳𝘢𝘭𝘪𝘻𝘪𝘯𝘨 lens
They differ only in where they want to point the self-righteous, moralizing, blaming, shaming finger—at the individual or at society
Jun 23 • 16 tweets • 3 min read
1/ We are the “authors” of all our thoughts & actions. We claim ownership of some of our thoughts and actions and disclaim ownership of others
When we claim ownership, we tend to use the word “I.” I did this. I said that
When we disclaim ownership, we tend to use the word “it”
2/ For example: I didn't mean it. The devil made me do it. It wasn’t me, it was the the alcohol. It wasn't me, that's not who I am. It just happened
Freud observed this & used exactly these words, “I” & “it,” to describe thoughts & actions that we claim & disclaim, respectively:
Jun 10 • 4 tweets • 1 min read
They’re discussing psychoanalytic object relations. Mental representations of self & other are are formed through relational experiences & internalized as part of our inner world. The representations become templates/schemas for subsequent relationships & the patterns get relived
/2 Psychotherapy is also a relationship and in one way or another, these relational templates are recreated in the therapy relationship too. The dividing line between meaningful psychotherapy vs. 'something else' is that in meaningful therapy, the relational patterns will be
Jun 9 • 6 tweets • 1 min read
1/ “These three roles [the abuser, the victim & the omnipotent rescuer] can appear in any particular order or sequence. A common sequence is for the therapist to start out in the role of rescuer (a role to which therapists are naturally inclined), while the patient begins in the
2/ role of victim. The therapist may become involved in an effort to be the perfect parent who will repair all the damage done by the real parent. This role is doomed to failure because the therapist is not a parent and will never be able to fulfill all of the patient's [needs]
Jun 2 • 19 tweets • 4 min read
1/ The “evidence-based therapy” game—explained with 🥞
I have a pancake recipe. I do randomized controlled trials (RCTs) showing that people like my 🥞 better than getting no breakfast at all
My🥞are now “evidence-based” & yours aren’t. I start telling everyone my🥞are superior
2/ I do more RCTs and compare my🥞to a fake🥞recipe. No one makes🥞with this fake recipe, I just made it up to be my “control group”—and left out key ingredients
I now have RCTs with an “active comparator” condition. My🥞 are empirically proven. They’re “the gold standard”
May 30 • 4 tweets • 1 min read
1/ “The term ‘support’ has positive connotations to many therapists. It implies they are being helpful & help is what therapists intend to offer. It is consequently easy for therapists to overlook the very real limitations of supportive, helping interventions. For example, rather
2/ than solving a problem for a patient, the therapist can work to build the patient’s capacity to solve problems autonomously. In other words, there is another route available to therapists. Supportive interventions can be enormously useful at a given time for certain patients,
May 18 • 8 tweets • 2 min read
1/ Therapy “outcome” is not a standardized scale a researcher, who's never met the patient, chooses in advance & superimposes on therapy process
Real outcome is a shared understanding of desired personal change that emerges organically from the therapy work—unique to each person
2/ Most therapy outcome researchers are not, in fact studying “outcome” in ways meaningful to patients or therapists. They’re making assumptions about what people they don't know want from psychotherapy, and the assumptions often have little to do with what patients actually want
May 15 • 5 tweets • 2 min read
1/ Rule of thumb, part 1
Most therapy patients will begin to feel somewhat better within first weeks. Expect 6-12 months to make headway with underlying psychological causes
part 2
Add 6 additional mos. for every prior treatment with manualized, "evidence-based" therapy
more⬇️ 2/ what they have to unlearn:
-that there’s a quick fix
-that therapist has the answers / can tell them what to do
-that there's a bypass around the honest hard work of self-reflection and self-understanding
-that therapy isn't a procedure done to them, it’s a relationship &
May 11 • 6 tweets • 1 min read
1/ I’m not sure, but leaning toward the view that all the research showing that therapeutic alliance predicts therapy outcome may be leading us astray. Here me out
Just about any well-intentioned therapist can develop a decent working alliance with someone at the healthier end
2/ of the spectrum of personality functioning (reasonably securely attached, good object relations, mature defenses, no serious personality pathology)
But it’s incredibly difficult to develop a working alliance with people with more severe character pathology (impaired capacity
Apr 30 • 9 tweets • 2 min read
1/ I made a list a while ago, about therapy🚩 that should make you think long & hard about whether you’re seeing right therapist
Starting another, please add
-agrees with nearly everything you say
-diagnoses people in your life
-gives you advice
-mawkish displays of “empathy"
2/ -defaults to calming/soothing in response to everything
-acts like cheerleader/coach
-wants to play role of hero or savior
-wants to plays role of spiritual or religious guide
-validates & affirms whatever you say
-speaks in jargon or “therapy speak” instead of plain English
Apr 26 • 7 tweets • 2 min read
1/ Absolutely none of these conclusions are justified
1️⃣ Patients who exercised showed some minimal improvement—but not enough to matter
2️⃣ The patients were not severely depressed to begin with
3️⃣ We already know that antidepressants & brief therapy (8-12 sessions, which is
2/ pretty much all that’s ever studied in research trials) are inadequate treatment for most depressed patients most of the time
(Avg effect of antidepressants in research trials is < 2 points on Hamilton Depression Rating Scale compared to controls—which is clinically trivial)
Apr 25 • 4 tweets • 1 min read
1/ “Therapists need to be oriented toward... patient’s degree of felt power to influence events.
