PhD/PsyD Psychiatrist "not providing therapy" on livestream

[psych.meout]

Self Selection Bias. But, yes.

"Meeting a need for mental health education among the gamer community" is obvious self-serving nonsense. What is the "need" exactly? That people (who likely have robust coverages such as State Medicaid or select insurances) won't help themselves unless you poke and prod them? How paternalist is that???

The community cannot really keep down this road of we are helpless but also "know best" in regards to to mental health functioning at the same time.

I think "meeting a need" in this context is not in reference to to gamers and streamers being indigent or helpless, but rather that they are somehow a special population that isn't served by any traditional psychotherapy and need unique treatments tailored for them. I don't know that there is empirical support for this beyond "I can make a buck by marketing this to a relatively affluent group who doesn't know better and likes the idea of being depicted as a special" and that he can make extra money through streaming/VOD revenue.

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[erg923]

I think "meeting a need" in this context is not in reference to to gamers and streamers being indigent or helpless, but rather that they are somehow a special population that isn't served by any traditional psychotherapy and need unique treatments tailored for them. I don't know that there is empirical support for this beyond "I can make a buck by marketing this to a relatively affluent group who doesn't know better and likes the idea of being depicted as a special" and that he can make extra money through streaming/VOD revenue.

I am normal and fine but "please help me" reminds me of another famous saying....

Sometimes "you" are the problem...is the problem.

 

[cara susanna]

I have followed this guy's videos from the inception and my impression has been that he's a psychiatrist playing what he thinks a psychologist does. I think he believes that psychologists or people practicing therapy are charismatic and drop knowledge on patients. Dr K claims that he is meeting a need for mental health education among the gamer community. For example, he said from the outset that he would do things like release a mental health guide for free (that guide now costs money on his website). What I find the most disturbing is that any criticism of him within the community is met with major backlash from his audience. They support this guy through anything. I can only imagine how that puts more fuel on the fire for him to keep going. It's kind of like a cult...

I think that you hit the nail on the head. To what you and erg are saying, I saw this comment on YT that was like, this is needed because he understands and is a part of "our community." It reminded me of what I encounter in the VA, but at least with Veterans I can see more rationale for that idea than with gamers. Also, a lot of VA therapists are not Veterans themselves.

 

[psych.meout]

I think that you hit the nail on the head. To what you and erg are saying, I saw this comment on YT that was like, this is needed because he understands and is a part of "our community." It reminded me of what I encounter in the VA, but at least with Veterans I can see more rationale for that idea than with gamers. Also, a lot of VA therapists are not Veterans themselves.

That kind of gets at the heart of people prioritizing lived experience over actual expertise and empirically-driven practices. It's intuitive to people (especially, though not solely, lay audiences) that someone with a particular lived experience is going to know about a given community and there will be better rapport with patients from that community due to the patient-provider concordance, therefore they'll be more effective when providing care to that community than someone who is not part of it, but that's not necessarily true. And we see this logic at various levels, from actual therapy contexts here to applicants for grad school wanting to write about their lived experience with psychopathology, trauma, etc. because they think it gives them a unique perspective and a leg up over other candidates who "just" have extensive research and clinical experience.

Without disclosing too much, some of my research is with veterans about these issues specifically and while many do prefer various forms of concordance with their providers (e.g., race, ethnicity, gender), there are a substantial number who don't like Veteran-status concordance with their providers. They feel like their providers who are also veterans are presumptuous and don't engage with them as patients as much (e.g., less shared decision-making) because the veteran providers assume they know everything about their patient's experience simply based on the concordance.

 

[R. Matey]

That kind of gets at the heart of people prioritizing lived experience over actual expertise and empirically-driven practices. It's intuitive to people (especially, though not solely, lay audiences) that someone with a particular lived experience is going to know about a given community and there will be better rapport with patients from that community due to the patient-provider concordance, therefore they'll be more effective when providing care to that community than someone who is not part of it, but that's not necessarily true. And we see this logic at various levels, from actual therapy contexts here to applicants for grad school wanting to write about their lived experience with psychopathology, trauma, etc. because they think it gives them a unique perspective and a leg up over other candidates who "just" have extensive research and clinical experience.

