Meaningful Psychotherapy: Psychoanalytic Principles in Modern Psychotherapy with Dr. Jonathan Shedler

Mark Mullen: [00:00:00] Welcome back to Psychiatry Bootcamp. If you are tuning into this episode and you have never been exposed to the work of Dr. Jonathan Shedler, you are in for a real treat. Dr. Shedler is a psychotherapist, researcher, and writer, and he has a way of explaining psychotherapeutic concepts that resonates on an intimate level.

I'm positive that by the end of this episode, you will see what I mean. And then I actually think you might listen a second time because his content is so refreshing, understandable, eye-opening and layered. Dr. Jonathan Shedler. Welcome to Psychiatry Bootcamp, and like all of our guests, I will ask you to introduce yourself to our audience.

Jonathan Shedler, PhD: I'm Jonathan Shedler. I'm a clinical professor in the Department of Psychiatry and Behavioral Sciences at UCSF. I'm also the, chair of Science Communications for the American Psychoanalytic Association. [00:01:00] 

Mark Mullen: Shedler, I'm so excited to have you. I wanna start out with a personal thank you. I have never had the opportunity to speak with you before, although I have truly pondered many times if I should book myself an intake with you.

But I've read a lot of your work over the years, and it's been really important to me during really formative years in my personal life and formative years in my professional development. And one of the reasons that I decided to start this podcast a few years ago is that it well, and that I feel called education and psychiatry, is that I am gravely concerned about the soul of psychiatry, by which I mean in the popular press on social media.

And I think even in professional level training programs, psychiatry is often reduced to checklists, symptoms, prescriptions, and it breaks my heart and it makes me really angry. And when I read your work, I feel so refreshed and I'm so grateful that we have a thought leader in our field who pushes back against the oversimplification of the psyche.

I think you promote rigorous thinking about the problems in our field and offer a deeper understanding of what it means to be human. Is [00:02:00] found elsewhere in our field. So Thank you, thank you. 

Jonathan Shedler, PhD: I try. 

Mark Mullen: I will start off with a very loaded question. What type of psychotherapy would you say you practice?

Would you classify your particular approach under any existing modality in our alphabet soup of therapy techniques? 

Jonathan Shedler, PhD: Yeah. Let me push back on the question here. 'cause I think what you just asked contains certain assumptions, and I think those assumptions are so common that they're invisible and I think they're destroying psychological thinking and destroying the field of psychotherapy.

Let me say two things. There are fundamental principles of good psychotherapy that really hold across all modalities of treatment that are effective. Some people call them common factors. I think that's a bit of a misunderstanding. These core principles derive from the [00:03:00] psychoanalytic tradition. the, very idea that you could treat symptoms or mental emotion, mental or emotional suffering by talking is a psychoanalytic idea.

And it, it dates to, you know, Freud and the late 19th and early 20th century, the idea that we could address suffering in psychological terms rather than in medical or neurobiological terms, derives from psychoanalysis. All of the things that therapists do that we take for granted. You know, treating people by talking, meeting for reg, meeting for regularly scheduled appointments, inviting people to tell us about themselves and helping them to tell us about their experience more fully and deeply.

All of these things derive from the psychoanalytic tradition. You know, I think of it as it's like a great tree and. Right now everybody is pushing or promoting some modality or some [00:04:00] brand or some acronym, and it's like people are playing around in the leaves and the branches of a great tree without really an understanding of the trunk and the roots.

So, you know, one answer is, I advocate good psychotherapy, and that follows from certain principles that we could talk about. The second is, I think it's the end of somebody's professional development. When they turn a theory or a modality into an identity, right? Then it, then the question stops being about how can I understand this more deeply?

How can I do this better? How can I test what I know and you know, sort of sift what's works and what's helpful from what doesn't. Then it becomes about circling the wagons and protecting our brand, which is now intertwined with our identity. 

Mark Mullen: It helps us to feel like we are smart, can help people are competent because we can stay in what we know and we don't have to deal with the uncomfortability that comes with [00:05:00] growth, embracing unknowns, et cetera.

Jonathan Shedler, PhD: Well, yeah, you just said something really important, embracing unknowns, and it sounds glib, but I wanna unpack it 'cause it's really important. The only place real psychological change comes from is from the unknown, right? It doesn't happen unless patient, and that means patient and therapist together enter the unknown.

You could think of our difficulties are rooted in what's familiar. We repeat and recreate certain patterns. They're very familiar to us. They've often been there from the beginning. They may be invisible to us the way, you know, presumably water is invisible to a fish, right? We have ways that we know and feel comfortable doing things and.

Ultimately what we're doing in therapy is moving from point A to point B. Point A is what's known, familiar but causing difficulties. Point B is something different, you know, other than what we're already [00:06:00] doing. We don't know what point B is when we start out, right? The only thing that we know for certain is that traversing from point A and point B, the only way to get from one to the other is to traverse into the unknown.

So one of the problems with what I would call descriptive diagnose and prescribe psychiatry, and also with prescriptive, you know, therapy brands, modalities, acronyms, worksheets, is that they all disregard that truth. that the clinician comes in with an apriori plan about what's supposed to happen.

It's not. Recognizing existing patterns, right? Relinquishing those patterns before new and hopefully better patterns are, consolidated, right? So therapy necessarily moves into a place where therapist and patient are [00:07:00] both, you know, uncomfortable and lost. As soon as you super impose a, you know, it's like an, algorithm or you know, an agenda driven therapy, you've actually undercut something that's fundamental to the essence of, psychotherapy.

Mark Mullen: It strikes me how counterintuitive it is that a doctor, a physician, would be acting in this way because I direct a medical student clerkship. And so a lot of the students that I teach are not going to be psychiatrists, but they have to make it through their psychiatry clerkship because that's sort of the system that we've set up.

I can, I can't imagine going to an orthopedic surgeon and my ankle is broken. And they say, 

Jonathan Shedler, PhD: yeah, and that's because the analogy breaks down. Right? And the practice of psych psychiatry generally. But the practice of psychotherapy in particular doesn't fit that model. And we keep pretending that it fits and we try keep trying to, you know, like shove a square peg into a round hole.

