Quick list Mistakes and myths

“a lot of the TCAs have a lot of anti-muscarinic activity. Paroxetine is very anticholinergic. The anti-Parkinsonian medications, the meds that treat overactive bladder and that are bladder relaxants. Benadryl is a big one”

“The same doctors who say never prescribe the Benzterpene are also the same ones who will not blink and give Zyprexa and Seroquel, which are themselves already anticholinergic”

“how often do we see patients on higher and higher doses of stimulants? Patients who, you know, they're running through the gambit of different antidepressants because the persons were not thinking through the hierarchy appropriately”

“clinicians are underestimating the risk of antipsychotic treatment because antipsychotic treatment is so easy. You don't have to draw labs and it works really fast, especially inpatient. So everyone gets antipsychotic. But they have side effects. And the risk of tardive dyskinesia is higher in people who don't have a primary psychotic disorder”

“unless you're sure, reasonably sure of what you're treating, I don't think you should throw on random medications. You're going to cause side effects. You're going to cause problems”

“Those are really just parts of the self that have been split off in terms of an experience, experienced as different or at least separate from the core self. And that does not, in my experience, and I think in the research, actually respond to dopamine blockade”

“if you take an example of people with a lot less experience with rare psychotic disorders and severe psychotic disorders, and you tell them to use the same rules, they might end up prescribing a lot of unnecessary antipsychotics to people”

“First is you have the wrong diagnosis. There's so many times that I'm supervising someone and they say, what medication should I add? And I go, what's their diagnosis? And they're like, I'm not really sure”

“If you're going to augment your antipsychotic treatment, I would first go back to the diagnosis and try to see if there are any what we might call mixed features or just additional psychopathological features and then psychosis”

“you kind of pick how conservative of a practitioner you want to be. And if you're conservative, then you're going to have more patients on unnecessary medications, but more stable patients”

“I really hate the practice of adding it to Haldol. You're basically making the medications fight each other because it binds so tightly to dopamine receptor that it essentially counteracts a lot of other antipsychotics”

“With clozapine, you wouldn't expect EPS, so it didn't make a lot of sense for me why he would be on cogettin if he didn't overtly have some weird EPS. He never noticed any difference, and I think I saved him some cognitive problems in the future”

“All anticholinergics are potentially unhealthy. We give tons of anticholinergics without calling them poison. Benztropine is perfectly fine. You just shouldn't give a medication that people don't need”

“The same doctors who say never prescribe the Benzterpene are also the same ones who will not blink and give Zyprexa and Seroquel, which are themselves already anticholinergic”

“sometimes I worry that medications without side effects like lamotrigine and bupropion, people will keep patients on and then not offer what the correct treatment is”

“it doesn't count as a trial if someone just doesn't take the medication. So I would see this all the time in the hospital. We would call it, someone would call it treatment resistant schizophrenia because the patient kept coming back to the hospital”

“The monitoring requirements basically make it impossible to use. Also, the titration requirements similarly make it extremely hard to use because who has that amount of time to get somebody stable these days? It essentially self-selects for patients who are lower acuity”

“It is a short-term treatment that helps you lift out the depression and then you have to do hardcore lifestyle changes and psychotherapy on top of that”

“there's so many patients now who are seeking it out to use it in a sense to ignore other problems and they're using it essentially as a drug as in they're making lifestyle choices that are That are almost bound to lead to stress levels that are not manageable”

“I'm not like suggesting everyone take ketamine even though it has a big effect size because it doesn't have lasting benefits”

“I also think that the old tale of it causing depression is overblown because I have successfully used it in many cases with mood features now, and they have improved in terms of depression”

“I really hate the practice of adding it to Haldol. You're basically making the medications fight each other because it binds so tightly to dopamine receptor that it essentially counteracts a lot of other antipsychotics”

“sometimes I worry that medications without side effects like lamotrigine and bupropion, people will keep patients on and then not offer what the correct treatment is”

“I'm definitely against that, personally speaking. I know some people are believers in that, and there's this tiny little signal from that old UK study. But I don't really believe in that”

“it's only 20% of patients who are taking it, 50% are taking Antidepressants, 60% are taking antipsychotics, 20% are taking lithium. And yet we think that it's one of the best tools that we have”

“Be very careful when you lower lithium though. Among the mood stabilizers, abrupt lowering of lithium or stopping the lithium may be more likely to even induce mania rather than simply unmask it”

“we might actually want to avoid lithium in people with genuine migraines. Not just headaches, migraines. Because it does seem to likely worsen the migraines in a lot of people”

“if you have anybody who gets fluctuating appetite because of their mood disorder or psychosis, then it becomes a no go because they're just going to intermittently decompensate if they start eating less dinner”

“S through B tier stuff, You really need it. Doing more re-diagnosis And, uh, work. Working on formulation and lifestyle changes, et cetera, et cetera”

“I just ask patients to use ones that have been Approved by like that pharmaceutical testing board at least. So that's basically nature made or like Costco brand is usually the easiest to find”

“I do think people should be at least thinking of mood stabilizers more often. You should at least be thinking of mood stabilizers more often. At least in my area, I think they are disgustingly under-prescribed”

“I think you really need to have at least some evidence of like a, you know, neurobiological type depression where there's episodes or stark changes in total functioning rather than simple mood or reactivity between human beings, interpersonal issues”

“I acknowledge the evidence-based that suggests those subtypes and those matching medications. We feel the same. I don't really subscribe to it. I feel like it's selection bias”

“They've talked about using mood stabilizers. I have not found that to be terribly helpful. Only the non-traditional mood stabilizers, not really mood stabilizers, Topamax and Gabapentin, I think, are more usable”

“I wouldn't give peroxidine. A lot of people like to use Paxil kind of for sleep, but this is an SSRI. This is a potent SSRI with a lot of withdrawal effects”

“I was taught that, hey, this is something you should consider for patients of poor med adherence. They'll know as to withdraw and remember to take medication. I feel like that's very outdated. Set alarm on the phone. Use a pill organizer”

“If you actually go out and look for an algorithm for sleep, there's none guiding psychiatrists. Exactly. The American Sleep ASAM recommends against all the medications we use for insomnia”

“a lot of practitioners just assume SNRI is a much stronger medication that you should reach for whenever something doesn't work. The number needed to treat is actually pretty big regards to if you use an SNRI compared to an SSRI. And it comes with risks. It comes with side effects”

“The combo that is a little famous is the California rocket fuel as coined by Stephen Stahl, which is mirtazapine and venlafaxine. Anyone who's using an SSRI and SNRI, stop it. Stop it”

“none of these respond to an SSRI. None of these respond to an antidepressant, primarily. So do not just think someone is suicidal or depressed, give an SSRI. You need to have a formulation, diagnosis, and treatment plan before you prescribe things”

“You really got to know what the general effect size of SSRI is. You shouldn't oversell it, right? Because if you oversell it, you're going to give people the false impression that this is a powerful medication that's going to change your problems”