And the fact he went to Harvard Medical School gives him a "superior" academic background to his critics among a lay audience. Because quacks obviously can't come from Harvard.

 

[cara susanna]

That kind of gets at the heart of people prioritizing lived experience over actual expertise and empirically-driven practices. It's intuitive to people (especially, though not solely, lay audiences) that someone with a particular lived experience is going to know about a given community and there will be better rapport with patients from that community due to the patient-provider concordance, therefore they'll be more effective when providing care to that community than someone who is not part of it, but that's not necessarily true. And we see this logic at various levels, from actual therapy contexts here to applicants for grad school wanting to write about their lived experience with psychopathology, trauma, etc. because they think it gives them a unique perspective and a leg up over other candidates who "just" have extensive research and clinical experience.

Without disclosing too much, some of my research is with veterans about these issues specifically and while many do prefer various forms of concordance with their providers (e.g., race, ethnicity, gender), there are a substantial number who don't like Veteran-status concordance with their providers. They feel like their providers who are also veterans are presumptuous and don't engage with them as patients as much (e.g., less shared decision-making) because the veteran providers assume they know everything about their patient's experience simply based on the concordance.

Imo that's the problem with valuing lived experience over actual expertise and evidence-based practice in general. The provider will have more difficulties being neutral or objective, and might assume that they understand how the patient is feeling.

I made a point earlier in this thread about how Dr. K wants to have his cake and eat it too. Is he an expert or is he just a lay person in his community who's helping out his friends? You can't have both.

And there's also the fact that, even if he is a trained psychiatrist, that doesn't make him an expert at providing therapy (in fact, it seems like mutliple psychologists or psychologists-in-training on this thread agree that he doesn't seem great at actually doing therapy as we would do therapy). And it's concerning especially because the public often confuses psychiatrists and psychologists.

 

[tr]

I have followed this guy's videos from the inception and my impression has been that he's a psychiatrist playing what he thinks a psychologist does. I think he believes that psychologists or people practicing therapy are charismatic and drop knowledge on patients.

No this kind of beard-stroking 'psychotherapy' is a subculture in psychiatry. I had specific supervision in this type of psychotherapy in residency. I thought it was garbage and ran away quickly. But lots of people loved it.

The idea, as you describe, seems to be to listen silently yet charismatically for an extended period of time and then drop a wise "interpretation". People doing this type of thing seem to classify themselves as either psychodynamically oriented or "eclectic." There is zero evidence base for any of it as far as I can tell. Or at least, neither of the people who provided this type of supervision to me seemed to be at all concerned with verifying whether it was actually effective. They assumed it was based on their clinical experience.

 

[psych.meout]

No this kind of beard-stroking 'psychotherapy' is a subculture in psychiatry. I had specific supervision in this type of psychotherapy in residency. I thought it was garbage and ran away quickly. But lots of people loved it.

The idea, as you describe, seems to be to listen silently yet charismatically for an extended period of time and then drop a wise "interpretation". People doing this type of thing seem to classify themselves as either psychodynamically oriented or "eclectic." There is zero evidence base for any of it as far as I can tell. Or at least, neither of the people who provided this type of supervision to me seemed to be at all concerned with verifying whether it was actually effective. They assumed it was based on their clinical experience.

I wonder if it's driven by a misunderstanding of Motivational Interviewing, which, from the interns, residents, and fellows with whom I've worked in practica, seems to be given exposure but not in-depth training in medical school. It's a bit like jumping to advanced reflections and summaries without understanding the concepts or doing the more fundamental practices to work up to those more advanced practices. And that goes without saying that you should have more tools in your bag than MI.

 

[R. Matey]

I wonder if it's driven by a misunderstanding of Motivational Interviewing, which, from the interns, residents, and fellows with whom I've worked in practica, seems to be given exposure but not in-depth training in medical school. It's a bit like jumping to advanced reflections and summaries without understanding the concepts or doing the more fundamental practices to work up to those more advanced practices. And that goes without saying that you should have more tools in your bag than MI.

I think it's more of a casual psychoanalysis. I'm under the impression that psychoanalytic didactics are embedded in residency training programs to a much greater degree than they are in our programs. At least, that was the case in the training programs with which I'm familiar.

