Austin Chenoweth
@FreudandBeyond
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Psychotherapist (AMFT), musician, and eternal student. 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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Pinned Tweet
Therapy isn’t about breaking down the wall; it’s about understanding the wall and why it’s there in the first place.
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The goal of psychotherapy is not to feel happy and blissful. It will not take away all your pain—it’s not a magic bullet. The purpose is to help patients come to know themselves more fully, and to live life more freely, to feel every emotion and tolerate a full affective range.
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Counseling is discussing trivial problems of the week and problem solving. Psychotherapy involves character work and requires a case formulation about who somebody is and why. And psychotherapy revolves around a relationship and frequent talks about therapeutic interactions.
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1/ Initial therapy session tip
It’s important to inform the client about the therapy process and what it’s going to look like. Specifically, I like to tell patients that I will ask them frequently about the therapy relationship throughout our time together.
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“Therapy is not an intellectual experience—it’s an emotional experience.”
-
@JonathanShedler
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Truly cannot fathom how there are practicing psychotherapists who have NEVER themselves been in therapy. Scary.
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“The first step in all therapeutic change is responsibility assumption. If one feels in no way responsible for one’s predicament, then how can one change it?”
- Irvin Yalom, Love’s Executioner
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Therapy sure as hell has not always made me feel better. It has challenged me time and time again, and has given me more access to myself. This is the true gift—the gift of freedom.
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1/ Therapy rooms at my agency usually have paintings which include affirmations of self-love and hope for the future; they say things will get better.
I may be making a big deal out of nothing, but these paintings (to me) send an implicit apathetic message to patients.
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“Psychoanalytic therapy encourages us to speak our grievances, to express in the transference our anger at the felt perpetrators of the wrongs we have suffered, to feel our grief about what has happened, and finally, to come to terms with the reality…
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“One of the chief aims of the psychotherapist is to help the patient overcome the fears and inhibitions that have led him to react to his normal and healthy feelings as if they were a threat.”
- Wachtel, 2011
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Wow. I have no words. This is the president of the APA. Psychology is doomed.
Let go of the fear.
Let go of the lies.
Let go of the control issues.
Let go of the manipulation.
Let go of the selfishness.
Let go of that which has been stolen.
Let go of the denial.
Let go of the tendency to dehumanize.
Let go of the greed.
Decolonize.
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“Some people who express suicidal ideas want to communicate their literal wish not to go on living, whereas others are giving metaphorical expression to an already existing sense of internal deadness.”
- McWilliams, 2004
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What’s therapy twitters thoughts on group psychotherapy? I’ve been interested in it more recently but it seems to be a dying art. Any thoughts?
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When a patient gets angry, frustrated, or ambivalent about therapy, it’s the job of the therapist to not get defensive or explain the “reality.”
It’s about holding a space where these feelings can be explored and worked through. The therapist should be curious and accepting.
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My therapist was gaslighting me earlier today. Oh, wait, that was just CBT.
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2/ As though their pain is not welcome here. And they totally send the wrong message about what therapy is and how it’s going to help. It’s just weird.
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7 features of psychodynamic therapy, adopted from
@JonathanShedler
1. Focus on affect and expression of emotion.
2. Exploration of attempts to avoid distressing thoughts and feelings.
3. Identification of recurring themes and patterns.
4. Discussion of past experiences
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On Choosing a Psychotherapist
1/ When choosing a therapist to work with, I wouldn’t put too much stalk into the specific title he or she holds (e.g. LMFT, Psychologist, LPCC, etc), or what schools they attended for that matter.
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A thought on psychotherapy goals:
Symptom reduction, while important, is not a psychological goal, which is the whole point of therapy.
It’s an outcome, sure, but it’s secondary to an actual goal that is related to the *self* which is what therapy can actually change.
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Therapists listen for what patients aren’t saying more than what they are…
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Beginning to think therapy doesn’t work if patients don’t invest some amount of money…
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that although our past cannot be changed, our future can be shaped by our growing sense of agency.”
- McWilliams, 2004
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Being a therapist is challenging. It often pushes you to confront the demons inside of you, for the purpose of helping another. What a gift as well.
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Without some friction—some fire and confrontation—there won’t be growth in psychotherapy. A therapist should push their patients, which will sometimes be upsetting for them. This is when the real work begins though , when anger is expressed, shown, and discussed.
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“Of all my credentials as a therapist, my most significant is that I’m a card-carrying member of the human race.”
- Lori Gottlieb
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I have the opportunity to get supervision from a fantastic analyst for a very fair price. It’s a group of experienced clinicians. I am extremely anxious as I feel I know nothing about therapy compared to the members. Any advice?
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5/ Therapy is a unique relationship that most patients have not experienced before. It’s critical that both parties start on the same page. This is but one element to discuss with patients in the initial meeting.
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4/ I do this because it is not as self-evident as clinicians think that patients will understand the point of some interventions the therapist uses. Without explanation, these interventions will fall flat and the patient will be confused often.