“how often do we see patients on higher and higher doses of stimulants? Patients who, you know, they're running through the gambit of different antidepressants because the persons were not thinking through the hierarchy appropriately”

“the biggest things that are ignored are trauma disorders, proper trauma disorders, not just people of history, trauma, um, What else is ignored is mood disorders, and the most harmful one to ignore is, of course, bipolar disorder”

“if we hide that behind a diagnosis, a medical diagnosis, and we have you push through it at the cost of your physical and mental health by putting you on essentially amphetamine speed, that's a detriment to your overall life, right”

“If you use a chemical defense, essentially, like in place of a psychological defense, you use exogenous chemicals in a manner where you're trying to rescue yourself from something or push yourself to some limit, that's a downward spiral”

“there is a financial incentive to diagnose ADHD. And there's a financial incentive to have a relatively loose diagnosis of ADHD. So, you know, primary care doctors, for example, if you have an ADHD patient, that's a patient that's going to come monthly”

“people want everyone on stimulants because they think it's a biological illness, right? If you thought that ADHD was purely a social construct, which, by the way, I don't actually believe, then you wouldn't medicate. You'd change the society”

“Don't forget also random herbs and supplements. A lot of these are unregulated and have some stimulant properties. And then finally, steroids, prednisone, or any other more esoteric or unique medications, prescription medications that can cause mania”

“I just ask patients to use ones that have been Approved by like that pharmaceutical testing board at least. So that's basically nature made or like Costco brand is usually the easiest to find”

“Low-dose trazodone is not a small antidepressant. So it is one of those medications that you need to get it to the higher doses”

“Alcohol, you know, Z-drugs, benzos, cannabis, I would all put in the same category as things that make people feel as if they're getting better or sleeping when they're not really necessarily getting better or sleeping”

“if you label ADHD as the primary problem, you will tunnel vision you and the patient to a lifetime of escalating stimulants”

“the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD. If someone is motivated to answer an affirmative to structured interview questions”

“Imagine if we made diagnoses of intellectual disability the same way some clinics will process adult ADHD. For example, the adult ADHD self-report scale. Do you or do you not have the criteria? They just show you the criteria”

“a lot of patients are coming in... thinking that all their problems are attributed to this one diagnosis, that ADHD can explain the emotional dysregulation, it can explain the conflicts I have in my relationships”

“The TikToks and the Instagrams about ADHD are funny. They're enjoyable. But there's a cost to consuming this kind of thing. And there's a cost to developing ideas like, I can't do this. I can't listen. I can't motivate”

“the vast majority of people coming in are not med-seeking. Even if they would like a stimulant, who wouldn't like a stimulant? I'd like a stimulant. Kind of joking, not joking. But even if they would like a stimulant, most people are making an effort to come in because they have some genuine problem in their lives”

“A common thing you'll hear is someone will say, this person doesn't have ADHD because they can focus for five hours on video games. Or, you know, if someone's really into car work, you know, they can sit there for four hours at a time and work on their car”

“pretty bad kids also are just as likely to have ADHD. Yeah. We've kind of talked about this earlier in that, like, yes, someone can have tons of personality problems. They're actually more likely to have mood symptoms”

“ADHD is highly heritable. You see heritability estimates at like 70 to 80%. So people who don't understand what heritability means say they look at the number and they go, oh, it's 70 to 80% biological, which that's not what it means”

“there's a lot of people who have a lot of stock in the idea that this is a biological disorder. And I think some of these people are acting in bad faith because when they say it's a biological disorder, what they're actually saying is that this is something that's wrong with me, that I have no control over”

“for a lot of people, that symptom is information that's important to be listening to. It doesn't mean I need to seal that over with a Band-Aid, you know. For some people, it means that the job isn't right for them”

“if we hide that behind a diagnosis, a medical diagnosis, and we have you push through it at the cost of your physical and mental health by putting you on essentially amphetamine speed, that's a detriment to your overall life, right”

“So much danger in over-interpreting things as Axis 1. And when you start thinking in terms of personality, you have more control. You have more ability to change your surroundings”

“it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed”

“an expert is just someone who can find what they're an expert in, in anyone”

“the childhood diagnoses, if you ever look at the Venn diagram overlap, it's very clear that they're not getting at something specific. And they're not nailing the underlying thing going on”

“As a provider, you can't resent certain types of patients because you'll actually manifest the difficult situation, not the patient”

“a lot of these people who chronically harm others or violate their rights, I think they are lacking innately in that sense of guilt and remorse. And then you have to manage people like that very differently”

“the insanity defense. traditionally excludes antisocial personality disorder. Everyone who has been trained appropriately and understands fundamentally why the insanity defense exists and who it applies to knows that it cannot apply to antisocial personality disorder”

“I have seen numerous cases now of Autism Spectrum Disorder being diagnosed in adults after the onset of schizophrenia. I'm not kidding. I am not kidding. The first testing and evaluation for autism is taking place after the clear onset of schizophrenia”

“if someone can go in a modern Western society for 30 years without an autism spectrum diagnosis, and then they begin to have new difficulties, I think you're doing a disservice if you don't consider all the other things that could be interacting with a baseline of autistic traits to produce now a global psychological or psychiatric disorder”

“diagnoses are most valid and reliable when based on multiple sources of information, including clinicians, observations, caregiver history, and self-report”

“it's almost as if asking the question begets an interview that's guaranteed to get that diagnosis when you do the structured interviews that are for those specific diagnoses”

“I don't think they are aggressive enough about the not better acceptable aspect. Yeah, the differential diagnosis. And I think it's probably because autism researchers and the framers of the definition of this diagnosis probably mostly work with children”

“If this single diagnosis accurately describes both these people, then that makes that diagnosis kind of useless, right, as a category. If you make your diagnostic category super broad, then it doesn't tell us anything at all”

“there's a false dichotomy that either you think it's overdiagnosed and all these people think they have autism when they don't, or you think it's underdiagnosed and there's people suffering who have a diagnosis that's underdiagnosed. And the much more obvious route is that both are true”

“It is probably the number one augmenting agent at a low dose for depression, proper depression when added to an antidepressant, but by itself doesn't really help in bipolar depression”

“Okay, so it's basically an SRI that's been combined with an antipsychotic. Very clever, you know, pharmacologically, but in my opinion, causes too much agitation and cycling in true bipolars”

“What are the antidepressants that I find a little safer? Not Wellbutrin, not Bupropion. That's what kind of is out there in the community. Kind of myth, if you ask me. I don't think we have any data to demonstrate that”

“A full-on light box at 18 inches is Can induce a manic episode. It's just, it's an antidepressant. So light is a powerful tool”

“it's as if unless this doctor sees mania and hypomania in front of them, the bipolar disorder cannot exist. That's not how you should practice medicine, right”

“BPD isn't the person's fault, and they deserve understanding. And CPTSD people can be manipulative, and they're responsible for what they do”