 

[cara susanna]

I can't stop thinking about the clip with the pink-haired woman. She didn't want to disclose specifics about her abuse (on a livestream viewable to the public), which Dr. K took as her being defensive, and then he was basically confrontational telling her oh yeah, do what you do, protect other people even if it hurts you. It made her break down into tears. I'm REALLY bothered by that moment especially. That is not how you work with a sexual trauma survivor, especially when asking her to talk about the trauma.

Tr's term of "beardstroker 'psychotherapy'" is such a great description for what he does.

I think it's more of a casual psychoanalysis. I'm under the impression that psychoanalytic didactics are embedded in residency training programs to a much greater degree than they are in our programs. At least, it was in the training programs with which I'm familiar. It's a cliche, but Harvard is in Boston...

They are. I supervise a psychiatry resident's therapy cases (as you all know, I am NOT psychodynamic) and they receive a lot of psychodynamic training. And we are not even on the east coast.

 

[tr]

I wonder if it's driven by a misunderstanding of Motivational Interviewing, which, from the interns, residents, and fellows with whom I've worked in practica, seems to be given exposure but not in-depth training in medical school. It's a bit like jumping to advanced reflections and summaries without understanding the concepts or doing the more fundamental practices to work up to those more advanced practices. And that goes without saying that you should have more tools in your bag than MI.

I think it predates MI. I think it might be an offshoot of psychoanalysis but without the extended psychoanalytic training. Not sure.

 

[tr]

They are. I supervise a psychiatry resident's therapy cases (as you all know, I am NOT psychodynamic) and they receive a lot of psychodynamic training. And we are not even on the east coast.

The east coast is awful for this. I trained on the West Coast and moved to the East Coast a couple of years ago. We did have this pseudo-psychoanalytic stuff at my previous institution (one of my two supervisors there who practiced this way was a psychologist btw) but there was also good availability of training in evidence-based therapy if you were interested in obtaining it.

I feel like a lot of the trainees as well as attendings I meet on the East Coast never really had good exposure to evidence-based therapies at all. Like I have had to explain the basic concepts of exposure therapy to a number of colleagues and trainees here, who reacted as if it were really quite new and interesting information.

 

[Therapist4Chnge]

I've definitely seen the "beard stroking" psychotherapy approach, almost exclusively from the "psychoanalysis" and "eclectic" professed clinicians, as @tr mentioned above. Unfortunately the faux-intellectualism has been propagated further by Hollywood and Life Coaches. Raising the profile of talking about mental health is generally a net positive, but so many people think therapy is sitting around and talking w. a really smart friend who gives you advice. This is one of the many reasons why when I recommend treatment to a patient I go through and describe exactly what is entailed, provide examples, and talk about expectations. I work almost exclusively with behavioral interventions, which I describe as "small c, big B" cBT. I forget who framed it that way first, but it always stuck with me.

 

[clausewitz2]

I think it predates MI. I think it might be an offshoot of psychoanalysis but without the extended psychoanalytic training. Not sure.

Everybody wanna be Kernberg but don't nobody wanna to pay for no long-*** analytic training.

In my current city there is an analytic institute so those people are around but for whatever historical reason we are absolutely flooded with the Gestalt people. So not so much beard-stroking as chair-talking, I guess.

 

[Therapist4Chnge]

I have some oooooold texts from Klein, Otto K, & Harry Stack Sullivan, etc....it's interesting in a retrospective way, but could I justify object relations / psychdynamic-flavored approaches in today's world....no.

 

[Sanman]

The east coast is awful for this. I trained on the West Coast and moved to the East Coast a couple of years ago. We did have this pseudo-psychoanalytic stuff at my previous institution (one of my two supervisors there who practiced this way was a psychologist btw) but there was also good availability of training in evidence-based therapy if you were interested in obtaining it.

I feel like a lot of the trainees as well as attendings I meet on the East Coast never really had good exposure to evidence-based therapies at all. Like I have had to explain the basic concepts of exposure therapy to a number of colleagues and trainees here, who reacted as if it were really quite new and interesting information.