I taught, [00:08:00] I still teach, I taught psychiatry residents as a full-time faculty member and an attending doctor in a psychiatry outpatient clinic. I taught psychiatry residents for years. And one of the biggest hurdles in teaching them to think psychologically and teaching them to do psychotherapy is that they really had to unlearn a lot of things, right?

They had to unlearn what they had learned about how to be a doctor. This is true at, the most fundamental level. So we would like to create a relationship if we're doing psychotherapy. And I would even say if we're, even if we're doing, you know, psychopharmacology, but doing it skillfully and Sally, we would like to create a relationship where the patient is an active participant.

Where, you know, the work is a partnership where it's not. Right. Right. What's the model [00:09:00] for almost any other kind of, you know, medical exam, diagnosis, disposition? You know, the patient comes in, they provide us with information, you know, their job is to give us information and we collect information. You know, we take a history, we do an examination, you know, we record signs and symptoms, we order a lab test, we gather this information, and then we come up with an answer.

So the patient is in a sort of a passive role, you know, beyond providing information and history. They're in a passive role. Once we have it, it's up to us to solve it and come up with an answer. And the patient receives treatment. Right. It's something we do to the patient. That's 

Mark Mullen: right.

We're a plumber. Yeah. 

Jonathan Shedler, PhD: I mean, ideally with their, you know, consent, active consent and cooperation, but it's done to that whole model of taking a, if, you start a psychological or a psychiatric treatment by taking a history, you [00:10:00] are already reinforcing a model of how this relationship is supposed to work that follows this sort of doctor patient, you know, format.

That's antithetical to what the work is. Because what the work is when we come in to do what I would call meaningful psychotherapy, our stance is very different. Our stance is, you know, you don't know what's you, if the patient don't know what's wrong and how to solve it, if you did, you wouldn't be here.

Right. That's a given. I don't know what's wrong and how to solve it, because I'm not inside your mind, right? I'm a different person. I can observe, I can infer, I can speculate, but I can't know your experience. So you don't know how to solve it. And I don't know how to solve it. But we can do something here.

We can put our heads together and maybe we can figure out a way to understand it and find a way through it together. So it's the difference between being the expert in the room who already has [00:11:00] the, answers versus joining with the patient, right? Not doing something to the patient, but doing something together with the patient to discover something really that's never been discovered before.

Because this person is not like any other person. Right. There's certain patterns and configurations. It's not like we're flying blind and you know, like we come into the room and know nothing. Right? I mean, we have pattern recognition going on. We understand that, you know, mental health concerns tend to fall into certain patterns.

We have the, you know, sort of broad guidelines of, you know, a map from a bird's eye view, but how it's going to unfold and play out with this specific person. There is nobody else like that person. So, part of what I say when psychiatrists have to unlearn that, you know, sort of medical history taking, you know, diagnose and disposition approach, part of what I mean is this, 

Mark Mullen: there's so much humility associated with this approach, and humility is so uncomfortable.

I think, especially for doctors. I wonder [00:12:00] if this is something, if embracing this uncertainty and embracing this role of unknowing with the patient and exploring with the patient as a partner, as opposed to an all knowing sort of. Trip director trip. I wonder if it's easier with more clinical experience, because I think for young therapists, for therapists that are in training just starting out, it's so reassuring to be able to clinging to a manual.

Jonathan Shedler, PhD: Yeah, of course. It is a manual, an algorithm, a prescription pad among other things, serve the function of helping to manage the clinician's anxiety. Right? So we can think of, you know, theory or treatment models as, you know, that, they're serving a function for the clinician. And we have to learn the treatment models, right?

We need a knowledge base. But the goal of training, you know, isn't to follow a treatment model. More formulaically. The goal of the training is to [00:13:00] internalize it and, you know, know it so well and understand the principles so well. When we sit in the room with the patient, we can be fully present with the patient, let go of our models, right?

So people talk about, you know, you have to get to the point where you can throw away the book. I would modify that and say, oh, yes, that's true, but you need to own the book before you can throw it away. the problem is, this is why trainees gravitate toward manualized treatments or gravitate toward a diagnose and prescribe approach.

The problem is some people never come out of that. They never move beyond it. And it takes three things to be able to move beyond it. One is, we really should be selecting people for the field who have the aptitude for doing the work. 

Mark Mullen: Love that, 

Jonathan Shedler, PhD: And in many cases, that's no longer true. 

Mark Mullen: Yep.

Jonathan Shedler, PhD: Second, when you go, you select people for, you know, with the aptitude. How do we overcome. [00:14:00] The anxiety of our own uncertainty. Right? Right. How do we sit in a room and communicate to the patient? But you know, I don't know the answers. I do know a method for finding out answers. And even though neither of us know yet exactly where this method is leading, I actually have hope and confidence.

Right? I believe that it is leading somewhere and it will lead somewhere to the, that's a solution to your problems. So I don't know what the solution is, but I believe we can find one. Right? What does it take for somebody to, it's not even necessarily in words, but to communicate that attitude and that view.

Well, for one thing, it takes our own in-depth personal psychotherapy or, psychoanalysis. We need to have the experience ourselves, not as a doctor, but as a struggling patient, right? This method. Works. We start off, we don't know where we're heading, but there's a method to, you know, how we go about [00:15:00] doing it.

Things happen that we can't anticipate or foresee, and those things are very beneficial, but it can't just be intellectual knowledge or book learning. We have to really, you know, know it in our bones. That comes from personal treatment for the clinician. And the third element is really good, high quality supervision, clinical supervision, which is happening less and less now, both in psychiatry and in other therapy, non-medical therapy professions.

The, field has succumbeded to so much external pressure from healthcare systems, from health insurers, from economic factors. The field in, the last decades, I've watched it happen. Has really gotten distorted in ways that are beyond recognition. And so the function of clinical supervision was always a mentorship relationship and a [00:16:00] teaching and training relationship with somebody who was a senior expert clinician who could fulfill the role of, teacher and mentor.

Right? You know, now the role of supervisors often reduced, you know, basically to a sort of administrative function, right? And so people don't have, people don't have the, emotional and psychological support to grow in the way they need to, through their own therapy or through their own supervision.