“What I'm not going to do is I'm not going to say that someone has complex PTSD or when they simply have a bunch of little t traumas in their history”

“some patients use it as a defense to not look at their personality dysfunction. And I feel like the McLean screen and the conversation about traits allows me to open up that conversation earlier”

“the patient and the providers making pretend that treatment is major depressive disorder in the back of their mind know that there's a personality disorder, but don't communicate it. And it's really setting up for bad treatment outcomes”

“If you're too supportive with the self-hating kind of depressive person, they tend to get more depressed because they think, you're a very nice person, but you don't get how bad I really am”

“the most common kind of personality type that existed in the literature, including the empirical literature before 1980, was depressive personality. But people on the mood disorders task force didn't want to have depressive personality in there”

“Often they come off the inpatient floor with a completely definite diagnosis, which was never talked to with the patient. Like it'll say schizophrenia. And then on the intake, you'll go like, okay, so you were diagnosed with schizophrenia. And authentically they go, oh, I didn't know that”

“99% of the time you're They're not really true. Treating the anxiety disorder when you use a benzodiazepine, a Z drug, or alcohol. Frankly, all about the same in terms of their use with different levels of tolerability for different people”

“Bupropion, in my opinion, worsens generalized anxiety disorder long term. It helps anxiety if the anxiety is This is a part of the depression. Depression. It doesn't help anxiety on its own, in my opinion”

“If you can meet DSM criteria for a psychiatric disorder, you are excluded from the sleep medication studies. So in my opinion, those guidelines are nearly worthless when it comes to the treatment of psychiatric conditions”

“If you actually go out and look for an algorithm for sleep, there's none guiding psychiatrists. Exactly. The American Sleep ASAM recommends against all the medications we use for insomnia”

“they are symptomatic treatments that create habits, build tolerance, and stop working. They're not fundamental treatments of the underlying condition, so much as they are that they're drugs that help people feel better temporarily”

“What you feel on a stim, on meth or cocaine or speed, which is what Adderall is, is an intoxicant effect. That is the euphoria and energy burst, and you will build tolerance to that”

“it doesn't treat depression in the long term. And what I've seen with so many patients who have ADHD plus depression is you're You're not treating the depression and you'll see irritability creep up. You'll see somatic symptoms creep up”

“I think genuinely a lot of people unconsciously will resist getting better because there's a lot of things that are scary or unknown about getting better. Or if we get better, we have to face the failures or regrets of the past”

“some people think once they get a whiff of personality, a whiff of borderline personality disorder, or a whiff of narcissism, then all the other stuff is explained away and the person can be discharged, which is... ridiculous”

“I think a lot of people reach for the vulnerable narcissism without adequate evidence, that they assume that that's the subtype just because you have somebody who is A, male, and B, male”

“Her image of herself is such that even normal human lying is something that she is completely outside of her awareness”

“we thought together of maybe it's something else going on other than OCD type symptoms and that this patient is putting us in this crazy situation of making this really complicated. Unlocated psychopharmacological switch”

“Make sure you have the right diagnosis, people. Treatment-resistant depression is where personality disorders go to hide”

“make sure you have the diagnosis correct because I do fear by saying polypharmacy is the rule, not the exception, that we're giving permission to over-medicate personality disorders or have someone on lithium and Depakote and Lamictal when someone really needs to reassess the diagnosis”

“and personality is the most neglected one i'm gonna say personality is the most clinically neglected category today uh but we'll leave that side um”

“The main problem in the clinical treatment of personality, in my opinion, is clinician feelings, the counter-transference feelings about the conditions, about themselves, and about a lot of different things”

“there's a big problem today in that people only want to apply personality disorder diagnoses to the people they dislike. And they think that the people they like should not have a diagnosis”

“the patient and the providers making pretend that treatment is major depressive disorder in the back of their mind know that there's a personality disorder, but don't communicate it. And it's really setting up for bad treatment outcomes”

“So I think what really happens in practice is people go like, I've identified what looks like major depression. Therefore, I can't make any other diagnoses, nor do I need to. And so people really should be longitudinally observing, re-diagnosing, re-testing it”

“Imagine if you said that about any other diagnosable psychiatric condition. Oh, I don't like to jump to bipolar. Oh, I don't like to jump to an eating disorder. I don't like to jump to an anxiety disorder”

“studies actually show that for both inpatient and outpatient clinical populations in psychiatry. Most people can meet criteria for a DSM personality disorder. It doesn't mean that's the main issue going on”

“in the emergency room, if someone comes in and says, I'm hearing voices, and then you talk to them and they're a little difficult, it's a difficult interview. Afterwards, you'd say, oh, this is just personality”

“a lot of severe personality pathology it's it's an internal struggle these people aren't manipulative problematic causing interpersonal whatever they're struggling internally”

“in a clinical setting, we don't diagnose to decide if something is purposeful or whether the patient is responsible, right? We're diagnosing to inform our treatment plan and to inform the patient of, What are your treatment targets”

“whether or not something is biological or psychological has no bearing on whether it's a clinical problem or not. And we want to medicalize, clinicalize these problems in order to help people”

“We don't want blame, but we do want productive change, and some productive change will be limited in a mild or significant way if we don't look at how the subject, the individual, contributes to what's going on”

“there's also a harm in ignoring a problem that you need to treat. It's as if we had some social stigma against OCD and we didn't want to recommend exposure and response therapy”

“So much danger in over-interpreting things as Axis 1. And when you start thinking in terms of personality, you have more control. You have more ability to change your surroundings”

“Two people of the same DSM diagnosis will have radically different behaviors and lives. And I don't know if people understand that diagnosis is not destiny”

“Most people use vague heuristics to diagnose just a few of the major personality disorders, and then from there feel as though medications won't work”

“traditionally traditionally mental illnesses did not include things like personality disorders because the personality disorders were thought to be fundamental to the person and not independent mental illness per se okay this is not a clinical reality it's a legal reality right you could call the legal fiction even in some places”

“Yes. In theory, you can just have a personality disorder and get SSI. So it is a medical condition”

“it's a bridge too far to go to diagnosis. We don't have the data for it. I think what's more important to note is that you can watch this stuff and you can say, these are not ordinary people”

“When we make this stuff about us versus them, we really miss that all these aspects are a part of ourselves. The best writers in regards to understanding personality are the ones who can find the pieces inside of them that are in the other people”

“a lot of these people who chronically harm others or violate their rights, I think they are lacking innately in that sense of guilt and remorse. And then you have to manage people like that very differently”

“being outside of the norm is not enough to say if someone is mentally ill for a professional, for a psychiatrist. We need to say in what particular way is he outside of the norm”

“I saw a lot of PTSD patients or to me, their diagnosis of PTSD who carried the diagnosis of depression. And we're on their 30th trial of a new antidepressant. And, you know, they were substance use disorder and depression. It's like, no, this is a classic PTSD case”