I would limit this more to the Northeast and mid-atlantic (Washington D.C. north). When I trained I had to look south of that to find an adequate number of programs with solid behavioral training. There are some notable exceptions in the northeast, but there is a lot more old school psychoanalytic folks.

 

[Sanman]

I've definitely seen the "beard stroking" psychotherapy approach, almost exclusively from the "psychoanalysis" and "eclectic" professed clinicians, as @tr mentioned above. Unfortunately the faux-intellectualism has been propagated further by Hollywood and Life Coaches. Raising the profile of talking about mental health is generally a net positive, but so many people think therapy is sitting around and talking w. a really smart friend who gives you advice. This is one of the many reasons why when I recommend treatment to a patient I go through and describe exactly what is entailed, provide examples, and talk about expectations. I work almost exclusively with behavioral interventions, which I describe as "small c, big B" cBT. I forget who framed it that way first, but it always stuck with me.

As a bearded person, I just want to point out one can be beard stroking and behavioral.

 

[cara susanna]

As a bearded person, I just want to point out one can be beard stroking and behavioral.

#notallbeardedpeople

 

[R. Matey]

As a bearded person, I just want to point out one can be beard stroking and behavioral.

But you have to be bearded in order to be "beard stroking", it's a necessary but insufficient criteria.

 

[psych.meout]

But you have to be bearded in order to be "beard stroking", it's a necessary but insufficient criteria.

I've had phantom beard syndrome since I shaved

 

[R. Matey]

I've had phantom beard syndrome since I shaved

Is it weird that I'm trying to figure out how a mirror box would work in that situation?

 

[Therapist4Chnge]

As a bearded person, I just want to point out one can be beard stroking and behavioral.

As a bearded behavioral person...strong agreement!

 

[psych.meout]

Is it weird that I'm trying to figure out how a mirror box would work in that situation?

You need a selfie stick

 

[Sanman]

You need a selfie stick

As the inaugural president of the Society of Beard stroking Behaviorists, I concur.

Sidenote: I will be publishing on bsdr therapy shortly (beard stroking desensitization and reprocessing). CEU talk in the works and there is a certificate course that will be available for $995 after completion of 10 CE hours via PESI.

 

[tr]

As the inaugural president of the Society of Beard stroking Behaviorists, I concur.

Sidenote: I will be publishing on bsdr therapy shortly (beard stroking desensitization and reprocessing). CEU talk in the works and there is a certificate course that will be available for $995 after completion of 10 CE hours via PESI.

You joke, sir; but really, EMDR seems to have a somewhat difficult-to-ignore evidence base from what I can tell (yes ok it's just exposure by another name, yes it has nothing to do with the eye movement, please don't hit me) but yet there's a ton of hate for it.

Meanwhile this pseudo-psychoanalytic stuff is taught quite widely, doesn't seem to have been specifically studied at all, and does seem like it could have the potential to be harmful if wielded badly (cf. @carasusanna's observation upthread about the pink-haired woman in the video). Yet I never see anyone trying to deconstruct it, not to say debunk it, and it seems a bit like a sacred cow honestly.

I really don't doubt that the physician in the video learned his approach at MGH. I did not train there but it seems quite consistent with what I've seen taught at peer institutions. I think it's a bit funny that things like EMDR (which is theoretically weak but has empirical support) and biofeedback (which has a quite solid scientific justification IMO) come in for a ton of scorn comparatively, yet nobody ever mentions that the beard-stroking emperors have no clothes.

 

[AcronymAllergy]

You joke, sir; but really, EMDR seems to have a somewhat difficult-to-ignore evidence base from what I can tell (yes ok it's just exposure by another name, yes it has nothing to do with the eye movement, please don't hit me) but yet there's a ton of hate for it.

Meanwhile this pseudo-psychoanalytic stuff is taught quite widely, doesn't seem to have been specifically studied at all, and does seem like it could have the potential to be harmful if wielded badly (cf. @carasusanna's observation upthread about the pink-haired woman in the video). Yet I never see anyone trying to deconstruct it, not to say debunk it, and it seems a bit like a sacred cow honestly.

I really don't doubt that the physician in the video learned his approach at MGH. I did not train there but it seems quite consistent with what I've seen taught at peer institutions. I think it's a bit funny that things like EMDR (which is theoretically weak but has empirical support) and biofeedback (which has a quite solid scientific justification IMO) come in for a ton of scorn comparatively, yet nobody ever mentions that the beard-stroking emperors have no clothes.

