Kemtrup
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Lecturer in Philosophy. LMFT in Private Practice.
Joined November 2016
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Thread on the confusingly many diff kinds of therapy and what we should do about it:
The public must be very confused about what they will experience when they see a psychotherapist. They hear many acronyms and names: EMDR, ACT, AEDP, EFT, DBT, CBT, Rogerian, etc. It takes...
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@matthewlehew
If they’re not gonna comply, you don’t have to either. Show up in properly fitted n95, face shield, paper scrubs. Speak low volume to not circulate air. Speak from windows and bring fan/hepa . If they can’t hear, shrug. Play taped lectures and stand quiet.
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@matthewlehew
I don’t mean to sound extreme. And how to respond to covid is complex, etc.
But sometimes we teachers go to far in assuming we need to just go along with the students needs, to sacrifice our needs to their needs. You could get feisty instead.
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Here are some core principles of psychoanalytic psychotherapy that over time have become well supported empirically:
-Winnicott’s theory about the importance of a “good enough” maternal (parental) environment for overall psychological development:
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So I’m very curious: What are people’s criticisms of psychoanalysis or psychodynamic therapy, either in part or whole, theory or technique. Let’s get it all down here in this thread. I won’t defend anything. Just wanna listen. Don’t worry if it’s “informed” or just an impression
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One of the biggest problems with the DSM is the the personality disorders are defined categorical (has it or doesn’t) instead of dimensional (there’s a spectrum and really everyone falls on there somewhere.)
1. A dimensional approach is true. You, I mean YOU, have aspects of PD.
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People in psychotherapy often quote (glibly?) Winnicott’s claim “It’s a joy to be hidden and a disaster not be found” to try to make the point that being in hiding, not having your emotions seen, is a tragedy. And although that is a tragedy, it is very much the opposite of
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I have started to conclude that in philosophy, psychology, and psychotherapy, the key to many questions is think through a developmental lens.
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An under discussed cause of insomnia is a need to have time to one’s self, alone, without the threat of being impinged upon (and actually being impinged upon.) When you’re supposed to be sleeping, you’re not required to do much else, thus impingement lessens. There are fewer
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There are two models of what a therapist does: pushing buttons and watering the plant.
Button Pushing: Teaching coping skills, breathing, mindfulness. Pointing out negative thought patterns. Making suggestions about how to think. Interventions. Techniques.
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I think there is a language that therapists (primarily those that aren’t psychoanalytic, existential, or humanist) tend to use w/pts that is very bloodless, very repressed, and it can get in the way of insight, catharsis, authentic connection, integrating the psyche, etc
🧵
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The most important words for a therapist are: maybe, perhaps, possibly, I don’t know but, it made me think, (even the overly used, stereotypical) I wonder.
The goal is not just to add these words in like salt to a soup but to create an atmosphere in sessions where everything
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Give me your best films (or shows) for psychotherapist trainees to watch or therapy teachers to assign
Ex.s include films about various mental conditions, addictions, relationships, families, psychotherapy, or whatever you think would help
Non-therapists plz add your picks too
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One of the biggest dangers for therapists is becoming conceited and vain enough to think you know how people should live, how they should fix their relationships. Not just explore a suggestion, but KNOWING what is right so much that you write advice and directives for the public.
This week in therapy ⬇️
Patient: I told my adult daughter I’m sorry & I did my best raising her, but that doesn’t seem to satisfy her.
Me: Maybe try, “I didn’t understand what you needed. What can I do better now?”
#thread
🧵
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Psychotherapists can’t read your mind and definitively know things you don’t about your unconscious. That would be magic.