“That patient may then project or rather attribute their paranoia. fear, aggression to you. They may start acting in a way that's maybe a little dicey or maybe even overtly aggressive, maybe yelling or being very oppositional”

“I don't think that the people writing about the, quote, schizophrenia, schizophrenogenic mothers, et cetera, et cetera, developmental contributors to schizophrenia, I don't think, A, they demonstrated that that's actually causal”

“The actual likelihood of a primary sleep disorder is actually on the lower side, in my experience. Because even when it's treated, it does not solve the other issues”

“The same doctors who say never prescribe the Benzterpene are also the same ones who will not blink and give Zyprexa and Seroquel, which are themselves already anticholinergic”

“in true psychotic disorders, is that sometimes in this discussion, somebody with schizophrenia will actually start to deny that they believe the delusion. Uh, because they, their ability to detect your social judgment is not impaired”

“some people, when you give them antipsychotics and they stop having that delusional perception anymore, they go like, well, I remember feeling that way about it, but that just seems strange now”

“it's not enough to hear a voice and follow the voice. What you believe at the time has to justify you following that voice in some sense, in a manner that would mean that you didn't understand it was wrong”

“the very first is to admit that Ruling out hypomania is effectively a fool's errand. It's impossible”

“I thought their baseline was their baseline, but once we tried bringing down the sedation a little bit, they almost changed their personality a bit. One of them even got worried was getting manic, but no, she was just getting back to normal”

“none of these respond to an SSRI. None of these respond to an antidepressant, primarily. So do not just think someone is suicidal or depressed, give an SSRI. You need to have a formulation, diagnosis, and treatment plan before you prescribe things”

“SSRIs have not been shown to specifically reduce suicidality. Though, of course, they have far less side effects and are much safer than older antidepressants”

“Why do some people get worse than antidepressants? In my opinion, it's mostly because they have some kind of a more bipolar disorder type condition and experience antidepressant-related agitation and sleep problems. That's probably, in my opinion, why we see the increased risk for suicidal ideation in people under the age of 25 on antidepressants”

“schizophrenia has its own rate of movement disorders, okay, without antipsychotic use. If you look at pre-antipsychotic studies, they were already developing tardive dyskinesia anyway”

“I think the reason why we think second generations have less of it is because we use lower doses of the second generations, and the patients were on the second generations for less time than the first generations, both reasons”

“I think that in modern day training, a lot of residents are basically taught three levels of disorganization, or maybe four. You have linear, non-disorganized, you have circumstantial, disorganized, and then you have tangential, fairly disorganized. That's really not sufficient”

“even bipolar mania can mimic psychotic features uh the speed of distractible thoughts, rushing thoughts and speech can appear and has been defined in the literature as thought disorientation”

“at the bottom of that evidence ladder sits bupropion and mirtazapine and basically buspirone, another antidepressant augmenting. So taking two antidepressants rarely ever works better than taking one, which is what we most often do”

“people reach for antipsychotic first because they're so used to it now right we're all primed to using the antipsychotic as augmentation depression anxiety even”

“If you add low dose Abilify to another antipsychotic, you're actually not adding more antipsychotic. You're taking antipsychotic away because the Abilify will bind more tightly most of the time and at a low dose will not be acting as an antipsychotic”

“a lot of psychiatrists, a lot of clinicians are afraid to do what are essentially technical confrontations. They can detect certain things that don't exactly add up, but because of their human kindness, they don't want to question about it”

“You have to have the evidence. You got to have receipts. Do not give an interpretation. until you have countless or at least numerous examples that you have already confronted with the patient”

“Because this is not something that you should be doing when you're totally upset, okay? If you're above like a 7 or 8 out of 10 in distress, There are different skills for that”

“we are trying not to associate the practice psychologically, consciously or unconsciously with distress. Right. If you need to teach distress tolerance skills, the DBT tip skills are great and you can pick other ones”

“Because frankly, at least the first time or the first few times, it works pretty well, grounding techniques and mindfulness, to escape panic or distress. It will stop working pretty quickly like any PRN if it's used that way”

“I do feel that Describe is a little riskier when it comes to Ruminators. But again, it's very individual, which is why I just buffet it”

“I just described like it's 4am um I've been sleeping for six hours and it actually worked really well. It helped me calm down, which is not the purpose of it, but it did work”

“right now, psychiatry, like 95% is practice of medication, next medication, next medication, next medication. And that's not in the algorithm”

“they will just develop different compulsions than what they were doing before. And you might not notice it at all. And that can be a reason why they're not getting better because all they're doing is suppressing the initial compulsions with a new compulsion”

“there's just a subset of people of ocd maybe they're even a plurality or even the majority they're very self uh effacing and they have a lot of depressive tendencies they're really mean to themselves basically And that can be an impediment to doing the ERP properly because they're too self-critical, too harsh”

“i just think that it's pointless to try to do exposures and response prevention type treatments until the patient can accept themselves and can accept that they have learned something in the past that's not working for them and they need to learn something new”

“Because frankly, at least the first time or the first few times, it works pretty well, grounding techniques and mindfulness, to escape panic or distress. It will stop working pretty quickly like any PRN if it's used that way”

“Often they come off the inpatient floor with a completely definite diagnosis, which was never talked to with the patient. Like it'll say schizophrenia. And then on the intake, you'll go like, okay, so you were diagnosed with schizophrenia. And authentically they go, oh, I didn't know that”

“it's always remarkable how different the perceptions are between people who have worked in the emergency department, have worked on inpatient units, and people who spend their time Doing outpatient psychotherapy”

“all the legwork is done on levels zero through three and that the interpretation is just a small skip it's not this gigantic jump”

“you do see people play-acting psychoanalysts in once-every-three-months therapy, or once-every-three-months medication management, and I think that does more harm than good”

“one thing that's important to notice is you hear this described as very narcissistically depleting in that this is not hot and sexy stuff where you're thinking of all these complex things”

“Because frankly, at least the first time or the first few times, it works pretty well, grounding techniques and mindfulness, to escape panic or distress. It will stop working pretty quickly like any PRN if it's used that way”

“Because this is not something that you should be doing when you're totally upset, okay? If you're above like a 7 or 8 out of 10 in distress, There are different skills for that”

“What should mindfulness not be? It should not be unpleasant. Okay, it should not be an unpleasant experience. It should not be significantly effortful. It should not be a struggle of some kind”

“it's not an outcomes focused Practice. If you try to practice mindfulness with a particular outcome in mind, it will subvert the efficacy of the practice itself”

“I also want to give a caveat to the caveat that also just enjoying things is not mindfulness because I saw that a lot of just like people think mindfulness is”

“Nothing wrong with using a YouTube video or a You know, app that has mindfulness practices at the beginning to get a flavor of things. But ideally, you should be practicing mindfulness in a way that does not depend on a particular setting or external source”

“if you skip the later developments that are easier to translate into today's language, it's easy to dismiss the whole field as kind of just pseudoscience and just nonsense. And that's a big mistake”