Good points. I think with EMDR and biofeedback, at least in my interactions with psychologists, it's not so much that folks say there's no evidence base or they have no place in treatment. It's more so a reaction to the fervency of some of the proponents and the willingness of some said proponents to expand use faaaaar beyond areas for which there's an inkling of theoretical (let alone empirical) support. It doesn't help that with EMDR, there also seems to be some jargony pseudo-neuroscience thrown around.

With the beard-stroking, I wonder if it's more that (current) psychologists just don't often have much direct experience with that style, so we don't think to direct criticism at it. And the psychologists who are familiar with it may be proponents themselves.

 

[smalltownpsych]

This thread makes me think about how hard real therapy is to do and also how hard it is to explain the difference between real and the pretenders. In my newest iteration of providing therapy and running/developing a practice, I’m actually struggling with that a bit myself. Feeling like I lost my mojo. Maybe the call I had yesterday from the family member of my current patient most likely to die has something to with that. They are in the hospital today so that’s good. Give me a patient with borderline PD and no substance use disorder over co-occurring active addiction any day. In short, I don’t know if I’ll be able to help my current patient and outpatient therapy is really not indicated for that anyway so we’ll see if they can get him into a program, but I probably could have helped that young man in the video.
One more key point, in person connection is needed for severe cases especially when dealing with the interpersonal. Part of the skillset and targeted intervention that I use is my emotional connection and two way interaction with the patient and decreasing the efficacy of that through distance is not appropriate for these patients.

 

[WisNeuro]

Good points. I think with EMDR and biofeedback, at least in my interactions with psychologists, it's not so much that folks say there's no evidence base or they have no place in treatment. It's more so a reaction to the fervency of some of the proponents and the willingness of some said proponents to expand use faaaaar beyond areas for which there's an inkling of theoretical (let alone empirical) support. It doesn't help that with EMDR, there also seems to be some jargony pseudo-neuroscience thrown around.

With the beard-stroking, I wonder if it's more that (current) psychologists just don't often have much direct experience with that style, so we don't think to direct criticism at it. And the psychologists who are familiar with it may be proponents themselves.

Seriously. Someone here is advertising EMDR for alcoholism and long COVID.

 

[clausewitz2]

I really don't doubt that the physician in the video learned his approach at MGH. I did not train there but it seems quite consistent with what I've seen taught at peer institutions. I think it's a bit funny that things like EMDR (which is theoretically weak but has empirical support) and biofeedback (which has a quite solid scientific justification IMO) come in for a ton of scorn comparatively, yet nobody ever mentions that the beard-stroking emperors have no clothes.

When I was finishing up residency I worked with a freshly hired attending who had done his residency at MGH. He had apparently advertised himself as an expert in MBT during the hiring process and he was duly assigned to provide supervision and co-precept an elective in MBT. For all that it is very psychodynamic in its origins I think it is fair to say that Fonagy et al at least take seriously the need for empirical validation and have made a good faith effort to do so, so this is best case scenario for approaches ultimately deriving from psychoanalysis, right?

It became rapidly clear that as an enthusiastic PGY-4 I knew the manual much better and certainly had read more about it, and while he had some of the buzzwords down in practice for him it was largely about falling back into the same half-assed interpretations and confrontations that were not obviously connected to addressing or assessing problems of mentalization and how they might apply to someone with a personality disorder. Thankfully a psychologist was also responsible for it and I did end up getting real supervision.

What I'm saying I guess is that I go beyond @tr to say I actually kind of believe more that he got his therapy training at MGH having now seen the video.


Makes it doubly sad he's not even -good- at the bull****.

 

[Sanman]

You joke, sir; but really, EMDR seems to have a somewhat difficult-to-ignore evidence base from what I can tell (yes ok it's just exposure by another name, yes it has nothing to do with the eye movement, please don't hit me) but yet there's a ton of hate for it.