Many people come to treatment feeling that things just ‘happen to’ them. The absence of a sense of agency is inferable when the therapist has asked a question such as, ‘Were you
2/ feeling sexual desire when you agreed to give oral sex to that guy?’ and meets a blank stare or a response like, ‘I don’t know. It seemed like the thing to do at the time.’ Patients who give such answers are often the same ones who wait passively for the therapist to tell
Apr 24 • 11 tweets • 2 min read
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 the methods to be 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 the minds about the purpose of & methods of therapy
Apr 13 • 12 tweets • 2 min read
1/ Contrary to what therapists are often taught, we don’t protect patient privacy & confidentiality because it’s an ethical or legal requirement, although it’s that too. We protect privacy & confidentiality because it is the 𝘱𝘳𝘦𝘤𝘰𝘯𝘥𝘪𝘵𝘪𝘰𝘯 for honest self-exploration
2/ We are asking the patient to share their most personal and vulnerable thoughts, feelings, desires, and fears. We are asking them to share things they may have never told another soul. We are asking them to tell us things they may have never previously told 𝘵𝘩𝘦𝘮𝘴𝘦𝘭𝘷𝘦𝘴
Apr 11 • 5 tweets • 1 min read
1/ The goal of psychotherapy is to insert spaces for reflection where they have not previously existed—and thereby create opportunities to know ourselves more fully, connect with others more deeply, and live life more congruently
2/ Psychotherapy is about slowing things down—so we can begin to see and understand the patterns that otherwise happen quickly, automatically, without reflection or awareness
Apr 11 • 6 tweets • 2 min read
1/ One reason the therapy world is so polarized is that CBT made psychoanalysis part of its PR narrative & origin story
The narrative is that CBT is evidence-based & psychoanalytic treatment is not, and science (good) triumphed over darkness (evil)
2/ The claims that CBT is science & "CBT Works" come from Randomized Controlled Trials (RCTs). The narrative is that RCTs evidence supports CBT not psychoanalysis
The problem is that RCTs of psychoanalytic therapy show equally good results (in long run, possibly better results)
Apr 10 • 6 tweets • 2 min read
1/ Absolutely none of these conclusions are justified
1️⃣ Patients who exercised showed some minimal improvement—but not enough to matter
2️⃣ The patients were not severely depressed to begin with
3️⃣ We already know that both antidepressants & brief therapy (8-12 sessions,
2/ tremendous pressure to do more with less, the clinicians are overwhelmed, and they just cannot spend the time with patients that patients really need
In large institutions, MBAs & accountants & lawyers may call the shots in the background, in ways that seriously impact
Mar 30 • 6 tweets • 1 min read
1/ People’s misconceptions about psychotherapy are dismaying
In last 2 days, I've seen tweets from people who think its purpose is to calm or soothe, to forgive, feel gratitude, be in a loving state of mind, become happy
it all sounds warm & fuzzy but, NO
And while it’s true
2/ any of these things may occur in the course of a particular therapy, or may possibly follow from it, none of them can be the purpose or goal of psychotherapy
Meaningful psychotherapy has one purpose: psychological change
More specifically, it’s to change something about
Mar 25 • 14 tweets • 3 min read
Therapy influencers get millions of follows w 1 core message
😇You are a victim & you are a good
😡Someone else is to blame & they are evil
It feels good because it sides with our defenses, not insight & self-awareness
In the long run, it’s a self-destructive & self-defeating
/2 More specifically, the message bolsters the defenses of splitting and primitive projection—among the costliest defenses of all defenses
Splitting is a form of dissociation where we compartmentalize good and bad feelings, dividing ourselves and others into binary categories
Mar 23 • 6 tweets • 2 min read
1/ I consider it malpractice for a psychotherapist to do paperwork in session. The patient has a right to our full presence and attention. That’s a bare minimum requirement for a psychotherapy relationship. Without that, psychotherapy is not happening
/2 What we’re really seeing is ever-greater encroachment & intrusion of administrative, bureaucratic, and financial agenda into the therapist-patient relationship & therapy “space,” with less and less space (if there is any space left at all) for the actual work of psychotherapy
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