There are all these pressures, you know, which almost always come down to, you know, seeing more patients in less time. And, all of these different forces are, really pushing people, not just away from doing what I call meaningful therapy. Even from ever being exposed to what it is. Right. We don't know what we don't know.

Mark Mullen: That's exactly right. You don't, you can't be it. If you can't see it, you can't even imagine it really, I think on number three, I feel that personally we, we provide supervision for our psychiatry residents. We block out [00:17:00] essentially an hour a week to do that. Most of us, some of us have more supervisees or we block out more time than that.

That time's not reimbursed. That's just lost income. It's just lost patient time and they're the system. The incentives are, do not support this model that you're suggesting. 

Jonathan Shedler, PhD: The incentives are absolutely broken and people hate when I say I've taken so much flack from colleagues, including colleagues I respect and look up to for saying this, but it's incredibly difficult to get meaningful psychotherapy or, you know, really good quality psychiatric care within an institutional setting.

It's not impossible, but it's really, difficult because there is so much external intrusion and impingement on the clinician patient relationship. it's like constantly an uphill battle and often you get into the situation you just described, if the clinician really wants to do good [00:18:00] work, you know, they're often working on a volunteer basis, you know, putting in time that they didn't get paid for.

And of course that's really not a fair thing to ask of clinicians. We didn't go into the field to become martyrs. 

Mark Mullen: Right. Which is not to say that if you're looking for a therapist, you have to find someone that's not at an institution or that people who are not at an institution are by definition practicing more meaningful psychotherapy.

'cause on the other hand, at least an institution does have some supervision and some oversight, even if it is administrative, right? I think we have these training programs now that don't offer these, maybe these three things that you just described, and so you can hang up a shingle. Provide private practice, pretty absolutely low quality, right?

Jonathan Shedler, PhD: Finding, finding a someone in private practice is no way a guarantee that you're gonna find a, you know, genuinely skilled clinician. But if you do it in an institutional setting, you might need to recognize that the deck is stacked against it before you even walk in. You know, you may walk into an institutional setting where the [00:19:00] norm is oh eight to 12 session manualized therapy.

Well, if you know the research literature and if you've practiced clinically for long enough, you know that meaningful therapy, right? not the kind that's a bomb or a salve or first aid for a symptom, the kind that actually creates meaningful psychological change that you know, that shifts the course of somebody's life, right?

That can't happen in 12 sessions. It doesn't even start in 12 sessions and research shows. So what research actually shows, not my research, published research is, you know, on average, obviously everyone is different, but meaningful change in therapy begins around six months, begins in most of the institutions where, you know, people go for treatment, the norm, and the expectation [00:20:00] is that treatment will be over long before that.

Right? So, you know, we have to understand that. and then once you go down that if you're, a clinician working in that system, if you take on supervisory or administrative responsibilities, which you'll be asked to do as you get more senior, if you're any good at it, it's very, hard for clinicians to live with that dissonance.

The dissonance is, I know I'm not really doing right by my patients. I know I could do better by them. I'm gonna do this anyway 'cause I'm compromising because these are the institutional requirements that I'm compromising with. Very few people can live with that. So it, becomes, I'm not doing right by my patients.

That morphs, right. Cognitive distance kicks in and it becomes, well, it's good enough for most patients. It actually morphs into, it's better than nothing and then it becomes, well no, it's really good enough for most patients. And then that morphs into, oh, you know, this is really the [00:21:00] standard of care. This is Right.

Right. And at that point, we professionals can betray ourselves. 

Mark Mullen: We have to convince ourselves of that to avoid that moral injury. 

Jonathan Shedler, PhD: Yeah. And I think it happens all around just, you know, go into any established prestigious, especially training institution and look around. 

Mark Mullen: Let's stick with the structure here for a little bit.

We're talking about structural factors. One thing that I've always kinda wondered in reading your work is, do you think there's a minimum dose required to achieve the type of goal that you're talking about? So you know, for meaningful life changing? I don't know what we wanna use if we're changing someone's self understanding.

Schema belief in themself in addition to just symptoms. Six months is when it typically begins. Probably no one size fits all, but is it even possible to do good therapy at a frequency of less than, let's say 50 minutes once per week? 

Jonathan Shedler, PhD: I don't think it is because there's not enough continuity to get beyond the surface of [00:22:00] things.

I think meeting once a week is a bare minimum. It's actually incredibly difficult to do therapy once a week. It takes much, much more skill on the part of the therapist to do therapy once a week than, to do therapy with the same person, you know, twice a week or even three times a week. What happens is.

A few things happen. One is it's very, difficult to get beyond the weekly catchup and you know, the review of symptoms. How am I doing? How am I feeling? So therapy tends to stay at that level. And then that shifts the entire purpose of therapy away from change in the person's underlying psychology, toward symptom management.

And then we say, oh, you know, well look, the patient score in the PHQ nine, you know, has improved. It sees therapy is successful. But I would say we're not doing psychotherapy. So there's a weird thing that happens in mental health. It's different from any other area of medicine. In every other area [00:23:00] of medicine.

Absolutely. Everybody is clear on the difference between medical treatment versus first aid, right? Right. I mean, we need first aid. Right? 

Mark Mullen: Right, 

Jonathan Shedler, PhD: right. But there's a difference between first aid and ongoing treatment for an underlying medical condition. In mental health and only in mental health. We're not clear on the distinction.

And we do two things. We sell first aid to patients and we tell them it's treatment and they believe it. Why wouldn't they like, you know? But then worse than that, we sell that. We sell that to the clinicians, to the providers. And many of them also start to believe it, especially if they've never been exposed to an alternative.

Mark Mullen: Sure. The blind leading the blind, so to speak. I wanna go back to the initial question here and ask about one thing. You mentioned. You mentioned that you have some [00:24:00] objections with the language of common factors, and if I followed you correctly, you're basically saying, because these are actually psychoanalytic factors that we've then taken and applied to other forms of therapy.

Is that a, fair enough understanding? 