Meanwhile this pseudo-psychoanalytic stuff is taught quite widely, doesn't seem to have been specifically studied at all, and does seem like it could have the potential to be harmful if wielded badly (cf. @carasusanna's observation upthread about the pink-haired woman in the video). Yet I never see anyone trying to deconstruct it, not to say debunk it, and it seems a bit like a sacred cow honestly.

I really don't doubt that the physician in the video learned his approach at MGH. I did not train there but it seems quite consistent with what I've seen taught at peer institutions. I think it's a bit funny that things like EMDR (which is theoretically weak but has empirical support) and biofeedback (which has a quite solid scientific justification IMO) come in for a ton of scorn comparatively, yet nobody ever mentions that the beard-stroking emperors have no clothes.

I mean, I am not disagreeing with anything you state here. I will say that I get more exposure to EMDR folks than anything psychoanalytic. Other than a couple of seminars about modern psychoanalysis from a psychiatrist in training, I have pretty much gone my entire career with much interaction with these folks. I see the emdr stuff every time I need to complete my annual CE requirements.

That said, it really boils down to science and snake oil. You can say EMDR is only partially snake oil, but it is what it is nonetheless. I wouldn't advocate pushing new med x on the public just because it is basically bright purple colored tylenol (or Nuedexta, which is all the rage in dementia/nursing home circles). Once you remove the fluff, the science is not as complicated.

 

[WisNeuro]

I mean, I am not disagreeing with anything you state here. I will say that I get more exposure to EMDR folks than anything psychoanalytic. Other than a couple of seminars about modern psychoanalysis from a psychiatrist in training, I have pretty much gone my entire career with much interaction with these folks. I see the emdr stuff every time I need to complete my annual CE requirements.

That said, it really boils down to science and snake oil. You can say EMDR is only partially snake oil, but it is what it is nonetheless. I wouldn't advocate pushing new med x on the public just because it is basically bright purple colored tylenol (or Nuedexta, which is all the rage in dementia/nursing home circles). Once you remove the fluff, the science is not as complicated.

Another part of this is that EMDR grossly takes advantage of providers who simply do not know any better, and/or cannot properly evaluate research. Look at the cost of trainings and "necessary equipment" to become "certified" in this garbage. And, as I have said before, there is a trend in the EMDR cult to disparage PE and other trauma methodologies in favor of their own thing. So it's not simply disliking EMDR for it's useless component, it's disliking EMDR because it is a legitimately harmful and manipulative force in healthcare.

 

[Sanman]

This thread makes me think about how hard real therapy is to do and also how hard it is to explain the difference between real and the pretenders. In my newest iteration of providing therapy and running/developing a practice, I’m actually struggling with that a bit myself. Feeling like I lost my mojo. Maybe the call I had yesterday from the family member of my current patient most likely to die has something to with that. They are in the hospital today so that’s good. Give me a patient with borderline PD and no substance use disorder over co-occurring active addiction any day. In short, I don’t know if I’ll be able to help my current patient and outpatient therapy is really not indicated for that anyway so we’ll see if they can get him into a program, but I probably could have helped that young man in the video.
One more key point, in person connection is needed for severe cases especially when dealing with the interpersonal. Part of the skillset and targeted intervention that I use is my emotional connection and two way interaction with the patient and decreasing the efficacy of that through distance is not appropriate for these patients.

It is hard. The two largest struggles I had as a young clinician in PP (outside of getting comfortable with confronting folks that wouldn't pay their bill) was what do to with folks that were really too complex for outpatient treatment but had no other options and folks with money that had an agenda in treatment (here is cash, fix my teenager, bye). One of the largest lessons I learned is that I felt I couldn't ethically do it until I was financially stable enough to not care who walked through the door. Even with the financial piece out of it, there is a balance to customer service and proper treatment.

 

[smalltownpsych]

It is hard. The two largest struggles I had as a young clinician in PP (outside of getting comfortable with confronting folks that wouldn't pay their bill) was what do to with folks that were really too complex for outpatient treatment but had no other options and folks with money that had an agenda in treatment (here is cash, fix my teenager, bye). One of the largest lessons I learned is that I felt I couldn't ethically do it until I was financially stable enough to not care who walked through the door. Even with the financial piece out of it, there is a balance to customer service and proper treatment.

