Earl De Guzman

psychiatrist | psychoanalysis | reverie in travel | views expressed are my own

[The Mel Jar @the_mel_jar]

Why we love the idea that anger is masking the deeper issue:

1) because we are uncomfortable with our own anger and wish to believe that we are neither ruled or defined by it, or that we have mastered it;

2) because we are uncomfortable with others’ anger, as it is unattractive and repellent to us, and it is difficult for us to remain compassionate and understanding in the face of true rage, unless we can make meaning of the deeper pain involved.

Of course, deeper pain IS involved. It’s just that a natural reaction to such pain is, in fact, anger. So “anger” is very often the exact thing we should learn to be capable of experiencing for ourselves, and experiencing in others, when it’s finally accessible and feels safe to admit to feeling, and to share this feeling.

The entire process of “civilization,” particularly in Western civilization contexts, has been predicated on us recognizing our anger and its potential for destruction, and so “channeling” it in “appropriate” outlets so that we do not destroy our own families, communities, and selves.

For women, this process has been even more repressive. Hundreds of years of women’s socialization in particular has resulted in “rage” itself — despite being one of the first expressions of affect that is clearly seen in any newborn human being or in any primate species — being categorized as unfeminine, unattractive, and often indicative of deep pathology, in women especially.

Women intuitively understand that to be called “angry” is not only a deep insult in terms of our character, but it is also an insult in terms of our gender conformity and identity. It is saying that we are unwell. Though this is true for when men are accused of being “too angry” as well, the bar is much lower for women.

Being called a “bitch,” or “cunt,” or “hag,” or “witch,” all communicate the same thing: “you are an angry woman.”

Women’s violence is felt emotionally, subjectively, and irrationally, by men and women alike, to be maybe ten or a hundred times more upsetting than men’s violence, no matter what the generalized results of the different forms of violence happen to be.

This is perhaps because of the fact that a woman’s anger would have led to our deaths as infants, had mother given into her rage. So we are primed to be especially fearful of women’s rage all the rest of our lives.

We should not trust ourselves to be objective judges of our anger.

If you feel compelled to say, “I was once very angry, but I worked through this,” or “I don’t really feel anger, as I feel ____” then you are either still in the dark about this one, your primal feelings, OR you are participating in the ongoing required social norms and rituals of civilization — which is fair, as we can’t really escape these, we can only become more conscious of them.

We don’t need to continue to deny our compulsion to deny anger. But confrontation sucks.

After all, Freud, Klein, etc. were not actually rejected simply because of their insistence on using sex and biology as ways to make sense of human psychology.

It was because they would not say what people most wanted to hear, which is that humans are primed MORE towards love and cooperation in the collective, rather than destructive rage.

Love and cooperation must be taught beginning in one’s infancy via the experience of nurture and care, but even this experience does not make rage go away. It does not diminish our capacity for rage, it just tempers it and allows us to control it more effectively, at best.

Without this experience, then we will still have our rage. No one needs to teach us any innate emotion that we must have the capacity to feel in order to ensure our survival.

Without the experience of love and nurture as a means to ensure our survival, then it is not seen as something to our advantage. It is instead seen as a weakness.

Ensuring that one is cared for and loved is often the survival strategy of dependency. And this, too, is why women may deny our anger.

[Earl De Guzman @ebdeguzman]

@DoctorPerin Hamnet!

[Earl De Guzman @ebdeguzman]

@atx_therapist New Center for Psychoanalysis in LA, but need to be licensed in CA.

[BrightonPsych @BrightonPsych]

🧵There’s no such thing as a patient (alone)

Winnicott famously said: “There is no such thing as a baby… there is a baby and someone.”
He meant that human beings only exist in relationship.
A mind emerges with & through another mind.
This has radical implications for therapy.👇

[Aziz S̸𓅒 @Psy_Lacanian]

Psychoanalysis Is Not ‘Better Therapy’ - It’s Not Therapy At All

Dr. Allen Frances recently argued against psychoanalysis in favor of brief psychodynamic therapy - calling psychoanalysis too rigid, too long, and too expensive. This critique is common in American psychiatry. This critique fundamentally misunderstands what analysis is. "Let me explain why. [1/14]"

[Jonathan Shedler @JonathanShedler]

When I consult on cases where psychotherapy feels stuck, the problem nearly always comes down to the same thing.

From the get go, therapist and patient never reached a *shared* understanding about the purpose of the therapy—let alone clarified what the patient desires to change about themselves, that psychotherapy can realistically help them to change.

It’s as if therapist and patient depart on a journey without a destination or map and wonder why they keep getting lost.

Some elaboration:

If a patient comes for (say) anxiety or depression, therapist and patient may mistakenly think they have a shared understanding of the the purpose of the work.

They do not.

They have not clarified what the patient desires to change about themselves.

Relief from anxiety or depression is a desired *outcome*—but it does not speak to psychological change.

Of course the patient wants to feel better.

The meaningful questions is: what would the patient need to change about themselves to make it possible for them to feel better?

So the purpose of psychotherapy cannot come into focus until therapist and patient can articulate together what it is about the person’s psychology that is giving rise to the anxiety or depression. What is driving it? Is it something psychotherapy could realistically help to change? And is it something the patient desires to change?

Reaching a mutual understanding and agreement takes skill on the part of the therapist, and serious work for both parties.