Jonathan Shedler, PhD: Well, all of the other forms of therapy, whether they wanna acknowledge it or not, I mean, I mean, there. Very, few exceptions. But generally speaking, all of the other forms of therapy are derived from psychoanalytic treatment. Are renaming or repackaging, time honored psychoanalytic concept, often pretending they're new discoveries or they're reactions against aspects of psychoanalysis.

but while preserving the, general structure can, lemme give you an example. It's a bit of a pet peeve of mine. You say the working alliance is a predictor outcome, a strong predictor outcome. And in research that's true. So it's like, oh, well that's a common factor, the working alliance. but let's really think about what that means.

Let's unpack that. So [00:25:00] a working alliance has three elements. It means there's connection or attachment. It means there's a shared understanding about the purpose of the work, right? We're in agreement, we're in the same page about what we're doing here. It means there's a shared understanding and commitment.

The methods, how we're gonna go about it. Now, if you take a pretty, you know, healthy, functioning person who's generally functioning and well in the world, who's capable of secure attachments, who's capable of, you know, interpersonal trust and, you know, decent interpersonal relations, who generally trusts the, you know, good intentions of other people, especially, you know, professionals, well, it's a piece of cake to develop that relationship.

So, what anyone could do it, I mean, you know, a sort of high school student with social skills can create a working alliance. So now it looks like working Alliance is a predictor of outcome. But what if actually working Alliance is a [00:26:00] proxy for the level of health versus the level of personality functioning of the patient?

You get into the character pathology realm or now, you know, personality disorder real. Now the therapist's actual skill comes into play, right? I mean, a high school student could create a good working alliance with somebody with good object relations, healthy attachment, secure attachment, benevolent worldview.

That's not why people come to psychotherapy. They come because they can't do those things. So it's like, okay, so the first pillar of an alliance is attachment connection, right? Attachment, trust and security. The person comes in because they're not capable of those things. Now we're getting into the realm where developing an alliance requires actual expertise, right?

Actual clinical expertise. So it's not the working alliance. The working alliance is right, the common factor. But it's a proxy for something else. What is our [00:27:00] professional expertise in navigating a relationship with somebody who is there largely because they cannot have healthy, functioning relationships?

And, how do we learn those skills? Well, you know, now we're back to our own personal psychotherapy or psychoanalysis and our own intensive in-depth, therapeutically meaningful supervision. So to answer your question, you say, why do I say I have some trouble with the concept of common factors? Well, there's one common factor, front and center.

But to develop that skill takes the kind of training that has always been part of this therapy tradition. 

Mark Mullen: Sticking with that thought, when I reviewed your work prepping for this episode, I felt like one takeaway was that there are no shortcuts to good psychotherapy, and we just went over that, right? I mean, even, I really appreciate a direct answer to the question of how much time does this take, right?

Yes. You have to spend time with someone to understand them. And build this relationship. 

Jonathan Shedler, PhD: And let me sharpen the question. Are [00:28:00] we doing first aid? Somebody comes in acute distress, can we do something to, you know, relieve their distress? In the short term, I would call that first aid. Are we trying to do something to change the underlying psychology that creates the vulnerability to that kind of distress?

Mark Mullen: You're not saying, let's not talk about your panic attack. We need to be talking about your attachment style. You're saying we can offer some first aid, but we can't stop there. 

Jonathan Shedler, PhD: Yeah. And the answer, so when I say meaningful psychological change begins at around six months, I'm talking about psychological change, not just, you know, some symptom relief.

And what we do now, often especially, and especially in you know, healthcare institutional settings, is, you know, we go for symptom relief and then consider the job done and take the victory lap. Knowing full. I mean, if we're good clinicians, we should know this. Knowing full well. Those symptoms are gonna return again at some point down the road.

You know, that's the typical course [00:29:00] when people for, the relative minority of people with major depression, who have a good, meaningful response to antidepressants, right? We put 'em on antidepressants, they get symptom relief, they're better, but it's so common, right? Then the patient comes back a year later, maybe two years later, they're, and, they don't say I'm depressed again, because we never dealt with the underlying psychology.

They come in and say, my antidepressants pooped out. That's the word. And then begins the, chase, oh, you know, we'll switch antidepressants, we'll change the dose, we'll augment it with something else. And there, you know, so begins this, you know, revolving door of treatments that never ends. 

Mark Mullen: I agree with your first two sort of factors that you think are required to train reasonably competent therapists, which would be selecting the right people for the field.

Selecting people who are willing to admit what they don't know, get into the unknown, embrace the discomfort with the patient, [00:30:00] and I agree with your statement that basically if we took a high schooler with good social skills, they would be able to develop a connection with a patient. I think that the second part of that productive relationship, which is a shared understanding of what your problem is and what we are going to do to fix the problem.

Maybe this is happening like in 1% of competent therapists, because I think there's such a misunderstanding even amongst the most highly trained right? Psychiatrists have eight years of post undergrad training, 

Jonathan Shedler, PhD: and most of it is devoted to things that have nothing to do with the practice of psychotherapy.

Mark Mullen: Right? I talked, I couldn't agree more, right? Because what is depression, right? How do we understand what depression? Is this a chemical imbalance? Is this just a label? Is it a set of symptoms? And. The A-C-G-M-E and the A DPN have a lot of requirements about things that we need to learn in psychiatry residency, but this sort of philosophical understanding of are we speaking the same language?

Do we have the same goal? 

Jonathan Shedler, PhD: We're not speaking the same language at all. And, right, and, that's the difficulty. We brought this confusion of tongues. You mentioned depression as an example. You know, what is it? Is it a neurochemical issue? [00:31:00] Is it irrational thoughts? Let me offer an alternative. So depression is the psychic equivalent of fever.

What is fever? Fever is a non-specific physiological response to an enormous range of, you know, possible underlying medical conditions, you know, from the common cold to Ebola, you know, right. It fever, the same fever. Could be a, you know, go home, get some rest, drink fluids, you know, call me in a couple days if things don't, you know, try to take a turn for the better.