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@SameiHuda
@rcpsych
Come on guys? Really? People can ask questions. If you get offended from a genuine question that’s on you
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“Though we try hard to go through life two by two or in groups, there are times, especially when death approaches, that the truth—that we are born alone and must die alone—breaks through with chilling clarity.”
- Yalom, 1989
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2/ I let them know that I will ask how they feel about me or how something I have said affects them at times. And I don’t do this because of some narcissistic need for validation. I do it because the here and now process is an important part of therapy and patterns that emerge.
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The new generation of therapists are being trained to be technicians, not legitimate experts in psychology and psychotherapy. The former involves a cookie cutter approach wherein they *do* therapy to patients, while the latter does therapy *with* patients and involves nuance.
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Helping patients become more comfortable with the unknown is a big part of psychotherapy.
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That feeling when you resonate so well with a patient, and land a perfect interpretation and the patient says “exactly.”
Love it.
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Recently started working out right when I wake up; this has helped my therapy sessions immensely. I am more grounded and calm, and far sharper and aware. Highly recommend.
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1/ Symptoms do not arise in a vacuum. You can’t separate a symptom from who somebody is (I.e. their personality). This is why specific interventions and techniques aimed at treating symptomatology do not help patients in the long-term.
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Some of the best books ever written on dynamic therapy right here. I encourage all to read them :)
Look what just came in the mail!
One might think that as a neuroscientist I would be drawn to CBT.
But this is where we are and I love it here 😍
#PsychodynamicTwitter
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1/ Defenses and disavowed emotions often originate in childhood. But they are then reinforced in a cyclical fashion with present interpersonal relationships.
E.g. The child who was not allowed to express anger in a healthy manner learns to hide it away…
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@JonathanShedler
@rascality
Indeed. The more rapport is built the easier it is for me. But early on I fear of getting fired sometimes. Lots of useful countertransference there. Or I fear retaliation. Also useful information.
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1/ “Neurotics—that is, most of us—have our conflicts and symptoms, but we manage to function in work and love, for better or worse, most of the time…”
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How do y’all go about addressing negative transferences towards you as the clinician?
When you feel countertransference how do you then use it to help the patient to gain awareness of it so it does not harm the therapy process?
Love to hear how different clinicians work.
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Just because you call it therapy does not mean therapy is what’s taking place…
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“Although we fail with some clients, most of our patients get better. They become more honest with themselves, lose disabling symptoms, learn more effective ways to cope with problems, improve their relationships, become more playful, develop a wider range of emotions…
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2/ “Psychotics typically don’t function at all in work or love. To be psychotic is largely to relate only to parts of the self—or to the world as an extension of oneself.”
- Deborah Luepnitz
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3/ I make it clear that I genuinely want to know their feelings towards me. Then I might explain in clear non-jargon language about projection and transference and how that’s a big part of the work.
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“The difficulties that bring patients to treatment usually involve unintegrated and undeveloped capacities to feel, think, and relate to others (and to themselves) in ways that work.”
- Wallin (2007)
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@jasonintrator
@expatriateact
It does not take a genius to understand when a paper is bullshit and obviously peer-reviewed by woke ideologues.
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“Hearing the story once may be important; repeatedly retelling the same story can serve as a defense or, worse, a form of retraumatization. When a client fills every moment of the session with words, they may serve as a wall against genuine engagement.”
- Louis Cozolino
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Sorta yeah. It’s definitely the job of the therapist to help patients move past venting and to see how it serves as a defense and to create an actual case formulation around psychological goal. If it can’t be found then yes, should end therapy.
if you see a therapist every week to vent about random shit and update them on your current situationship and you don’t have, like, severe mental illness, you are being scammed
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Brought up
@JonathanShedler
explanation of masochism and victim entitlement to supervisor, in regards to a pt to see if it fits and how to work with them. She looked at me like I was high…smh
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Agencies care more about your notes, treatment plans, assessments, intakes, and quota over the patient. It’s such an exhausting environment to be in.
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Retweeting again because this should really go viral. Anyone know how to send this to universities?
1/ Teaching "Freud" in psych 101 is a terrible idea
Students in biology 101 don't study "Darwin"
Students in astronomy 101 don't study "Copernicus"
Focus should be subject matter, not historical person Contemporary concepts, not history
But psych textbooks make no distinction
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Would love to hear everyone’s thoughts on introjective and anaclitic depression. How do you view and conceptualize the two?
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Frustrating hearing psychiatrists abandon their patients without even a termination session or saying goodbye before transferring them. Are there any left that understand how important relationships are and that good treatment still relies on human connection.
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3/ Really what matters is can you connect with this individual? Can he explain therapy without jargon, and has he done his own in-depth therapy over many years. Further, can he take in criticism and anger without being defensive?And does he view you as unique?
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@JonathanShedler
It’s such an alien concept to people. We all want to react and soothe—to get them to look at the bright side of why life is beautiful. This strands people in the worst possible pain imaginable.
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No matter how much one exercises (and we of course should), it will not treat a psychological issue such as an insecure attachment style, and the way you operate in relationships.