It requires developing a clinical case formulation that’s specific to the patient, that links their symptoms or distress to *underlying psychological causes*—which are rarely obvious at the outset.

Thus, three things are inseparable:

1️⃣ a sound clinical case formulation,
2️⃣ a shared understanding of the purpose of therapy, which follows from the case formulation
3️⃣a working alliance between clinician and patient around that shared purpose, as well as the methods to achieve it

This is the foundation of all effective psychotherapy.

When psychotherapy feels stuck, one way to get un-struck is to go back to the basics—and consider whether therapist and patient ever established a sound foundation to build from.

“The goals in therapy are a collaborative effort in which therapist and patient together identify what is distressing to the patient, what the patient would like to change, and what is realistically possible to change in the course of psychotherapy.”
—Glen Gabbard

[Earl De Guzman @ebdeguzman]

@SleeperSFGiants @Baysuperfans Jeff Brantley

[Earl De Guzman @ebdeguzman]

@GiantHotTakes DFA

[Earl De Guzman @ebdeguzman]

@michaelmalice Carpe

[Earl De Guzman @ebdeguzman]

@GiantHotTakes With or without walker closing it out?

[Dr Sanil Rege FRANZCP | MRCPsych @sanilrege]

🧵When Patients Feel Harmed by Treatment - Is There More to the Story? 🚨 1/21

This will get backlash.

It’s not about denying harm.

It’s about understanding how harm is experienced, amplified, encoded, and communicated and

how that understanding can help people move forward in a world that’s flawed and uncertain.

1/21👇

[Earl De Guzman @ebdeguzman]

@AaronKheriatyMD Not only nurses but doctors, therapists and others within the healthcare and helping professions.

[Earl De Guzman @ebdeguzman]

@JonathanShedler Unfortunately, the trend within some psych residencies has been to do exactly the latter.

[Earl De Guzman @ebdeguzman]

@FeistyKittyPie Objet petit cat

[Earl De Guzman @ebdeguzman]

@SleeperSFGiants Mediocre

[Jonathan Shedler @JonathanShedler]

Some factors contributing to dramatic decline of psychotherapy in recent decades

1️⃣Deep intrusion of health insurance agendas into psychotherapy and psychotherapy training

2️⃣Dramatic decline in reimbursement. Psychologists in managed care paid 70% less in inflation-adjusted dollars than 1980s. “Best and brightest” now choose other careers

3️⃣Out-of-control proliferation of for-profit graduate training programs that admit and graduate anyone who can pay

4️⃣Influx into psychotherapy professions of vast numbers of practitioners who lack adequate training and aptitude

5️⃣Pharmaceutical marketing/PR campaigns changed public perceptions, normalized meds as solution for problems in living

6️⃣Pharmaceutical marketing/PR campaigns changed public perceptions, normalized seeking MH care from primary care doctors (“talk to your doctor”). Few have a clue what good psychotherapy is or looks like. Most patients leave with Rx

7️⃣Therapy researchers operate in academic silos with little knowledge of psychotherapy and no contact with real-world psychotherapists. Most “therapy” research irrelevant and useless to clinical practitioners (see next two items)

8️⃣Conflation of psychological problems with DSM diagnoses (by health insurers and academics researchers both)

9️⃣Conflation of psychotherapy “outcome” with DSM symptom lists (driven by health insurers and academics researchers both)

1️⃣0️⃣Rise of social media therapy influencers; inability of public to differentiate knowledge & training from self-promotion/popularity (“the death of expertise”)

1️⃣1️⃣Intense politicization of therapy professions; emergence of a training culture that incentivizes “right” politics & ideology over professional competence

1️⃣2️⃣ Impact of tech companies/private equity. Eg, lowest tier therapists recruited, marketed, paid like Uber drivers. Advertising deliberately erases distinctions between levels of training and experience

1️⃣3️⃣ Low or no barriers to entry; MH field is low hanging fruit for al manner of self-promoters and opportunists

What else is playing a role? What else would you add?

[Earl De Guzman @ebdeguzman]

@GiantHotTakes Maybe Preller was right about Melvin all along.

[Michael Golding @mgoldingmd]

Sometimes people correctly attribute the explanation of their disability to a single medication they once took or a procedure they had, like saying an SSRI antidepressant or an anti-cancer drug, or a plastic surgery procedure, or a war injury, absolutely injured them.

But in many cases, the explanations of the current disability are multi-factoral, even from known initial damaging precipitants or causes, and of course include the psychological response to the problem.

Although it’s psychologically easy to wrap one’s head around a single cause of a problem, oftentimes that misses the psychological and physiological context from which the problem originated and which treatment must take into account to be effective.

Dr. Rege does a nice job explaining the need to include these factors, below.

Explaining is Dr. Rege’s superpower. :-)

[Earl De Guzman @ebdeguzman]

@BadreNicolas It’s a shame some psychiatrists still dismiss psychotherapy training. Helping someone find meaningful change through a therapeutic relationship is vital to our work.

[Dr Beech 🌤 @DrDBeech]

In a forensic case a cross-examining attorney asked a witness (a forensic psychiatrist, also a psychoanalyst) whether repression, mentioned during testimony could be proven empirically. The expert replied “Counsel, thoughts of any kind, yours nor mine, can be proven empirically.”