But they can create a psychologically quiet environment where both you and the therapist start to notice things that you don’t normally notice in the noise
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@christapeterso
She just goes sooo far out of the way to make the “elf slavery is good and you’re an annoying busy body to object.” I mean, in the earlier books the food just magically appears on plates, but then it’s like “no, it’s magical slaves that make the food and you just never saw them”
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My hills to die on. Psychotherapists should:
-read and watch more great novels and films and pay less attention to reading about manualized therapies (and psychoanalytic theory too)
-build and respect a strong frame
-aim at avoiding impinging on pts by valuing neutrality more
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A thread on how psychoanalytic theories conflict with Stoicism’s -and by extension CBT’s- account of the good life, and how psychoanalytic theories (esp Klein) support Kierkegaard, Nie., and existentialism.
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4th Wave CBT: “Maybe we should sometimes have the patient lay on a couch, free associate, see them more frequently…”
I kid, I kid :)
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Some people cannot help but see psychotherapy as either a paid reassuring friend OR a teacher who teaches you self-help strategies and advises you OR a technician who performs a technique on you, gives you ketamine and asks questions. Real psychotherapy is none of these things.
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Good Therapy:
Person with depth, creativity and knowledge becomes therapist and takes the weighty responsibility of being therapist VERY seriously
Therapist pursues their own therapy and gets years of supervision
Therapist prioritizes the frame so as to create a space of
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Here is my first blog article for Psychology Today.
The next one will be about neutrality!
Retweets appreciated!
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Psychoanalytic theory INCL Freud: Defense mechanisms, incl repressing neg feelings are not inherently unhealthy or bad. It is part of healthy psych function.
It’s a caricature of psychoanalysis and/or common sense to say otherwise.
So what is the problem with defense mechs?
Don't listen to Freud! Suppressing your fears or negative thoughts is actually a good idea!
Training people (120 participants from different countries) to suppress their fears had positive effects.
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IMO, a lot of the academic debate on diagnosis, psychotherapy, psychiatry is too bloodless and concerned with mostly semantic stuff. The debate amongst activists on Twitter is too bloody and ignores common ground. Here is my attempt to lay out something we can all agree on.
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Some people are shocked by hearing “In therapy for 5 years” but at 1x/week (with vacations and illness, you probably only get 45 weeks in a year, max) that’s 220 therapy hours (50 minutes each) or 183 real hours (60 minutes.) that’s the equivalent of 1/2 an hour day for a year..
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One thing people looking for a therapist should know is that diff therapists tend to offer diff kinds of therapeutic relationship.
It’s misleading that we just have the one word, “psychotherapy” that names very diff things.
Here are 4 common kinds of psych relationships🧵
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I think the thing that bothers me most about the concept of “self care” is the implicit idea that people who don’t value themselves enough and others too much just need to be told they deserve to or ought to take care of themselves. Those that need this advice most can’t take it.
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Anti-psychiatry was born on the left (though in some sense it’s more libertarian), where no one paid it any attention, but it’s inevitable that it will move, is moving, to the right where it will do extreme damage.
The psychiatric industry has turned every negative human emotion and behavior into a disease. I'm going to keep talking about this problem, no matter how mad the outrage mob gets.
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When people think of psychoanalysis they often think of either Freud’s work or rather hard to understand ideas from Lacan and others that get discussed in the humanities less than clinical psych. This is mistaken Think of psychoanalysis as a tree. Freud is the trunk, with Jung
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-Object relations and parataxic distortions (transference and projection): Past experience with other people heavily determines what we perceive and believe about people’s thoughts and feelings now. Much of what we think we perceive in other people is actually projection.
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A thing that being a psychotherapist has proven to me is that wide swaths of people don’t tend to value, focus on, understand, prioritize their inner life: thoughts, wishes, feelings, motivations, unconscious workings, biases, etc.
Why is this? It’s incredibly important.🧵
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More than “good enough” parenting has significantly less impact on child development, but a failure to provide “good enough” (safety, curiosity, regularity) is massively consequential.
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@matthewlehew
You probably can’t do all that but still I wish I could get them to just bend a little bit for you
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The distinction between the mentally healthy, “normal,” happy folks and those with psychopathology is mostly built out of denial and repression in the normal folks, inability to see how their own minds work, that they too slide into and out of illness, and that very repression
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I wonder what happens when a whole society is led to believe that their emotions are NEVER problematic, ALWAYS connected to reality, and, NEVER, symptoms of a dysfunction (stigmatic labels!) It would be a society that’s paralyzed; a society that lives in an infantile state.