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Daily reminder that your progress notes just need to pass—there’s no extra credit for doing them well. They do not help the patient.
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As my symptoms have slowly faded away I begin to see the real problems that I face. And I look forward to working through and understanding them as I continue to grow.
I see now what is accessible to me—what I have been missing in life. It’s a process of becoming more human.
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Why CBT frustrates me--a short 🧵
1/ There was once a time when Behavioral therapy appeared experiential and novel--clinicians were tired of patients simply talking about feelings and avoidances, as in the early days of psychoanalysis.
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Bonus:
Psychotherapy is not about feeling good—it’s about changing. Unfortunately, change requires confrontation with one’s disavowed and painful emotions. It’s the therapists job to assist patients in facing these uncomfortable parts. Of course, this is done with tact…
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4/ That it, does he view you as having your own personality and idiosyncrasies. Does he attempt to shove his predetermined scripts onto you or does he shape and mend to what you need in therapy? And, is he authentic and genuine? Does he care?
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@JonathanShedler
Yep, all my supervisors care about is safety of patients. They are supportive but never push or challenge me to think about my patients or best way to help them change. Literally teaching myself with my own therapy, books, and this platform…
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@JonathanShedler
Isn’t that the whole point of therapy? All we can do is change something about our self, not others
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Doesn’t matter what you post on Twitter. Someone, somewhere, will take your tweet out of context and proclaim you’re wrong, while pretending to be morally superior to you.
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@JonathanShedler
@rascality
“What’s coming up for you right now as you say this?”
“What happened?”
“Do you feel that happening between us right now?”
“And what about here and now, do you feel I am judging you as well?”
Just a few. I have turned them all into statements as well, but they feel odd.
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First time being sick as a therapist this week. It feels awful trying to rebalance schedule and cancel some patients, meanwhile not even having enough sick days. How do you guys do it?
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@JonathanShedler
@rascality
Still asking a lot of questions as a clinician. I have what I want to say and I pause, but I can’t seem to formulate it as statement. If I do, it sounds more like an interpretation, but with no room for reflection. Any advice to practice statements more?
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“I often wonder how beginning therapists decide when and how to intervene if they have not internalized a rhythm of interaction that emerges from a well-functioning psychotherapy dyad.”
- McWilliams, 2004
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Only a mother can provide that.
i don't understand how things went so wrong in my 20s. all i was asking for was unconditional love from everybody i met.
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What psychodynamic books are people reading? I haven’t seen any new ones to get in a while.
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@bitesizetherapy
@JonathanShedler
It’s like being a secret agent. You get to do amazing stuff and save the world, but you don’t get to tell people about it…nobody will ever know.
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@PNWfirefly
@ChristinePsyD
Good God, we are in trouble. The mental gymnastics are truly astounding here.
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“Psychoanalysis may have a PR problem, but it doesn’t have a utility problem.”
-
@bitesizetherapy
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“A comment whose focal message is accurate but whose meta-message is poorly wrought can have an effect similar to that of a potentially curative organ transplant that is rejected by the patient’s body because it is registered as alien.”
- Wachtel, 2011
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5. Focus on interpersonal relations
6. Focus on therapy relationship
7. Exploration of wishes and fantasies
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@bitesizetherapy
Right! I thought I was crazy. Going to talk to management about having them removed. Why not put up some cool abstract and a fake plant or 2 instead
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@JonathanShedler
How do you get this across to patients? Sometimes the damage feels irreversible and so they drop out of real therapy when it appears so different.
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@ChristinePsyD
A part of whiteness? There are quite a lot of assumptions being made here. This kinda seems racist—or am I crazy? Can you help me understand?
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@JonathanShedler
@rascality
Oh wow, I haven’t been that direct. Perhaps I have been colluding in avoidance there. Thank you 🙏
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Hot take that shouldn’t be:
Every new dumb alphabet therapy modality is literally a repackaged and copied aspect of an already established and successful model.
Follow the money.
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Not sure about this. It shuts down room for exploration and understanding. I have said it before. But it’s very rare. I would usually explore transference and countertransference instead. It may be a true statement, but many patients will not accept or believe such a statement.
One of the best things a client can hear from their therapist is “you matter to me.”
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@streetswept
@SameiHuda
@rcpsych
Even still, if the ideology can’t hold up to questioning what does that say about it?
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@JonathanShedler
So therapists have disavowed aspects of self that are objects like anger, rage, and a desire to hurt others? So we go into the field to do the opposite thing—heal, be kind, use empathy, etc. It’s not untill we recognize these disavowed aspects that we can really help another?
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That’s not trauma.
Doctors still don't get how traumatizing it can be for patients to not be believed.
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2/ If therapy is not aimed at psychological change, nothing permanent can really occur. And if therapy is not addressing something about the *self* then it’s not really psychotherapy in the first place.
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3/ Psychotherapy is not about symptom reduction. Can symptoms improve? Yes of course—and they should. But that’s not the point of therapy, as symptoms are not the psychological issue—they are a side effect of it.
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