Two, this is a medical emergency and you need to be, you know, hospitalized in an intensive care right now where you're gonna die. But the symptom is the same. It's fever, right? Non-specific depression is a non-specific psychic response to an enormous range of underlying difficulties. And Right. The idea that I'm treating depression, and that's the job is [00:32:00] to me, a, pro, a profound misunderstanding is we have to say, okay, but if we're gonna be real clinicians, right?

That, the job isn't to deliver aspirin. The job is, can we figure out the cause of the fever? So now to come back to your question, do we have an agreement about the purpose of the work? If it's the kind of therapy I'm talking about, the purpose of the work is to change something about oneself for the patient, right?

Real psychological change to change something about oneself that. Either causing difficulties or limitations that the person desires to change about themselves and that psychotherapy could realistically help them to change. 'cause I see people, you know, embarking on therapy all the time to address things that aren't actually psychological issues.

We don't know that on session one. So you don't come up with a treatment plan on session one. What we, need is a case formulation [00:33:00] and you know, what's a case formulation? It's making the link between, you know, the surface difficulties, right? The fever and what's going on, you know, under the surface that's creating the vulnerability to that.

And that takes time and that takes real expertise. And the patient doesn't come in and they're on board with that change. They don't even know, you know, where the area of change should be. Neither does the clinician, right? So it takes some time. To begin to formulate a case and basically say to the patient, not as a conclusion, but as a hypothesis.

Here's what I'm seeing, here's what I think I'm understanding. I think this has everything to do with why you get depressed. I think if we could address this in therapy, it would make things different for you, right? And the clinician is going to tell the patient something that likely they've never considered before.

So it's not, a conclusion, it's a hypothesis for [00:34:00] mutual discussion. And now what I want is for the patient to engage with it. And it may be it resonates with the patient and they go, oh my God. That's right. I never thought about it like that. I do, these things. Why why do I do that?

It's like, yeah, well, I don't know why, but we could answer that together in therapy if that's what you'd like to do. So what we want from the patient is they really take it in, they think about it. It feels like it fits. They elaborate on it and provide more information and then we hone and refine the formulation.

Or the patient says, no, that doesn't fit. That's not my experience. Even better and just as good certainly. And we want them and to, right. And then, you know, what we want is for the patient to correct us and say that's not it, and elaborate on what their experience is. So we're starting in a cyclical, iterative process of offering hypotheses in very, personal experience, near language, and thinking about it together with the patient.

And the process [00:35:00] repeats iteratively until we can hone in on an understanding. That neither person had when they came in. And that becomes the purpose of the therapy. 

Mark Mullen: The case formulation is not a secret little expert level series of fancy words that the psychiatrist can use to sort of put the patient in a little box and say, this is for me.

Now I understand you because I'm so smart. It's something that A, the patient's always going to read it now in the age of open notes. But really the utility in it is that we are going to put it out in the open. We're gonna shine the sunlight on it, and we're gonna develop it over time and we're gonna see what sticks and what doesn't.

Jonathan Shedler, PhD: and it's not hypothetical and intellectual, it's rooted in data, but not the kind of data. We usually talk about a different kind of data because what we're trying to do is identify psychological, recurring psychological patterns, right? Sort of ingrained or, you know, well worn grooves in the patient's functioning that are causing difficulty.

It's not a game of [00:36:00] speculation, it's those patterns are unfolding in the session with us, right? We're not hearing about their difficulties that are happening in another time, in another place with someone else. We are an observer and a participant in those difficulties. So there are the facts of our, you know, actual experience, interpersonal experience in the therapy room.

So, you know, when the therapist says, here's what I see, it's not hypothetical. It's a shared lived experience. And the patient says, if you get into the cataract character disorder range, the patient might say, no, that's not true. I didn't, you know, that's not what happened. I said, well, that was your experience of it, but let me tell you what I just observed this, but what happened in the room, right?

It has to tie to something that concrete and, of course that's what we discuss in terms of transference. A transference is a fancy way of saying. The, human condition is we live out certain [00:37:00] relationship patterns that are formed. We form these patterns very, early, on in life. Through our earliest attachments, we continue to live them out, for better or worse, for the rest of our lives.

We bring them into all of our other relationships, real psychotherapy, as a relationship. So the patient brings their relational patterns into the psychotherapy relationship, where we call it transference. That's where we have direct access, where we can see and recognize and begin to understand those patterns.

So, you know, in one way, especially for physician, non-psychiatric physicians or psychiatrists who aren't trained in therapy, it sounds very abstract and philosophical and esoteric. On the other hand, it's actually very rooted in immediate real data. 

Mark Mullen: It's very concrete in that way. I think that's a really good segue into our next section when you talked about, the patient having one experience of something and the clinician having another experience of that same thing.

We're gonna go to break and when we come back, we're gonna [00:38:00] talk about different forms of therapy speak. I think in this case, the example would be, this is my truth, and we'll talk about, oh, I can't wait. Maybe how that is helpful or at times unhelpful. standby.

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Welcome back. I wanna make one follow-up comment on the fever. I think a corollary of what you mentioned about depression being a non-specific symptom, like a fever and depression being a signal to us of changes that might need to happen in a person's life. 

Jonathan Shedler, PhD: Same for anxiety, also a non-specific symptom like fever.

Mark Mullen: Absolutely, and I think we could probably go down the list there. I having experienced this myself, and I will say if I had not had that [00:40:00] fever, I would not have made meaningful changes in my psychological life, and I certainly wouldn't be the person who I'm today. I think a corollary is the fever is not the enemy, right?

The goal of treatment is not fever, bad fever, whack-a-mole. You're having this problem, you're having this discomfort. The, it's more like what is the fever telling us, right? Is the fever important? Should we even get rid of the fever? Have we done what we need to do with it yet? 

Jonathan Shedler, PhD: And thank you. You just gave me an opportunity to mention something that I would've otherwise forgotten.

So the thing is, patients actually understand this at some level, but a, paper just came out just last year in Lancet, you know, the most prestigious medical journal of all. There's a service set. I don't have the numbers at my fingertips, but it was several hundred studies, several thousand patients, therapy patients.

And it asked the patients, what are the things that you wanted out of therapy? What are the things that you got from therapy that were most important, [00:41:00] that were the most value to you? And, you know, they had a, list of the things that were mentioned most, frequently, right? And these were qualitative.