I wonder what happens when a whole society is led to believe that their emotions are problematic, disconnected from reality, and, quite possibly, symptoms of a brain dysfunction. It would be a society that’s paralyzed; a society that lives in an infantile state.
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Reifying depression, treatment resistant depression, and many other DSM diagnoses, as things that are causes of symptoms instead of names of clusters of symptoms is the biggest source of confusion about mental health in the public and MANY clinicians are contributing to the prob
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What are the virtues needed to be the kind of psychotherapist who is likely to form a therapy relationship that leads to growth and change? IMO, contemp psychoanalysis would say all of the following:
Tact
Humility
Non-impinging
Adaptability
Alpha-Function
Emotional Reciprocity
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This foolishly assumes that trying to do something faster means you must be better at it. And given that the primary job of psychotherapy is forming a powerful, intimate relationship that leads to change, faster isn’t more skilled, it’s just forced and often lower quality.
Brief therapy requires more skill than long because you have to be better at:
1)forming quick/strong alliance
2)finding therapy focus
3)setting realistic goals
4)teaching how therapy works
5)homework
6)preparing for post treatment problems
7)saying goodbye
8)finding new patients
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The new neutrality:
1. Be humble, lay a groundwork of saying “I don’t know” and “It’s possible” so often that it almost goes without saying whenever you speak. Mean it when you say it. Therapy requires “negative capability,” not knowing and exploring many possible meanings.
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Here is my best attempt to say something balanced about the rise of mental health diagnoses and diagnoses becoming identity categories and maybe about the psychological pros and cons of having various identity categories more generally.
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@ValkyrieRiding
@gabrielsherman
@JoyAnnReid
Many red states will fall in line. Movement across state lines will mean that the spread will be unstoppable.
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@BarakRavid
It stopped being a deal when Trump intentionally destroyed the deal. They aren’t violating any “deal.”
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Thesis: Most people you know fit criteria for a psychiatric DSM diagnosis. Many you know fit 2-4. Dysfunction is rampant.
Antithesis: Almost everyone you know is working, forming relationships, having some fun in a way that is “functional,” despite struggles. Dysfunction is rare.
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We need to strongly distinguish between the following two kinds of therapy:
A. Techniques and skills therapies
B. Developmental therapies
I don’t wish to argue the merits of either kind here, just that pts need and deserve to know which kind they are getting.
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The “biopsychosocial” thing is not a model of what causes mental illness but a pledge to not be reductive about what causes MI. It’s not all trauma, not all genetics, etc. In a sense it’s so obv correct that it’s not even worth saying AND people fail to live up to it all the time
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One driver of unethical harm in psychotherapy is when the therapist grooms the patient to meet the therapist’s need for sex. But some therapists groom patients to give them friendship, adulation, and approval. We rightly decry the cases where the therapist uses the
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I think the phrase “worried well” is often meant to minimize extremely serious psych probs, things that lead to suicide and lives of quiet emptiness or inner turmoil, in those who are able to maintain a thin outer shell of function: job, chit chat with “friends,” a family life of
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Things that reduce feelings associated with relying on other people: AI therapy-bots, stoicism, pop-psychology, self-help books, pop-psych therapy-speak, manualized CBT.
They are the many heads of the same anti-interdependence/attachment hydra.
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One reason therapists must work very hard to make sure they aren’t imposing their values or POVs on their pts, ie why they should aim at neutrality, is that the one of biggest causes of psychological problems is the imposition of POVs and values on the pt.
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Winnicott’s main point. He is trying to argue the value, the necessity, of keeping a core part of yourself hidden and private, and how family dysfunction, trauma, environmental threats, etc can destroy that, causing various kinds of psychopathology.
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I think the most important lesson that any psychotherapist can learn is HOW to follow Bion’s advice that the therapist must work without “memory or desire.”
