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

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

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

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)

But the narrative is a lie

https://twitter.com/JonathanShedler/status/1656157914581839873

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)

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,

https://twitter.com/drkristieleong/status/1777026381500633139

2/ which is 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 Rating Scale for Depression [HAM-D] compared to controls—which

1/ People have to understand that MH care changes when it’s provided in institutional settings—often profoundly, and rarely for the better

Institutions have administrative & financial agenda that are not necessarily aligned with patient’s interests. Usually, they’re under

https://twitter.com/rwillowfish/status/1774338920253194745

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

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

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

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

https://twitter.com/yello_zello/status/1771224341780353136

/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

Psychiatrist told my patient she had generalized anxiety disorder & would need to take meds (SSRIs) for life. When she objected, he said the meds were like eyeglasses—she could live without them but would always be handicapped

Symptoms gone after 6 mos psychotherapy & no meds /1 She even asked the psychiatrist if psychotherapy could address her difficulties. That’s when he came up with the eyeglass nonsense. He seemed to operate from the assumption that “GAD” (generalized anxiety disorder) is a medical disease to treat with medication, and a chronic
/2

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
4️⃣ More 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 & interdependently (communally)

People misunderstand therapy because they have no template for what serious psychotherapy is. They’ve never encountered it. So they apply their existing templates (friend, teacher) and get it wrong. Many poorly-trained therapist also get it wrong—they’ve never seen the real deal

https://twitter.com/KemtrupTweets/status/1762502629568164030

What people don’t get—and really cannot get unless they’ve been exposed to it—is that a psychotherapy relationship is NOT like other relationships. It’s not like a a friend, teacher, parent, coach, advisor, etc. It’s not like any other social or professional relationship. It’s /2

I did 10 podcast interviews in the past year. These 3 are the best of the best. Have a listen to any of them—you won't be disappointed!

1️⃣"Championing relational therapeutic solutions in a quick fix world"

Spotify

Apple podcasts
open.spotify.com/episode/7iQCLi…
podcasts.apple.com/us/podcast/tra…
2️⃣ "Evidence for Psychodynamic Psychotherapy"
thecarlatreport.com/blogs/2-the-ca…

💥Beginning the Treatment💥

When therapy gets stuck, it's usually because therapy started on the wrong foot

Here’s how to start on the right one

Maybe my best podcast ever!

YouTube

Spotify

Apple podcasts

open.spotify.com/episode/2bebLC…
podcasts.apple.com/us/podcast/psy…
2/ Hear the full interview on the Psychiatry and Psychotherapy Podcast with Dr.
@DavidPuder

Highlights: ROLE PLAYS showing how to work with resistance to engaging in therapy

Please share your comments and questions here!
podcasts.apple.com/us/podcast/205…

As well-trained clinicians know, psychosis refers to “formal thought disorder.” 𝘍𝘰𝘳𝘮𝘢𝘭 in this context means the form of the thought process—how a belief is arrived at—not the content of the belief

Eg, someone who believes a song playing on the radio is a secret message /1

https://twitter.com/philosofacespin/status/1759093832740671945

meant for them personally, telling them the government is corrupt & must be overthrown, is showing signs of a formal thought disorder. The issues is not whether the belief accords with reality. The govt may actually be corrupt, or not. It may or may not be a widely-held, /2

1/ "Moral masochism is relatively prevalent in the mental health and other helping professions. These professions offer ample opportunities for self-sacrifice, for example, by attending to others’ needs at the expense of one’s own. Disavowed sadism is often revealed through 2/ intolerance, harshly critical attitudes, or outright aggression toward others who fail the moral masochist’s tests of purity. Thus, moral superiority, self-righteousness, self-sacrifice, and sadistic cruelty can coexist.

A variant of moral masochism which is often referred to

1/ Truth is, many patients do not come to therapy to change. Not really.

They may say & think they want to change. It soon becomes evident they want to continue being exactly the person they have been, and living life in the same self-limiting ways, but 𝑓𝑒𝑒𝑙 better doing it. 2/ Real therapy begins with helping the person to not only understand but truly take to heart that what they want is impossible.

In other words, the real work of therapy may begin with crushing disappointment, as the patient struggles to reconcile with the painful truth that

1/ "By virtue of being human, we acquire certain relationship patterns, forged in the context of our earliest formative relationships. We view other people and relationships through these lenses. As a result, we tend to repeat certain relationship patterns
thecarlatreport.com/blogs/2-the-ca… 2/ throughout our lives. We bring these patterns and lenses into the psychotherapy relationship too—and in one way or another, we proceed to recreate them in the therapy relationship.

That's what we *want* to happen in psychotherapy. If we do therapy well, if we arrange things

1 "I'm sure your patients are getting better, just not—never—100%, right?"

"I don’t know what 100% better is. At some point, as my patients emerge from desperate pain, or self-constructed prisons, or endless looping of the same bad film, there is an inflection point in therapy, 2/ not necessarily a joyful one. Then arises the question: if not that, what?

The previously unspoken illusion of achieving perfection, nirvana, bliss collapses. If life is no longer defined by crushing depression or fear or inhibition... then what?

We cannot cure the condition

1/ "The model of projective identification, which provides a bridge between the intrapsychic & the interpersonal, can be applied to 3 of the common internal self- & object-representations one finds in borderline patients. These are the abuser, the victim & the omnipotent rescuer. 2/ "These tree roles can appear in any 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 role of victim. The therapist may become involved in an effort

Therapists of different persuasions talk past each other all the time, completely missing where the other is coming from

I think most therapy wars boil down to one thing

We either appreciate that unconscious mental life is with us always & central to psychotherapy

Or we do not 2/ If we think psychotherapy is about coming to know ourselves more fully & deeply (making conscious what has been unconscious), certain *principles* follow

This has nothing to do with following "rules"

It has to do with creating the conditions that make this work possible