“If you take certain things in, let's say, the DSM at face value without understanding the history behind it, you're practicing almost cargo cult psychiatry”

“most of the time maybe 80 to 90 of the time the terminology is needlessly abstract uh to capture you know the information that is trying to be communicated”

“if you have a reader or a thinker grapple with something difficult they may emerge you know, at the end of it with more than they would have had if you made it very, very concrete and plain and non-abstract”

“Freud always wrote hypotheses and then his followers would then say, this is what's happening, you know? And then they overstate things. I think they attribute too much meaning to repetition, like saying it's a desire for mastery”

“Freud didn't work with patients with primary psychotic illness. Most of his theories were based on patients with hysteria. His formulations and understanding of psychosis were based on a totally different subset of patients”

“you can't do good treatment without giving some degree of normal psychoeducation, and at least advice in the form of not direct advice, like, I think you should do this specific thing, but in suggestion. It's interesting that you did this one thing. Did you ever consider doing this other thing”

“it's basically impossible for any two year four year seven year nine year uh program to really cover everything in a meaningful fashion you know and anyone that claims to say that i think is making some kind of an error”

“The loss in terms of, you know, where the question comes from, is it still relevant today, is that many clinicians aren't as able to think psychologically as they were before”

“it superficially sounds like you're staying close to the material when you say does that remind you of someone from the past? Because it's like someone could argue, it's like, oh, I'm just making a connection. But you're not paying attention to the person's internal experience”

“venting itself is not actually helpful. It really bothers me when I see venting being documented as a psychotherapy intervention. The venting is not the operating procedure that actually helps people. It's the reflections you do”

“I do see people use psychodynamic and psychoanalytic concepts and abuse them in short bursts during psychiatric appointments”

“when I was anxious, I would feel pulled to explain what I was thinking or what I was doing rather than let the process unfold naturally because of the discomfort of sitting in silence”

“one thing that's important to notice is you hear this described as very narcissistically depleting in that this is not hot and sexy stuff where you're thinking of all these complex things”

“to the extent that someone may say they're doing a psychodynamic psychotherapy and all they've done is maybe read some Freud or done a class or two and they've never really been formally trained in the technique”

“it's not the first time you point it out. It's not the fifth time you point it out. It's the 10th time, a year and a half into treatment”

“the level system. Again, I do not recommend you do it in session. Don't think about the levels when you're in the session. It's for retrospective analysis only”

“when I was anxious, I would feel pulled to explain what I was thinking or what I was doing rather than let the process unfold naturally because of the discomfort of sitting in silence”

“a therapy does not work by giving the answers. You give answers to a patient. Right. diagnostically, formulation-wise, even if you're 100% accurate, it might as well look like black magic to the patient”

“a therapy does not work by giving the answers. You give answers to a patient. Right. diagnostically, formulation-wise, even if you're 100% accurate, it might as well look like black magic to the patient”

“handing someone a generic sheet with a bunch of sleep hygiene rules doesn't work um but that doesn't mean that the things that are on it don't work”

“He actually talks about taking sleep hygiene too far in that when patients become so preoccupied with having the absolute perfect sleep environment, it can backfire. And with that said, that's not applicable to the majority of patients who have awful sleep hygiene”

“you could just invite people to start dimming the lights after say 8 p.m. if they're going to try to have a regular bedtime at 10 p.m. Yeah, in my experience, people don't do that very well either”

“the first one is going to bed at a regular time. Zillions of reasons to have that not happen in people's lives. The morning rise time, at least there's an alarm clock and usually a fixed need, like work, family, school, to get people going in the morning”

“occasionally you're going to stay up later than your regular bedtime. That's okay. Just like maybe an hour later would be good, not five hours later. Or when you do that, you need to be aware that you're taking a risk to your rhythm”

“in forensics, as much as I'm a fan of the alternative model, it's not very practical for use, especially for one-off evaluations, yet it's still so important”

“sometimes collateral is not that useful. I've had people just completely not even notice clear disorganized schizophrenia in the family member that they cohabitate with”

“Patient comes into primary care doctor. And they go, I have a cough. They don't get told they have a cough disorder. We have to figure out what's going on underneath”

“So top of the differential usually is substances, personality, and mood disorders. OK, so now you're going to assess for those and you're going to you can't just assess responsibly when there is high dangerousness based on the output statements and behaviors on one look of a patient”

“Imagine if you said that about any other diagnosable psychiatric condition. Oh, I don't like to jump to bipolar. Oh, I don't like to jump to an eating disorder. I don't like to jump to an anxiety disorder”

“Don't write anything that you would not testify to under oath. OK, think about that”

“You can't sign every single paperwork for everyone who asked for it. And you can't deny every single person who asked for it on some vague principles”

“I see a lot of patients be put on disability with like, you know, a therapist or a psychiatrist will put them on and then not have any sort of additional treatment that they're providing”

“My thoughts or my politics or considerations of whether or not someone should have time off or whether or not... uh someone should be getting paid while they're not working or whether or not they're i dislike them because of their personality disorder simply should that should not be any sort of that should not be involved whatsoever”

“These are forms that are generated by the attorney for you to basically do free expert work. I don't fill out those forms unless I think there's a very clear case and that the patient needs to get disability payments fast”

“They either ignore it entirely and say, listen, this isn't your job. Send it to a forensic evaluator, which is not appropriate, by the way. You can hardly get a forensic evaluator for forensic cases”

“if you quote assess someone for a specific condition and you simply ask them if it's there or not you could have just asked a patient do you think you have adhd and then ended the interview”

“So if you go into that kind of evaluation and you do a structured interview, they're just going to deny every single symptom that you ask about. They'll say, no, doctor, I'm perfectly fine”

“the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD. If someone is motivated to answer an affirmative to structured interview questions”

“ADHD has become a general marker for psychosocial distress of some kind. Right. And so it's almost meaningless in terms of a chief complaint. All it tells us is that this person is not functioning to the degree that they want to be in their work or school”

“college age, you know, like the 18 to 25 range is when a lot of the more serious mental illnesses start to develop. And there often is a prodromal phase where the core symptoms that they experience might be inattention”

“if your problems with concentration are happening because of a stressor of fear over losing an unfortunate relationship or all these fights that keep happening over and over in your relationship, then the method of successfully treating that is not going to be Zoloft”

“Most people have at least some kind of a more subtle early onset of axis one problems that have essentially deviated their path towards the life that they want to have. And so if you just focus on one diagnosis and one medication and not everything else, you're going to be a little limited in your treatment effects”

“anxiety is complicated. It might not be its own thing in most cases, that there are many different sources for anxiety and that you got to do a thorough assessment before you can make reasonable recommendations”

“just hundreds of people being, you know, I really liked, you know, just a touch of Abilify. Is no one going to ask what's going on in this woman's life”