What follows is an oversimplification and just my reading. 🧵
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Good psychotherapists (and psychiatrists) don’t have an agenda, except to help a person with their own stated psychological problem.* I think many of the harshest critics of psychiatry, the medical model, etc have an agenda of getting patients to not see themselves as ill…
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-a set of rigid “False Self” personality structures that are just about managing others
-not really expressing, relating, taking in, growing, etc
-a sort of rigidity that makes real growth near impossible
-a sense of internal deadness
-pts may describe this as loss of motivation
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I love podcasts but if I hear one more ad for Better Help, as it turns psychotherapy into Uber…
I mean why is that the ONLY advertiser for podcasts? It’s wild. If the ad time is valuable and cheap, why aren’t others buying more?
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Hat tip and credit to the irreplaceable
@JonathanShedler
I think I was influenced by his writing here without consciously remembering it.
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The therapist who can do this work must be extremely conscious of and thoughtful about transference and countertransference, and must be both patient and able to say things that are helping the patient articulate their inner world instead of teaching, explaining, or training.
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Re: MA and PsyD level therapists cause it’s the topic of the day,
1. Dear prospective pts, please don’t think what degree a licensed psychotherapist has is at all, at all a useful metric of what quality of therapy you’ll get. It’s going to either distract you from important
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The thing about Socratic Questioning as a central part of some therapies that doesn’t get discussed enough is that Socratic Questioning almost always leans towards being humiliating.
Socrates humiliated people, his “students” were the ones enjoying him humiliate the powerful.
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his control is gone.
What Winnicott is arguing is that when that internal sense of privacy and omnipotence are shattered, internal creativity, vitality, capacity to grow and change are destroyed too and psychopathology ensues:
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I wish we saw more articles like this: Gave psychoanalytic therapy a try, realized all the preconceptions were false, found it more useful than CBT and some other things.
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-Bion’s theory of alpha function and containment: Feeling often comes into the mind in an intense way where it is hard to capture the words in feeling (beta elements) and it is hard to pay attention to much else while these feelings are present.
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In various therapist forums, I see requests for “therapist who knows about” or “has experience with” X, where sometimes X is VERY specific. Like has experience with people who work in finance, or has triplets, etc.
Here’s a very important thing: IMO you don’t need a therapist
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@tylerblack32
It’s a great example of projection. The parents are nervous about how hard it will be on them that the kids aren’t in school. But it’s selfish to own that. So they project and say “it’s hard on the kids.”
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“Unconditional positive regard” (a Carl Rogers term) doesn’t mean letting patients, or anyone, hit you in the face. Like at all. Nor is it something all therapists agree is correct,
This is not useful social commentary by a person who understands ANYTHING about psychotherapy.
They call this "Gentle Parenting."
I call it "Battered Mommy Syndrome."
This kid hits, kicks, and slaps his mother, who responds with pleading and tears.
This child doesn't need the "unconditional positive regard" of therapy.
He needs parents - for his sake and ours.
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patient can experience the freedom to say or think anything without real, consequential retaliation.
This cannot be done with an artificial clock ticking where the therapy will end, eg in 16 weeks. That’s a joke.
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This is important. Psychoanalysts and therapists in general are no better at giving you life advice than a person you randomly meet on the street.
This is one reason why psychoanalytic theory/technique avoid (mostly, there are always exceptions) advice giving.
“Psychoanalysts are rarely hermits or holy men, or even rebels. One finds more psychoanalysts in the Hamptons than the Himalayans. In truth, the patient has no very good reason to trust our directions.” -Edgar Levenson
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-anxious hyper vigilance about maintaining one’s False Self.
One consequence of Winnicott’s view is that psychotherapy must be non-impinging. That is the therapist must not tell the pt what to do explicitly or implicitly because that will simply stir up the patients False Self
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@awaisaftab
I think calling them anti-depressants is a big part of the problem. That name sort of sells them as a magic bullet.
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My latest. Post and retweet if you like!