We didn't say to the patient, here are the things you could get out of, you know, treatment. Was it A, B, C, or D? Right? That would just confirm the researchers starting assumptions. It was just asking the patient what was of most value to you. And recording responses and coding them according to categories.

So they came up with quite a long list of things that patients valued. Number one on the list was insight and self-understanding, self-awareness. I think symptom remission or symptom reduction was like number seven or eight on the list. It was way far down of what patients said they, you know, valued most in therapy.

So then think about that. There's a real mismatch between expert clinicians are trying to do what real world patients really want from therapy and what we study as outcomes in [00:42:00] research where it's like apples and oranges. We do this research and we get our findings and we pretend that we've demonstrated the benefits of therapy and we're not even measuring the benefits that real patients want and expert clinicians are trying to provide.

Mark Mullen: I think when we're critiquing this nebulous idea of kind of therapy as it is in vivo in the world around us, a medical student listening might say, well, yeah, that's bad psychotherapy, that's not evidence-based psychotherapy. And you are indicting that whole, the whole argument of, well, we have to be doing things that are evidence-based because you're saying garbage in, garbage out.

Right? What does evidence-based even mean? 

Jonathan Shedler, PhD: Yeah. and this is science, right? what's, I mean, real science. Real science is not an RCT, right? That's, a math, that's a tool. I mean, real science is, I think I might know something. How do I find out if what I think I know is right or wrong? What do I need to do?

And [00:43:00] any research method we bring rests on certain assumptions that are baked into the research method. If the assumptions are false, indefensible. The research findings are meaningless. And you know, I would say real working scientists in the basic sciences or in that natural sciences, everybody understands this.

What we have in mental health unfortunately, is we have all of these assumptions baked in and nobody examines them. Nobody says, Hey, wait a minute, all of your findings rest on the assumption that the purpose of therapy is to lower your score on a Hamilton Depression rating Scale. Well, that's not what the clinicians think is the purpose, and that's not what the patients think is the purpose.

So in what parallel universe are you're operating in your parallel universe, these assumptions hold in the real world with real patients. These assumptions don't hold, maybe we're not doing this right. 

Mark Mullen: No, it's a very cogent argument. It just makes me wanna jump outta my skin and [00:44:00] take my diploma off the wall and throw it out the window though.

So we're gonna have to move on because I can't sit with that discomfort too much longer. So let's talk about therapy speak. So broadly speaking, how would you define therapy speak, and what is your beef. 

Jonathan Shedler, PhD: Well, I think everybody knows what therapy Speak is. Therapy speak is the language of popular psych, pop psychology and social media.

And it's, I think you sent me a, you know, a list of words. What was it? You know, everything is trauma. You know, everybody who offends us is a narcissist. It's just this, is collection of pop psychology, words that are everywhere. Toxic people, toxic relationships, you know, trauma. 

Mark Mullen: Valid feelings.

Jonathan Shedler, PhD: My truth. Your feelings are valid, 

Mark Mullen: right? 

Jonathan Shedler, PhD: This is a safe space, 

Mark Mullen: right? 

Jonathan Shedler, PhD: You have insecure attachment. it's your, it's your vagal nerve response. It's your mitochondria. 

Mark Mullen: Well, that's a whole nother level of sort of bastardization, I think, to me, of scientific words, but things like valid [00:45:00] feelings. You know, why is it wrong to say someone's feelings are valid?

What's the threat in that? I mean, to me, holding a safe space for someone, I'm 

Jonathan Shedler, PhD: gonna explain it. I'm gonna show you, 

Mark Mullen: okay? 

Jonathan Shedler, PhD: What does it mean? 

Mark Mullen: I suppose having valid feelings means that you have feelings that are real for you. 

Jonathan Shedler, PhD: Meaning you have feelings and you feel them. 

Mark Mullen: Yeah. I think that's what that means.

Yeah. 

Jonathan Shedler, PhD: You mean it's completely tautological? 

Mark Mullen: Yeah. Right. 

Jonathan Shedler, PhD: You are having feelings and you feel that you're having feelings. 

Mark Mullen: Yeah. 

Jonathan Shedler, PhD: So when you say value or feelings are valid though, 'cause otherwise you could just say 

Mark Mullen: you're having feelings, 

Jonathan Shedler, PhD: that's what you're feeling. 

Mark Mullen: Yeah. Right. 

Jonathan Shedler, PhD: When you say your feelings are valid, it adds a layer of something on top of it and you are very careful.

You side stepped it. But what do you think? No, you're 

Mark Mullen: right. 

Jonathan Shedler, PhD: What do you think, you know, the average person, what do you think the public thinks? 

Mark Mullen: They think I'm right. I should be angry. 

Jonathan Shedler, PhD: Yeah. Right It right. So I mean, the word valid has it. [00:46:00] Definition in the dictionary, or it has several definitions in the dictionary.

Mark Mullen: Not only that, but my therapist, who's an expert, says that it's okay that I'm angry, 

Jonathan Shedler, PhD: basically. Valid is a synonym for, you know, like accurate, you know, accurate. Correct. One of the definitions was, you know, logically sound right? Like a valid argument. Actually, none of those words, none of those concepts even applies to feelings.

So the problem with this kind of word salad therapy speak, I call it lop, 

Mark Mullen: like that 

Jonathan Shedler, PhD: is, it violates right? I said, all good therapy is based on certain psychological principles. It violates a really, fundamental principle. The purpose or the, principle of really good psychotherapy work. Is we're working to help the person to understand themselves more deeply, to be more self-aware, to be more [00:47:00] whole, to be more integrated, to know their interior terrain, right?

In ways they don't, when they come in, that requires certain things as principles of working. And, what it requires is that we move from the general to the specific, from the abstract to the particular. So a patient comes in, any competent psychiatrist knows to do this. You know, why are you here? Said, I'm depressed.

Tell me about your depression. How are you experiencing that? Right? What form does that take for you? So we ask the patient to move from a, global abstract term to the specifics and the particulars of their individual experience. That's just competent work. It's a longstanding understanding that.