“a patient will come and say, I have anxiety. They could be blatantly manic and it's like, oh, their problem is anxiety. To me, it's irresponsible To me, it's It's irresponsible to be treating someone without them knowing your diagnosis”

“the vast majority of people coming in are not med-seeking. Even if they would like a stimulant, who wouldn't like a stimulant? I'd like a stimulant. Kind of joking, not joking. But even if they would like a stimulant, most people are making an effort to come in because they have some genuine problem in their lives”

“Even if they don't pay a cent, they are paying emotionally. And that is a big toll”

“It doesn't exist. Yeah, you can't do that with confidence. What you can do is gather all the other data that will help you Adjust your assessment of probabilities. And you're trying to get the greatest confidence either because, of course, we're making a treatment decision, right”

“I feel like the patients that I have answer yes, when I get more narrative, it doesn't at all fit with bipolar. And the patients who say no, if I get more narrative, a lot of times I'll be able to figure out episodes. So screener questions are particularly bad in bipolar”

“Oh, yeah, there has been periods where I've had tons of energy. And then there are patients who say no to everything. So it's important to have an approach”

“this is the absolute worst thing you can do, is say, were you depressed and use that as your screener for depression. And what I recommend is using something like the Madras. So the Madras has questions that are linked to the DSM criteria”

“the majority of completed suicides are not from patients presenting reporting suicidality. Okay, majority of people who complete suicide are actually people who've never even seen a psychiatrist and usually have never mentioned suicidality at all”

“if you do it blindly, you're doing cargo cult psychiatry, as I've in the early episodes had the tendency to refer to. We can't simply do the ritual. We have to understand where the ritual comes from and why it's done”

“it's actually really doing a lot of danger because it teaches patients that like if I want to get discharged in the hospital I just have to answer these questions the way I know they expect to be answered and then I'm done”

“I've seen a lot of novice providers go up to patients, especially like in the emergency room and go like, Any thoughts are hurting yourself or hurting other people. And the person obviously is going to get defensive and blocked down”

“in the emergency room, if a patient has 15 suicide attempts, it sounds like that they're super high risk, but it doesn't actually indicate anything about risk for the patient in front of you”

“patients with borderline personality disorder are at an elevated risk compared to patients without borderline personality disorder of completing suicide”

“There are patients who will genuinely believe that And it will be true at the time of the interview that they are not dangerous in some fashion. And then they will go kill themselves or hurt somebody else within 24 hours of release”

“I was consulted by a surgeon. to assess for suicidality in somebody who just went through some kind of a painful waking procedure and afterwards said something along the lines of, boy, if I have to go through that again, I'm going to kill myself”

“the majority of states will punish the doctor Okay, punish the doctor for being more lax rather than being more strict in terms of you will not go wrong for involuntary detainment and allowing a judge or judicial officer to release the patient”

“There's so many patients where it's like, yeah, you're having problems. Let's call it generalized anxiety disorder, give you Zoloft. It kind of works. We're not really talking about the real problem, but we can both put our blinders on and pretend that it's just this categorical thing”

“When DSM-3 was coming out in the 80s, there was a lot of concern. There were some studies showing psychopaths. And so, you know, a big concern was, you know, getting things down to reliability and checklists and emotions were felt to be unimaginable”

“nowhere once in any of those studies in the review and anything was rage mentioned anywhere. Nowhere once was anything about what the animal literature, what the brain science shows about what the NK1 system is for”

“a huge part of that is avoiding avoidance. And by signing that paperwork, you're promoting the avoidance”

“If you use mindfulness practice as an escape from fear, it will make it not mindfulness practice and we'll make it another avoidance behavior which just perpetuates the problem”

“the temperament of a therapist typically is open, accepting, non-confrontational. And if you don't have this good conceptualization of the importance of setting boundaries, I see early therapists and psychiatrists really struggle with setting boundaries”

“a lot of patients act out their conflicts and truly because they're on. It's weird because they're unable to think about them because it's so overwhelming. They act them out”

“The only thing I can take issue about is maybe discussion of your own professional work and achievements when it's not necessarily pertinent to the treatment process”

“malpractice insurance might specifically exclude coverage for mishandling the transference which actually is a uh disguised way of saying having sex with your patients”

“A lot of clinicians can't formulate how personality shapes a presentation. And then that clinician thinks everything that doesn't respond to meds is some form of treatment resistance”

“we may pretend that we're playing a biological game. And we're not. We're playing a psychosocial game”

“The loss in terms of, you know, where the question comes from, is it still relevant today, is that many clinicians aren't as able to think psychologically as they were before”

“a diagnosis can obscure if we simply call it generalized anxiety disorder or PTSD. And then we ignore the personality components, the developmental components, all kinds of components that should belong in that formulation. Then the diagnosis robs us of vision rather than gives us clarity”

“You have a patient who's cutting themselves, identity diffusion, chaotic, unstable interpersonal relationships, devaluing the therapist. And the therapist is reluctant to call that borderline personality disorder”

“Use common sense. Night shift is the worst thing a human being can do. Yeah. Don't let people convince you of things that go against your common sense”

“if you label ADHD as the primary problem, you will tunnel vision you and the patient to a lifetime of escalating stimulants”

“ADHD isn't this thing that explains all aspects of an individual. You can't say this person's ADHD, so that's how I explain this characteristic, this characteristic, this characteristic, this characteristic”

“so many patients that I see for psychotherapy come to me and they have been diagnosed with four or five or six different psychiatric conditions. Historically, by the way, that was never done. Before DSM-3, That was an exceptionally rare situation”

“We have a rampant comorbidity problem, and that's the other issue that we talk about in the paper. And this sort of idea would help resolve a lot of what we believe is really spurious or false comorbidity in psychiatry”

“they go, you know, I have a patient, they have bipolar. MDD, ADHD, GAD, Lupus. Yeah. And now they can't focus and I don't know what medication I should go start. They don't really have a frame of reference for how to even think through the problem”

“venting itself is not actually helpful. It really bothers me when I see venting being documented as a psychotherapy intervention. The venting is not the operating procedure that actually helps people. It's the reflections you do”

“I fear that that's what occurs in a lot of therapies is just unconditional support for the primary process of what the person's experiencing rather than a curiosity and a desire to expand and understand it”

“They go off their countertransference rather than digging up and evaluating the clinical data across the lifespan”

“The main problem in the clinical treatment of personality, in my opinion, is clinician feelings, the counter-transference feelings about the conditions, about themselves, and about a lot of different things”

“I believe that stigma exists primarily because of clinician reactions, which are sometimes understandable to difficult patients. Let's face it, some patients are simply more difficult than others”

“If you're expecting that the treatment's going to fail, if you're expecting that you're not going to get along with the patient, you're going to make that true to some extent, or you're going to make it more likely for it to be true”

“As a provider, you can't resent certain types of patients because you'll actually manifest the difficult situation, not the patient”

“That patient may then project or rather attribute their paranoia. fear, aggression to you. They may start acting in a way that's maybe a little dicey or maybe even overtly aggressive, maybe yelling or being very oppositional”