Contemporary Psychoanalytic Therapy Isn’t Weird | Psychology Today
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One reason I think a lot of therapists who publicly complain about pts bad behavior, suggesting that pts should treat therapists better, actually don’t really understand therapy is this. You actually want to invite them to bring the negativity if they authentically feel it.
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These feelings have often big phys components. Putting the feelings into words, attaching them to imagery (alpha elements) “contains” the beta elements and the person has greater control. Without containment the person has to “expel” the beta element feelings, eg rage, drinking.
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If you believe in the power of thoughtless dehumanizing, believe also in the power of thoughtful care to humanize.
This is often what is required to flourish, to humanize others, demand oneself be humanized by others, to work to have others humanize each other.
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The psychoanalytic question that should always be on the therapist’s mind: what is missing here? There is more here that is either enacted, repressed, unsaid or unthinkable. Whatever that is needs to come up eventually, for better or worse in the short term.
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Therapy often fails by pretending or colluding in the fantasy that things are easier and better than they are. This often happens when therapists imply or state;
-You only need X number of sessions
-My advice will solve the problem
-These exercises will change the situation
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Here is a (too long) thread on some psychoanalytically-inspired ideas about some of the different reasons, motivations and psychological structures that cause people to have low self-esteem, believe harshly negative things about themselves, feel excessive shame or guilt.
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“…young people interact with psychiatric labels… such as anxiety and depression. We demonstrate how the participants gave new meaning to these psych labels… and by doing so transformed them into cultural categories rather than diagnostic categories”
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to manage the therapist by appeasing them, fighting them, seducing them, etc.
Many therapists are being appeased, while impinging on the patient, the patient isn’t changing, and the therapist has no idea that’s what is happening.
Rather, the therapy must offer a space where the
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Respectfully, this is not great advice, IMO.
There are no “keys,” no tricks, no magic, no salesman-like attention grabbing.
You need to be curious, adaptive, emotionally attuned, patient, brave, self-aware, creative, tactful, authentic, knowledgeable, neutral but caring,
Psychotherapy should never feel routine or dull.
Key to good outcome is getting/holding patient's attention.
Watch for "magic moments" when you can stimulate new hope/action/insight/feelings.
You never know when one will happen/so must always be ready.
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Then government should pay for high quality, not artificially time limited, depth therapy (not manualized) where the psychotherapy relationship develops as it needs to in order to create lasting change, especially for low income people.
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Am interested in readings about the concept and phenomena of deep humiliation.
It seems to me (could be wrong) that a lot of extreme violence is driven by people (usually men) feeling (whether it’s rational or not) a rising sense of deep humiliation. 🧵
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Must read.
One of the most important lessons I learned -and it’s a core part of psychoanalytic therapy that a pt telling you how well you’ve done, how helped they are is ALWAYS, at best, half the story. It’s the therapists job to help them feel and
I went to therapy for years. I saw a few different therapists. I’d always thank them, I’d always tell them they helped me, I’d always tell them I felt better after the session. But very often, this was not true. I was in my fawn state, people pleasing, and trying to be “good.”
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We all do. This is a basic principle of psychoanalytic theory and just ordinary folk wisdom about people. Look at borderline personality traits: splitting (making things idealized or demonized), lack of sense of self, interpersonal conflict. Those features are EVERYWHERE. Look
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All of this is to say that trauma-informed skills building, trauma informed brief therapies are not really trauma-informed enough if they don’t get how impinging teaching and coaching are and that many people need a relationship that impinges as minimally as possible to rebuild
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1. “Psychotherapy is very hard.”
2. “Psychotherapy will change patients quickly” (within 8-12 hours)
3. “Any psychotherapist will be as good as another as long as they follow the manual.”
1 suggests 2 and 3 are false
Why do researchers keep acting as though 2 and 3 are true?