When people speak in abstractions or generalities or cliches to defense against noticing and going more deeply into the specifics [00:48:00] of, their experience. And we have to work with it as a defense. And that's the process of moving from the general to the particular, you know, or from, you know, the abstract to the specific, if a patient comes in speaking in therapy, speak.

Right? That's just, this is, nothing new. Therapy speak is new, right? This is a phenomenon of let's say the last, you know, 10 years and driven by largely, you know, social media and pop culture. But the larger issue of speaking in vague terms and cliches and abstractions has been understood for generations and generations.

So the patient comes in, they speak in therapy, speak, it's a defense if the therapist also speaks at that level. What we're actually doing is colluding with the defense and we don't know anything. There was an example, I posted something about this on Twitter, her ex pretty recently. It was actually a patient who posted something and she described, she, she's told her therapist about [00:49:00] having meltdowns where she, an adult woman where she would scream and throw things and break things and have these emotional meltdowns.

And the therapist, I mean, if we believe what the patient wrote, your feelings and reactions are valid. That was the word valid. And the patient, this was what her tweet was about. The patient herself questioned that and said, but is it really 

Mark Mullen: right? Right. 

Jonathan Shedler, PhD: And she says, no. I mean, it, you know, just taking it at face value.

It's absolutely incompetent therapy. So for one thing, the word was your feelings and reactions are valid. Actually, those are com two completely different things. Every therapist understands that thoughts and feelings are not actions and behavior. So it's already blurring a critical distinction. There's what you feel and there's what you do, there's what you feel and there's weather and how you act on it.

That just disappeared. And it was [00:50:00] like, your feelings are valid. That's not even starting at therapy. It's like, you know, therapy is, you are really getting overwhelmed by these feelings. Something like that. And the patient says, you know, yeah, I just, I lose my shit. I get overwhelmed. I can't control myself.

So the first starting point is, right, do we have an agreement about the purpose of the work? Right? Here's a place to make a little, you know, the agreement is made up of a lot of little agreements, right? But here's one of the little ones. How overwhelming your feelings are, how much you get flooded by them.

Blindsided by them, to the point that you're really not in control of yourself. This is a problem for you. I said that as a statement, but it's really a question. Right? It's my hypothesis it right? As soon as the patient says, yeah, that is, that's right. Which the patient is going to say, assuming they're somewhat in touch with reality.

So then our task is to understand what's going on. Like, like what's [00:51:00] stirring up such strong feelings, why they become so overwhelming, why you get blindsided by them. This is something you'd like to change about yourself. I mean, I'm condensing what would be a long conversation, but if sure as hell aren't gonna tell the patient your feelings are valid, you've just.

You haven't bypassed something in therapy, you've bypassed the entirety of psychotherapy. 

Mark Mullen: Yeah, I mean, I think the most basic thing that we need to agree on is that feelings and behaviors are two different things, and you have completely thrown that out the window. It's interesting, I, you know, your response to the therapies because sort of, Hey, mark, words have meanings.

Like that's why we use them. Words mean something, and that didn't quite occur to me, but it's, very real. It's, you know, when you can just say, well, he's a narcissist. You know, it's putting a label on something. It's saying, I don't have to think about something. Yeah. 

Jonathan Shedler, PhD: So the patient says, you know, he's a narcissist.

My boss, my boyfriend, my father, you know, whatever. And, a, I mean, a, competent therapist response is, tell me what happened. [00:52:00] Right? Again, the same principle, moving from the general to the particular, if the patient isn't tracking with that, I might even say something like, narcissist is a conclusion, a summary statement.

I'm interested in the experiences and the thoughts and the feelings. I led you to that conclusion. You know, bring me into the situation with you. Help me understand what you experienced with him. Help me understand it from inside your perspective. Right? So I wanna open the door to talk about it. Anytime a patient uses a cliche and it stays there, right?

The therapy isn't moving forward. That's the defense. That's what we have to work with. 

Mark Mullen: That's, so, I think that's gonna be so helpful for any therapist listening to this. Moving from the vague into the particular, let me move into the particular a little bit now. Do you think that high quality psychotherapy is always going to have some element of antagonism or confrontation?

Jonathan Shedler, PhD: Well, what do you mean by, 

Mark Mullen: I [00:53:00] mean it, I would say to some degree that's therapeutic confrontation, 

Jonathan Shedler, PhD: I would say. Yeah. Okay. So, so words, matter, and if you attach the word antagonism to it, right, that takes on a certain framing. That's not really the framing that we want. So one of the things that we're trying to do in psychotherapy, both in the work with our patient, but internally in our own work as therapists and our own mind and our own training and our own preparation, there, there is this horrible thing that is going on in, in the culture.

And you, see it everywhere where making an effort to understand something is assumed to be pointing a finger of blame. So just the other day I said something like, to a patient, described something they did, and I said, there must have been a reason that you responded that way. And my intent was, I'm trying to [00:54:00] invite the person's curiosity.

Right? They, responded the way they did. Right? That's normal for them. Can we pay attention to it? Can we notice what thoughts or feelings, memories, images, sensations, et cetera, come up around it? Can we understand it beyond what's on the very surface? So it was an invitation to think about the reason, and the patient responded by saying, well, I think that's perfectly normal.

That's perfectly normal response. It's not an abnormal response. So the patient conflated my curiosity with blame. What we're trying to do is cultivate an attitude in ourselves and our patients that everything is open to exploration, to inquiry, to paying attention, and thinking about, and it's not a process of blaming, it's a process of understanding and coming to know ourselves more deeply.

So when you say words like adversarial, it really runs counter to what we're trying to do, [00:55:00] but. I think I understand where your question is coming from because there's something else that's really, bad that's been happening in therapy culture, which is that therapists, a lot of therapists are sort of becoming, you know, sycophantic.

Yes. Men and yes women, and that's also not psychotherapy. So, you know, psychotherapy is the art of helping people to see and hear and think about things that might be quite uncomfortable, and to help them to do that, you know, without them feeling blamed or shamed to feel you're doing this because you're interested in them, because you're interested in helping them, because you're interested in them becoming more interested in themselves because you're trying to open the door, you know, not to rub your nose in it or ruminate or dwell or so you feel bad, have to feel bad about something all over again.

