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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Many clinicians are afraid to say this because they fear being judged as incompetent (at least I do). It takes some practice but saying it is incredibly powerful.
Many therapists think they’re supposed to know what to say.
Most would do well to focus less on what to say and more on how to listen.
If a patient expects an answer, it’s all right to say “I don't know” or “I don't understand yet. Let’s keep talking and see where it leads.”
I wish more therapists recognized that “I don't know” can be a constructive intervention in its own right. It’s not punting or buying time. The meta-message is: it’s okay to experience the unknown. It’s okay to sit with feelings we don’t yet understand, to create more space to notice and reflect, to allow ourselves to be fallible humans. It’s okay to resist the seductive allure of imagined omnipotence.
“I don't know” is sometimes the most effective intervention.
A therapist who always knows what to say is not doing the work of psychotherapy because that’s not how the work goes. I’m not sure what they’re doing, but it’s not psychotherapy.
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So sad, but true.
Therapists no longer own therapy. Sure, there are clinicians out there in private practice, some of them even swinging a successful cash-based practice (good for them), but for the majority, that is not the case.
Therapy is owned by the insurance companies, the tech platforms, the Big Box Therapy places, and soon by AI. The rogues who break free are not celebrated but rather pointed to as the reason that mental healthcare is “not accessible.” This highlights the unfortunate truth: the Mental Health Industrial Complex is built upon cheap clinical labor. The “shortage” does not refer to a headcount but rather to the number of clinicians willing to tolerate dogshit wages and outrageously high caseloads.
Early-career clinicians, beware: many outside parties conspire to capture you as part of their profit engine.
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Therapy can help you to become more aware of your emotions and others’ around you. It allows you to pause more and notice things in a different light. This pause further aids you in making different choices and reacting differently, in a new way that’s more helpful for you.
Blows my mind when people say psychoanalysis or psychology is not science based. It’s really as if all they have only ever heard of Freud and haven’t realized it professed and evolved like every other field in life. It got better.
Science is a method. Psychoanalytic and psychodynamic techniques are tested. They have been refined for over a century and shared through aggregation of data across generations and national borders. The unconscious mind has more scientific rigor invested into it than meets the eye.
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Austin Chenoweth, LMFT retweeted
Science is a method. Psychoanalytic and psychodynamic techniques are tested. They have been refined for over a century and shared through aggregation of data across generations and national borders. The unconscious mind has more scientific rigor invested into it than meets the eye.
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
d/o
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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