“It's possible for both on the clinician end and on the patient end to hyper focus, hyper energize on one topic or particular problem. And in a way that obscures another, maybe deeper or at least parallel and important problem”

“a therapist and the patient of the same culture may both mutually ignore some glaring aspect of the clinical situation because for both of them, it's a cultural norm”

“I think it's a natural instinct to distance ourselves from the problem. And like, you know, identify, oh, that was a big mistake. That was a huge mistake”

“I think we're just tempted to believe this idea that If there is a diagnosis in the DSM and the patient meets the criteria for the diagnosis, we give the diagnosis. I think it's actually a very harmful way of thinking that's really philosophically and scientifically flawed”

“We have a rampant comorbidity problem, and that's the other issue that we talk about in the paper. And this sort of idea would help resolve a lot of what we believe is really spurious or false comorbidity in psychiatry”

“they go, you know, I have a patient, they have bipolar. MDD, ADHD, GAD, Lupus. Yeah. And now they can't focus and I don't know what medication I should go start. They don't really have a frame of reference for how to even think through the problem”

“Do you guys know what the diagnostic hierarchy is? And every single time, at least 80% have never heard of it. And this is residents. This is psychiatry residents at reputable residencies”

“there's so much emphasis on symptoms and entire systems now being developed around symptoms like HITOP, the hierarchical taxonomy of psychopathology. But that's one, it's only one of the classic validators. Think about in general medicine, how many diseases share symptoms like cough and fever and pain”

“they share a third of their, a third of associated genes. They diverge on two thirds of their associated genes. They share some symptoms, but their courses are different. They have completely different longitudinal courses”

“There's an emphasis on transdiagnostic markers and symptoms, a real skepticism towards the idea that there are natural kinds in psychopathology, that there actually are different diseases or conditions”

“if you create a box that forces people to do something that properly is a complex thinking task, then it replaces the complex thinking task because it becomes a symbol in place of the actual process”

“Just because someone has an erotic transference is no diagnostic information about their psychological functioning”

“exploring sexual fantasies is not a normal part of medication management right and if you are starting to do something in the medication management that is markedly different from what you do with other patients that's a red flag”

“Unless you have a very clear idea of what you're doing, I highly recommend that you seek supervision”

“If you offer or agree to an ineffective treatment and you don't warn that, then you're liable if something bad happens”

“I have had to have some creative conversations around informed consent for individuals who had depression and were actively suicidal and they hear that under general anesthesia there's a chance of dying and that's their indication that they want to sign up”

“the estimate is that only about 1% of felony cases raised in Sanity 8 defense at all. And that shouldn't surprise you. Because of the long commitment times and the long hearing times required, most people would rather take a deal”

“The prosecution then has to prove that a person was able to conform their conduct to the law, which I've said before, there's no uniform, readily acceptable medical way of determining that. It's so subjective”

“it's not enough to hear a voice and follow the voice. What you believe at the time has to justify you following that voice in some sense, in a manner that would mean that you didn't understand it was wrong”

“Just like psychosis, voices can come from a lot of different mental conditions. It can come from being an ordinary person. Some people simply hear an internal monologue, for example”

“being outside of the norm is not enough to say if someone is mentally ill for a professional, for a psychiatrist. We need to say in what particular way is he outside of the norm”

“the insanity defense. traditionally excludes antisocial personality disorder. Everyone who has been trained appropriately and understands fundamentally why the insanity defense exists and who it applies to knows that it cannot apply to antisocial personality disorder”

“you should not equate or confuse your moral reasoning and your moral ideas and wishes with legal conclusions. And I do think a responsible forensic expert working in a case, they are giving an opinion based on the legal conclusion”

“I can't go to this thing because of my, you know, whatever, insert mental illness. It's a very, very, very dangerous, self-fulfilling prophecy”

“I also don't think it's good for people to be overly simplistic in explaining themselves in only one fashion. Let's say neurobiological. Everyone is so much more complicated than that”

“first year residency is inpatient, where it feels like your entire job is get patient to take medication. And sometimes that can spill over into the future outpatient years. And that's not our role”

“I think as a society, we have a obligation to detect early on when someone's mental illness makes them unable to actually make a rational decision about treatment. And then we have to intervene, but we don't”

“But that becomes another barrier to actually just doing some of these behavior changes. This idea that you're supposed to fill out this thing. Well, I forgot to fill it out yesterday. Maybe I just don't want to do this”

“no one is going to meaningfully recover or get better from email and texting i'm sorry that is not a standard or acceptable treatment modality and the more we sort of lean into encouraging even implicitly by being overly interesting or validating on our emails that mode of communication”

“If you could have access to an MRI anytime, That would mean unnecessary imaging that would cause panic and anxiety and keep you from sticking with one set of findings. Right. Getting more information or contact with the doctor is not necessarily a good thing for treatment”

“every person I've supervised, when they say they're working until 8 p.m. or whatever, I go through their emails and I'm like, this is way too much. This is way too much. This is way too friendly”

“so many patients that I see for psychotherapy come to me and they have been diagnosed with four or five or six different psychiatric conditions. Historically, by the way, that was never done. Before DSM-3, That was an exceptionally rare situation”

“First is you have the wrong diagnosis. There's so many times that I'm supervising someone and they say, what medication should I add? And I go, what's their diagnosis? And they're like, I'm not really sure”

“trying to medicalize human behavior that falls within the range of normal even when it's an extreme in the range of normal or human behavior that's rationally driven Turning that into a medical diagnosis is a mistake because then there's this implicit philosophical understanding or belief that it's out of control”

“diagnostic labels initially can kind of help people understand themselves better because it's putting words to experience that before they didn't have words to. And what we've seen more and more is that the The diagnostic label is actually allowing less insight and less self-understanding”

“there is quite a trend in the community of diagnosing off vibes only, off countertransference only. Probably what I mostly see is that they ignore personality”

“be very careful about the possibility of any diagnosis, but particularly culturally laden or emotionally invested diagnoses in functioning as a form of resistance to appropriate treatment, consciously or unconsciously for patients”

“a lot of people out there in the community have a habit of diagnosing post-traumatic stress disorder without Actually going through the criteria. They can identify that someone is in a persistent fear or mood problem and that they have a criteria in a trauma and they say, well, they've got that”

“A lot of people come in with a very, very strong, almost culturally embedded idea of what they have. And sometimes that's wrong”

“it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed”

“Often they come off the inpatient floor with a completely definite diagnosis, which was never talked to with the patient. Like it'll say schizophrenia. And then on the intake, you'll go like, okay, so you were diagnosed with schizophrenia. And authentically they go, oh, I didn't know that”

“I think we're just tempted to believe this idea that If there is a diagnosis in the DSM and the patient meets the criteria for the diagnosis, we give the diagnosis. I think it's actually a very harmful way of thinking that's really philosophically and scientifically flawed”