Yes. It is tough when the financial piece plays into the equation. Two months in and I am getting to even and definitely feeling a little more optimistic, but the standard roller coaster of providing treatment is definitely magnified right now. That last piece is key and sometimes the most effective treatment is about saying no. I have had times when confronting patient on lack of commitment or progress in treatment has been very key. It also models effective boundaries and how to communicate them. I have to be able to practice what I preach and like many in this field, my natural tendency is to be a people pleaser so definitely an area of growth.

 

[thebalmofhurtminds]

Another part of this is that EMDR grossly takes advantage of providers who simply do not know any better, and/or cannot properly evaluate research. Look at the cost of trainings and "necessary equipment" to become "certified" in this garbage. And, as I have said before, there is a trend in the EMDR cult to disparage PE and other trauma methodologies in favor of their own thing. So it's not simply disliking EMDR for it's useless component, it's disliking EMDR because it is a legitimately harmful and manipulative force in healthcare.

Exactly, and the risk is incredibly high that when a provider states they do "EMDR," they're only referring to the eye movement/other snake oil piece and aren't actually doing the exposure piece - the effective mechanism! Even though I predominantly treat chronic pain (don't get me started on EMDR for pain), I spend an abnormally large part of my intake evaluations explaining how trauma focused therapy works and finding alternate referral sources for trauma patients who are doing EMDR to no effect.

 

[cara susanna]

You joke, sir; but really, EMDR seems to have a somewhat difficult-to-ignore evidence base from what I can tell (yes ok it's just exposure by another name, yes it has nothing to do with the eye movement, please don't hit me) but yet there's a ton of hate for it.

Meanwhile this pseudo-psychoanalytic stuff is taught quite widely, doesn't seem to have been specifically studied at all, and does seem like it could have the potential to be harmful if wielded badly (cf. @carasusanna's observation upthread about the pink-haired woman in the video). Yet I never see anyone trying to deconstruct it, not to say debunk it, and it seems a bit like a sacred cow honestly.

I really don't doubt that the physician in the video learned his approach at MGH. I did not train there but it seems quite consistent with what I've seen taught at peer institutions. I think it's a bit funny that things like EMDR (which is theoretically weak but has empirical support) and biofeedback (which has a quite solid scientific justification IMO) come in for a ton of scorn comparatively, yet nobody ever mentions that the beard-stroking emperors have no clothes.

If it helps, I bash both equally. Well, probably EMDR more, but that's because I encounter it more in the VA PTSD world. Also, what WisNeuro said.

 

[R. Matey]

When I was finishing up residency I worked with a freshly hired attending who had done his residency at MGH. He had apparently advertised himself as an expert in MBT during the hiring process and he was duly assigned to provide supervision and co-precept an elective in MBT. For all that it is very psychodynamic in its origins I think it is fair to say that Fonagy et al at least take seriously the need for empirical validation and have made a good faith effort to do so, so this is best case scenario for approaches ultimately deriving from psychoanalysis, right?

It became rapidly clear that as an enthusiastic PGY-4 I knew the manual much better and certainly had read more about it, and while he had some of the buzzwords down in practice for him it was largely about falling back into the same half-assed interpretations and confrontations that were not obviously connected to addressing or assessing problems of mentalization and how they might apply to someone with a personality disorder. Thankfully a psychologist was also responsible for it and I did end up getting real supervision.

FWIW, I had three psychodynamic supervisors in training (all psychologists, obviously) as part of supervision teams, but I think I've had more exposure than many (?) psychologists though I wouldn't consider myself psychodynamic at all. I know there are some psychologists who practice and conduct research in this, most notably Hanna Levinson and her work on brief dynamic as well as the IPT folks, despite their claim that their model is "medical," whatever that means. I've taken flack here for this opinion before, but if we're serious about science, we would at least be open to the perspective that some elements of psychodynamic psychotherapy might be clinically effective beyond placebo. I mean, it's hard to imagine in 100 years of clinical practice that exactly zero percent of smart people practicing these techniques were effective in treating their patients.