But [00:56:00] to open the door. To being able to do things differently, to not have to repeat the same unhappy patterns and, you know, relive the same unhappy outcomes. So yeah, I mean, therapy is not all affirmation and validation and support. I mean, real therapy is talking about what's difficult and that's why our patients come to us.

It, even knowing that it's difficult, even knowing something in them is going to fight that at every step of the way. And that's what we call in the psychoanalytic tradition. That's what we call resistance. It's with us in the treatment every step of the way. But that's not all that the, that's there, right?

That's a part of the patient. There's also another part of the patient. That wants to know themselves more deeply. There's a part of the patient that wants to have other options about how they function, right? What they do in the world, how they solve life's challenges, interpersonal challenges, right? All of these different parts of the patient are in the mix at the same [00:57:00] time.

So we're not adversarily confronting the patient, we're joining with the parts of the patient that are looking for better alternatives, you know, and want to understand themselves more deeply. We're joining with those parts to take a close look together as a shared partnership and other parts that aren't so well known and, that are causing difficulties for them.

That's how I would say it. 

Mark Mullen: And in any shared partnership, you have to have difficult conversations. So there's going to be uncomfortable moments so that we can work effectively together and understand each other better. 

Jonathan Shedler, PhD: Yeah, and, what therapists are really doing when they just, you know, affirm, validate, support, nurture, caretaker, et cetera.

First of all, they're abdicating their responsibility to do therapy assuming they ever knew how to do therapy. And second of all, assuming, I mean, the truth is a lot of people's practices is made up of people. I, there's some categorical distinction between, you [00:58:00] know, healthy personality versus personality disorder, but there's a continuum of functioning, right?

And, at the lowest end of the continuum, we dip into what we call personality disorders or, character pathology. That makes up a lot of our practices. So we're often working with patients who are really interpersonally very difficult, and that's not an obstacle to therapy, that's why they're in therapy.

When we collude and affirm and support and tell them they're right and agree that, you know, the problems are entirely due to their husband or their wife because that person is a toxic narcissist. And when we get, you know, we're not only abdicating our responsibility to do therapy, we're also martyring ourselves.

The therapists tell themselves, I am being supportive, I'm being doing my job. But what's actually happening in the room is they're interacting with somebody who is very interpersonally difficult. And [00:59:00] instead of noticing it, naming it, bringing it into discussion is something to think about. They just keep sucking it up.

Right. So it's not psychotherapy, it's martyrdom. And, that's a pretty tough in working with supervision or teaching. I mean that, that's a pretty tough nut to crack when you have somebody who's functioning in that way and you're trying to help your supervis. To recognize, you know, they're enacting something 

Mark Mullen: and they're ready to die on that hill.

We're talking about martyrdom. 

Jonathan Shedler, PhD: Yes. Because they tell themselves and other people tell 'em, they get reinforced for it. That this is virtuous and it's not virtuous. Being a martyr isn't virtuous and failing to help your patient change in ways that you know, they really need to change is also not virtuous.

Colluding 

Mark Mullen: with resistance. Yeah. 

Jonathan Shedler, PhD: What's the vir? Yeah, exactly. What's the virtue? 

Mark Mullen: Yeah. Dr. Schuler, you mentioned earlier when we talked about case formulation, that all of these fancy words that we have about [01:00:00] psychodynamic understanding and all, a lot of different, you know, things that we learn in our formal training aren't really that helpful when you're actually talking to a person about what is, I think they're helpful for our own self understanding and conceptualization of the patient, but when we're speaking with the patient, we need to use words that are simple, precise, and make sense to the patient.

I have to tell you, if I can toot my own horn a little bit, I think one of the reasons that I have. I've been able to develop this podcast at this point is that I really like restating the complicated things that my guests say in simple and precise language for our listeners. And I've had a really so common time with that.

Ive had a really tough time with that for this hour because everything you've said has been so simple and intuitive and easy to understand. So I really appreciate that, but I'm talking 

Jonathan Shedler, PhD: about complex things like transference and counter transference and working with defense and transference, counter transference, enactments.

Right. And the principles of a working alliance. But I mean, it certainly doesn't do any good to talk to our students and our trainees that way. [01:01:00] I mean, they need to learn the vocabulary of course, but, they also need to, you know, get it and you know, immediately, you know, in a real way. And it certainly doesn't do any good to talk to the public that way.

Mark Mullen: Right. Dr. Shedler, it's time for us to wrap up. Do you have any final thoughts for our audience? you've said a lot. 

Jonathan Shedler, PhD: Yeah, I've said a lot. I guess, I would 

Mark Mullen: follow me on X maybe, 

Jonathan Shedler, PhD: you can follow me on X substack Instagram, substack in particular, because every week I, post a, short essay about a topic in psychotherapy, and I've only been doing it for a few months, but it seems to be enormously popular.

Mark Mullen: It is enormously popular, and it's where a lot of our questions from today came from. So if you were interested in this, please connect with Dr. Sheer on Substack. Dr. Sheer, thanks so much for coming on Psychiatry Bootcamp. I really appreciate it. 

Jonathan Shedler, PhD: Thank you so much. It was, fun to be here.

Mark Mullen: Thanks so much for listening to this episode of Psychiatry Bootcamp. If you're enjoying the show, I'd love to [01:02:00] know what you think. You can connect with me on TikTok or Instagram at Psych Bootcamp, or you can email me mark@psychiatrybootcamp.com. And you can visit psychiatry bootcamp.com to sign up for our new newsletter.

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Season four is produced by Matthew Braddock, and this episode was outlined by Annika Nadu. Our editor and engineer is Jason Portizo. Our theme music was generously donated by Cave Radio. I'm actually [01:03:00] going to a cave radio concert tonight. I can't wait to see him. Find Cave Radio on Spotify and other music was by O Mayor Ben V to learn about our program, disclaimer and ethics policy, our submission verification, and licensing terms, and our HIPAA release terms, go to psychiatry bootcamp.com or you can also find episode transcripts and reach out to us with any questions.

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