Licensed psychotherapist. Lover of psychoanalytic therapy. Tweets about psychology, psychotherapy and psychiatry. Views are my own!
San Fransisco Bay Area
Joined June 2020
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Beautiful and succinct explanation of therapy.
The essence
1. Identify recurring themes in the patient’s life. They are recognizable across different relationships, in the past and present, and in interactions with the therapist.
2. Patients cannot tell us about the themes and patterns they live out because they do not know. We observe, infer, and experience them.
3. Recognize and address the core themes and patterns as they arise in the therapy relationship.
4. Recognize that addressing them in the therapy relationship can be painful for patient and therapist both. The patterns recur for a reason and protect against deeper pain. This work requires timing and tact. It requires a paradoxical balance of empathy and confrontation.
5. Recognize that you will need to revisit the same themes over time from many angles and over many iterations.
The rest is the details.
The best therapy advice I ever received:
Shut up and listen. And keep it simple. Then repeat. It’s not an intellectual experience, let your ego go. It’s not about you, it’s about your patient. Brevity is king.
Once you’ve practiced therapy for even a few weeks using insurance and the DSM you realize what a sham it is. Basically nobody fits into a DSM diagnosis.
Patients’ problems are far more complex and intertwined with personality. The DSM is mostly absurd minus biological
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Austin Chenoweth, LMFT retweeted
In grad school, therapists in training are told about the healing power of the therapy relationships, the importance of rapport and empathy.
Their first job is at a large organization that reduces treatment a to a series of metrics. PHQ9, GAD7, MH-QoL, along with a series of scoring systems populate a various dashboards that need to be checked regularly. Clinician success is tracked with intake to follow up conversation rate, documentation completion rate, and amount of monthly completed visits.
Emails regarding progress get sent out saying things like, "Case 244011 has had persistent PHQ9 for last several months. May be beneficial to explore distressing thoughts and strengthen coping, self-soothing, and hopefulness." Further clinical development comes in the form of self taught training modules online.
Client, clinician, and treatment have all been reduced to abstracts.
No matter how offten an agency pushes for safety plans remember this:
Safety plans do not prevent suicide. A piece of paper won’t stop someone from killing themselves. But a meaningful relationship will. It won’t hurt but don’t delude yourself.
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Austin Chenoweth, LMFT retweeted
If you believe that someone needs to change, you must first change yourself and how you present yourself to that person. It is only through your changing that another can be influenced to change. Change starts with you.
Jeffrey G. Duarte
Austin Chenoweth, LMFT retweeted
We are not equals.
I am the professional and you are the patient. That’s an obvious power differential.
You have the money, that’s a power differential where you have the upside. And you can sue me.
The only way we are equals: we’re both people with flaws and gifts
The dishonesty in psychotherapy:
They say: “We are doing this together as equals.”
The reality: One person is an institutional authority evaluating the other against a hidden playbook.
They say: “You’re the expert on your own life.”
The reality: If they truly believed you were the ultimate authority, their entire multi-year training architecture and diagnostic billing system would be entirely redundant.
They say: “I’m just reflecting your words.”
The reality: They are actively filtering, selecting, and categorizing your words through a proprietary theoretical map you didn’t choose and don’t have access to.
Austin Chenoweth, LMFT retweeted
"I just wonder if the sad I'd be without you would be less than the sad I get from being with you."
— Succession, HBO
Happy Friday therapists! Did you finish your progress notes yet? That was a rhetorical question, I know you didn’t.
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Really the look you should get when you say none nowadays. It’s almost as if the more “certifications” a therapist has the worse he or she is.
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You mean there’s no shortcut for putting in the work, there’s no quick fix for ingrained personality? Who would have thought…don’t tell me Ketamine is BS too LOL!
Who could have predicted that a new treatment in psychiatry overpromised and underdelivered?
Some were telling me that withholding SAINT TMS was unethical. While I am a fan of short and time-limited interventions, we should learn to moderate our enthusiasm.
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Austin Chenoweth, LMFT retweeted
Training in psychotherapy begins in earnest when it finally sinks in that giving advice does not help.
And it sinks in that common-sense solutions didn’t help in the past and won’t help now.
Meaningful psychotherapy is not an extension of common sense. It is something else entirely.
Why don't advice and common sense help?
ONE crucial reason is that the problem you see on the surface is rarely the problem that therapy needs to address.
There is the surface or “manifest” problem—and there are the underlying psychological problems that give rise to it, and have gotten in the way of previous efforts to address it.
In other words, there is WAY more going on than meets the eye. What you see is almost never what you get.
Advice and commonsense solutions focus on “first-order” causes. Meaningful psychotherapy addresses 2nd-, 3rd-, and nth-order causes.
This is why meaningful psychotherapy requires real expertise and years of training. *We are not addressing the same problems*.
This is why psychotherapy is so often misunderstood.
This is why therapists who are still trying to give advice or provide common-sense solutions are not expert therapists. Their psychotherapy training never began in earnest.
No matter what degrees they have or how how many years of experience, they are operating with a beginner-level understanding of human psychology and providing beginner-level psychotherapy.
“Training in psychotherapy begins in earnest when it finally sinks in that giving advice doesn’t help.”
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✍️ Related essay: Much of What Is Called Therapy Is Not Psychotherapy
jonathanshedler.substack.com…
Hot take:
You probably don’t have ADHD. A stimulant helping you be more productive and functional in life is not proof, nor evidence, that you have ADHD. That’s simply proof you took a STIMULANT.
There are hundreds of reasons why you might be exhibiting ADHD symptoms.
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1/ AI cannot and will not ever be able to do legitimate psychotherapy.
Psychotherapy is an exploration and treatment of the psyche, or the soul. To do this, another soul must be present. Unless AI can develop a soul (which it cannot), it cannot do psychotherapy.
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