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Brief therapy is idealized for very understandable reasons. If most people can become resilient, functional, no longer fitting criteria for a dx, in fulfilling relationships by growing to therapy for a few months, life is not so scary, not so awful. And maybe we can find a magic
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one’s inner world that has been violated, laid bare, etc. This is work that is incredibly hard, takes a long time, is often very painful. It is not done through saccharine kindness or merely being giving and helpful.
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This is a great Q. Lemme try to answer in a brief thread.
1. Try not to think so much about WHAT to do or say (though you do have to think about it a bit obv.) Rather, think about what does this mean, what is going on in this person’s mind as a response to their life.
do you guys have any super basic 101 articles on teaching a therapist how to listen? i know a supervisor leading a didactic tomorrow w some v beginner therapists and could def use some literature!! 😚
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The oldest grift. (Think about how this might work with “brands” of therapy or the latest trends in MH):
Step 1: Take something complicated and painful and say it’s simple. Show lots of outward empathy. Tell a story about “I also suffered, but now I’m cured.” Many will buy in.
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Watering the plant: Being curious, empathic, thoughtful. Receiving what the patient says, being affected, living in reality with them. Affecting the patient, watering them with your self in relationship.
Button pushing can happen on a timetable. Push these buttons 6-12 sessions.
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A lot of therapists can’t admit their lack of competence and it ends up harming patients.
I’m on a listserv where one therapist said something like “Please help. I don’t know what to do. A client keeps coming to session and won’t say anything at all, all session.”
@Alejandra__Hope
I definitely don’t like how pts get dropped by their therapist and get told to seek DBT. Better to say “I’m sorry. I’m not experienced and capable enough to help you” than “only DBT can save you.” And that happens.
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This brief piece by Feldman-Barrett captures, in a very simple way, a lot of what makes me concerned about psychology as a field. Is it wrong/overly simple? Thoughts? ht:
@awaisaftab
@peez
@tamler
@EikoFried
@JonathanShedler
@talyarkoni
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Much brief therapy that performs interventions and teaches lessons uses carrots and sticks, small interpersonal rewards and punishments in the context of a rel based on overall encouragement. In some contexts that’s good. A swim coach, for ex, is good at small acts of
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One thing that leads to a lot of confusion about MH diagnosis* is that it’s often tentative and provisional. Diagnosis often should be “it seems likely at THIS point that you fit this category but…” not “we know with certainty you for this category.”
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Psychoanalytic therapy isn’t more expensive or less accessible than any other modality! To say otherwise is a lie.
It’s true that brief, time limited therapy (8-16 sessions) is cheaper, but the best CBT therapists say that sort of therapy isn’t what is best for patients.
Thread
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You’d be surprised how much people who have harmed each other can reconcile. And you’d be surprised how much children can see their parents’ battles as pointless and inhumane. This is the best part of world history -we all agree- and in families it is the primary thing that
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The rise of fascism, the psychoanalyst Bollas seems to argue, is driven by a reduction in the inner complexity of people. Interestingly, this is analogous to Plato’s idea in the Republic about what causes tyranny to rise.
I think both Plato and Bollas are on to something.
Am reading this paper by Bollas on “Fascistic states of mind” and am interested in what others think.
I don’t want to make too many political arguments here but this seems like an important topic psychologically one way or the other.
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Couples come for help with relationship problems (not psychological problems, though psychological problems can cause and be caused by relationship problems in a Gordian knot.
The goal is to help the couple grow so as to ameliorate or lessen the problems, but by a three person
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destructive to the foundation of the therapy relationship.
But if a “blank” psychotherapist is not relating to the patient, that won’t work either. The psychotherapist has to have real authentic reactions AND must help the patient confront
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Most of you know the language I’m referring to. It’s spoken in soft, calm tones and dripping with “This is me empathizing.” It’s as if someone did a survey of the subtle facial expressions and tones associated w/empathy and made them into a caricature. But not such a caricature
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I think film noir (or the Big Lebowski which is a kind of comedic film noir) is the best representation of what it’s like to be a therapist. You’re in over your head not fully understanding what you need to, the world is confusingly morally grey, there is danger, but somehow
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