1/ Highlights from this crucially important paper:

About 7 out of 10 patients who get “evidence-based therapy” for depression are still depressed after treatment

Of the 3 that get well, about half would have gotten well without treatment

No significant differences between types of therapy (the “dodo bird verdict”)

“Third wave” therapies (eg, ACT) no better than plain old CBT, or any other form of treatment

From the paper: “Most patients do not respond or remit after therapy, and more effective treatments are clearly needed”

So… can someone please explain to me again why these treatments are routinely called “evidence-based therapy?” 2/ When the benchmark is “getting better”—not just doing better than a control group—this is what research shows

Most patients get little or no benefit from brief therapy. This is what research has has shown for 40-50 years. The findings have been consistent for half a century

1/ This quotation needs more psychological nuance. In fact, it’s in our human nature to take pleasure in others’ downfall, for many reasons—often unconscious

It’s not so much that we “make monsters of ourselves,” because the monster is already within. In the words of Aleksandr

https://twitter.com/JonathanShedler/status/1947380492661363038

2/ Solzhenitsyn, “The line dividing good and evil cuts through the heart of every human being”

It is that *acting* on these impulses—publicly reveling in sadistic glee, joining in the pile-on, inciting others to pile on—feeds that inner monster. It grows larger and uglier, and

Your grad school professors likely had no idea what “neutrality” means. Most never learned and just parrot the misinformation they were taught

It means *ultimate respect for client’s autonomy and self-determination*

You are in favor of that, aren’t you? In Freud’s own words👇

https://twitter.com/JonathanShedler/status/1590759003818426368

2/ In historic usage, it referred to taking a position (as a matter of *technique,* aimed at self-knowledge) equidistant from id, ego, & superego—terms that no longer hold currency in contemporary psychoanalytic theory, and that are now meaningless to most

So here’s an update:

My first major research article showed it’s impossible to measure mental health by self-report data (eg, a survey). Data are uninterpretable

If people *report* good mental health, it MAY mean good MH. But it’s at least as likely to mean defensiveness and self-deception

source👇

https://twitter.com/charliekirk11/status/1929912533378576590

2/ This is called “Illusory Mental Health”

Published in American Psychologist (premier/flagship journal of the American Psychological Association) jonathanshedler.com/PDFs/Shedler%2…

1/ Depressive Personality Style
“Despite its omission from the DSM, depressive personality is the most common personality syndrome seen in clinical practice. It is a personality syndrome in every sense of the term: an enduring pattern of psychological functioning evident by 2/ adolescence and encompassing the full spectrum of personality processes.

People with depressive personalities are chronically vulnerable to painful affect, especially feelings of inadequacy, sadness, guilt, and shame. They have difficulty recognizing their needs, and when

1/6 The goal of psychotherapy is to insert spaces for noticing and reflecting where space has not previously existed—and thereby create opportunities to know ourselves more fully, connect with others more deeply, and live our lives more congruently 2/6 Psychotherapy is about slowing things down—so we can begin to see and understand patterns and responses that otherwise happen quickly, automatically, without awareness or understanding

1/ This post is misleading. The research does NOT show people who get these CBT treatments get well—what people take “effective” to mean. Overwhelming majority do NOT. They do better than a control group, which is a totally different issue

People go to therapy to get well, or

https://twitter.com/jamapsych/status/1916462337155858894

2/ at least meaningfully better

Not to do better than a control group which gets no treatment that’s meant to help (or no treatment at all)

This is why people have become so skeptical of “experts.” What they get isn’t what they’re led to expect

1/ The essence of real psychotherapy is exploring and understanding why things go wrong, so we don't have to keep repeating the same painful, self-defeating patterns

👉 But... many poorly-trained therapists cannot differentiate between exploring and understanding vs. BLAMING 2/ When they confuse exploration with blaming, they’re trapped. Psychological inquiry can lead only to (1) blaming the patient or (2) blaming the patient’s problems on someone or something else

👉They can’t blame the patient, because they’re

1/ Why MH diagnostic language sounds stigmatizing

“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, 2/ labels for certain conditions ineluctably come 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

1/ Malignant narcissism

“Malignant narcissism is a variant of narcissistic personality that has gained public attention in recent years. It is, in fact, the intersection of narcissistic personality and antisocial-psychopathic personality, blending the characteristics of both. 2/ Malignant narcissism is also described by clinical theorists as narcissism suffused with sadistic aggression. It is not sufficient for the malignant narcissist to feel important and special; it is necessary for someone else to be demeaned or vanquished.

“In a large meta-analysis of 562 randomized controlled trials… we found no indication that the effects of therapies have improved over time”

—from Cuijpers et al (2023), Five Decades of Research on Psychological Treatments of Depression 2/ Over time, the no. of published studies increased dramatically—but no increase in benefits to patients

Also, more & more of the research is on CBT and its endless new variants, always hyped—in name of “science”—as advances/breakthroughs

The actual evidence contradicts this

I don't know what “self love” means

Developmentally, a healthy sense of self is formed via relationships, as we internalize relational experiences of care and attunement. Real change in self-experience requires a real relationship

“Self love” in a vacuum is narcissism 2/ We cannot internalize experiences of care and attunement from interactions with apps, bots, AI, worksheets, or parasocial relationships with people who don’t actually know us—or any of the other things we’re often offered as psychotherapy “alternatives”

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