“a diagnosis can obscure if we simply call it generalized anxiety disorder or PTSD. And then we ignore the personality components, the developmental components, all kinds of components that should belong in that formulation. Then the diagnosis robs us of vision rather than gives us clarity”

“The problem is that you build your foundational psychiatric knowledge on the most severe cases. So I see a lot of practitioners who think that if it's not severe, near psychotic bipolar, it's not bipolar”

“they may not adequately consider or have knowledge about the basic theory and concept and the frame of how these kinds of different techniques and therapies are utilized”

“just because I read a paper on some deep psychoanalysis three times a week and how that therapist responded to sexual transference doesn't mean I do a half-baked attempt at recreating what that intervention was”

“Let's think about it more as, you know, they're going to happen. They can be small. They present opportunities. And I think that attitude helps us approach them with openness, non-defensiveness, curiosity”

“they think of ruptures as like these very explosive things. And especially for therapists, withdrawal and receding your own needs is a huge blind spot”

“this wasn't a time to make a connection to the past or, you know, like intellectualize and think of all the way that connections in this person's life. This is a time to be there and sit there with that emotion”

“So far, research comparing online therapy and in-person therapy are finding little to no difference”

“the patient and the providers making pretend that treatment is major depressive disorder in the back of their mind know that there's a personality disorder, but don't communicate it. And it's really setting up for bad treatment outcomes”

“Sometimes I've run to clinicians who don't even really fundamentally understand personality disorders. They really apply the diagnosis like person I don't like or unpleasant person. But that's really not what it means”

“it really shifts the idea of borderline personality disorder isn't this untreatable uh condition these aren't bad patients um a lot of patients uh they want to get better they don't know why they're suffering”

“i don't think that manipulation and being a bad person is part of the diagnosis whatsoever”

“there's also a harm in ignoring a problem that you need to treat. It's as if we had some social stigma against OCD and we didn't want to recommend exposure and response therapy”

“Imagine if you said that about any other diagnosable psychiatric condition. Oh, I don't like to jump to bipolar. Oh, I don't like to jump to an eating disorder. I don't like to jump to an anxiety disorder”

“whether or not you do something on purpose is also not the same thing of whether or not you had control over it”

“There's a concept called the parallel process, even, where in a psychodynamic or psychoanalytic supervision, what happens within the patient-therapist interaction will begin to replicate itself within the supervision session, and you have to manage that”

“the temperament of a therapist typically is open, accepting, non-confrontational. And if you don't have this good conceptualization of the importance of setting boundaries, I see early therapists and psychiatrists really struggle with setting boundaries”

“many, many supervisors purposefully ignore personality and formulation and diagnosis. They purposefully ignore it. I think there's stigma”

“every person I've supervised, when they say they're working until 8 p.m. or whatever, I go through their emails and I'm like, this is way too much. This is way too much. This is way too friendly”

“I can't go to this thing because of my, you know, whatever, insert mental illness. It's a very, very, very dangerous, self-fulfilling prophecy”

“most of the time maybe 80 to 90 of the time the terminology is needlessly abstract uh to capture you know the information that is trying to be communicated”

“the patient-clinician relationship is one where the patient comes in with a lack, okay? There's something that they're lacking or they don't have and that your job as a clinician is to find that thing and give it to them”

“they might, for example, think that you're what they think is a therapist, right? That instead of trying to figure out what is medically going on and to recommend treatments and to lead them through those treatments, that you're there to listen, for example”

“The psychiatrist is used to finding pretty discrete pathologies often and fixing them. And for people who want to optimize or don't have specific pathologies – psychiatrists and the role of medication management and all that entails might not it's not the best treatment for everyone and that's okay”

“first year residency is inpatient, where it feels like your entire job is get patient to take medication. And sometimes that can spill over into the future outpatient years. And that's not our role”

“the patient-clinician relationship is one where the patient comes in with a lack, okay? There's something that they're lacking or they don't have and that your job as a clinician is to find that thing and give it to them”

“A psychiatric treatment shouldn't be one medication and then you're done. That works for about 4% of patients. But the 96% of patients, they need something more”

“If you're expecting that the treatment's going to fail, if you're expecting that you're not going to get along with the patient, you're going to make that true to some extent, or you're going to make it more likely for it to be true”

“I think a lot of providers have a tendency to let things go unsaid. And it mucks up the treatment”

“Telling someone they have a personality disorder is about the most invalidating thing you can do. Right. I mean, it's it's it's it's frankly insulting. And, you know, a lot of patients aren't going to engage in that”

“I think denigrating your formulation is not helpful to the patient. What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it”

“People do come in and they think how this works is I'm going to tell my doctor all my traumas. I'm going to trauma dump on the doctor or I'm going to tell my doctor about my crisis of the day or I'm going to tell my doctor about my past and my story”

“if you try to make this shift way too fast or without explaining yourself, people will rightfully get angry at you. They're going to leave treatment with you. They're going to say, what are you doing to me? OK, I'm used to this”

“there are a ton of patients that I feel used by and I feel dumped on by. And then there are patients that will have almost the exact same session, but in the context of my relationship with the patient, I find it's something that is necessary for them and helpful for them and therapeutic for them”

“I don't just go like, oh, no worries. You're 10 minutes late. We still have 10 minutes. Let's get this done. We focus on it and we talk about it”

“I appreciate you telling me that. I'm curious by what you mean by special. As I see it, we have the typical special. doctor-patient relationship that I try to have with all my patients, you know, a good working alliance”

“you have to keep strict boundaries in frame. then you have to refer back to that frame and the therapeutic alliance when you notice anything that is amiss”

“by having this framework, you know, I stopped projecting my ideas of all the problems of the world and work with the patient in a way that works for both of us”

“you can't just be a passive person who's perfectly good at listening and perfectly supportive. So you have to practice doing things that might not come natural to you”

“oftentimes I'll have a patient will push back or or fight with me in the moment and and then the next month i'll see the positive change happen so in some sense you have to have faith that what you're doing is the right thing”

“adherence is a iatrogenic phenomenon. It's up to you to figure out the regimen that you're inviting people to participate in and make it something that they want to do, not something that they don't want to do”

“I saw a lot of PTSD patients or to me, their diagnosis of PTSD who carried the diagnosis of depression. And we're on their 30th trial of a new antidepressant. And, you know, they were substance use disorder and depression. It's like, no, this is a classic PTSD case”

“there's more to life than trauma. There's who you are when you're born, your temperament. There's non-traumatic but still upsetting things that happened to you growing up”

“We don't want blame, but we do want productive change, and some productive change will be limited in a mild or significant way if we don't look at how the subject, the individual, contributes to what's going on”

“You're telling me that to understand myself, I need a diagnosis that 80% of practitioners are going to negatively judge me and interpret my thoughts, behaviors through this pretty hurtful lens”

“a huge part of that is avoiding avoidance. And by signing that paperwork, you're promoting the avoidance”