Another part of this is that EMDR grossly takes advantage of providers who simply do not know any better, and/or cannot properly evaluate research. Look at the cost of trainings and "necessary equipment" to become "certified" in this garbage. And, as I have said before, there is a trend in the EMDR cult to disparage PE and other trauma methodologies in favor of their own thing. So it's not simply disliking EMDR for it's useless component, it's disliking EMDR because it is a legitimately harmful and manipulative force in healthcare.

Agree with this, and I'll only add that EMDR doubling-down on their pseudoscientific bulls*** also makes it a quotidian piñata among psychologists. Master's level clinicians and FPPS grads don't typically have the skills to critically evaluate the claims, thus adding to the mystery. People like mystery more than they like hard work.

 

[cara susanna]

Yeah, I'd respect EMDR a LOT more if they were like "it's exposure but with eye movements."

 

[tr]

FWIW, I had three psychodynamic supervisors in training (all psychologists, obviously) as part of supervision teams, but I think I've had more exposure than many (?) psychologists though I wouldn't consider myself psychodynamic at all. I know there are some psychologists who practice and conduct research in this, most notably Hanna Levinson and her work on brief dynamic as well as the IPT folks, despite their claim that their model is "medical," whatever that means. I've taken flack here for this opinion before, but if we're serious about science, we would at least be open to the perspective that some elements of psychodynamic psychotherapy might be clinically effective beyond placebo. I mean, it's hard to imagine in 100 years of clinical practice that exactly zero percent of smart people practicing these techniques were effective in treating their patients.

I'm completely open to that and agree with you that there are likely important elements of psychodynamic psychotherapy that are effective.
My concern is more that it doesn't seem possible (or perhaps nobody has tried) to figure out what those elements are and to codify and teach them.

For what it's worth I have had exposure to both TLDP and IPT and there seemed to be a rationale and an evidence base for both of them as well as a structure (looser than CBT but certainly there) so I wouldn't put either of them in the beard-stroking category. I didn't personally enjoy working in that way but I would never insinuate that those interventions are meritless woo.

This thing that is being done in the video, though, this beard-stroking or "eclectic" or does-it-even-have-a-name, it is widespread and I really do think it can be meritless or even harmful. The problem is that there doesn't seem to be any kind of good-faith effort to quantify what it even is (but I know it when I see it!), to figure out what elements are helpful vs harmful, and to systematically educate trainees in the elements that are helpful and stop them from doing things that are harmful. The supervision that I received in this vein never touched on any of those, and based on the little I watched of the Dr K videos I would bet his never did either.

 

[R. Matey]

This thing that is being done in the video, though, this beard-stroking or "eclectic" or does-it-even-have-a-name, it is widespread and I really do think it can be meritless or even harmful. The problem is that there doesn't seem to be any kind of good-faith effort to quantify what it even is (but I know it when I see it!), to figure out what elements are helpful vs harmful, and to systematically educate trainees in the elements that are helpful and stop them from doing things that are harmful. The supervision that I received in this vein never touched on any of those, and based on the little I watched of the Dr K videos I would bet his never did either.

Agree on all points. Honestly, I think poor training in psychotherapy plus overconfidence in psychotherapy providers is so widespread that I have no issues with calling it a public health crisis.

 

[smalltownpsych]

I consider myself a psychodynamic practitioner and think that some of the concepts and constructs within that community/philosophy are quite useful, but I am also a broadly trained psychologist and am grounded in research so I also recognize that the behavioral principles underlying CBT and DBT are of benefit. I tend to think the phenomenon of the beard-stroker has more to do with using a little bit of psychodynamic theory and acting as though that is sufficient.

I see the same with DBT all day long. Practitioners who say they are DBT therapists, but all they do is tell clients "use your skills" and when the client self-harms "you didn't use your skills". Weak. Regardless of your emphasis on behavior, emotion, biology, interpersonal, cognition, if you don't dive in and know the limits of your expertise then you are just faking it. I see the same with "trauma therapists" who have a level of understanding of "just talk about the trauma and you'll get better". This one has caused a lot of harm and you mix it in with some toxic messages from society and me and my patients who have been victims of trauma and the system have quite a bit of unravelling to do in addition to the trauma work.

Speaking of trauma, just to be more explicit for any students who might be reading, pressuring someone to do something that makes them uncomfortable when they have a history of this same dynamic has a high likelihood of making them worse and if you don't put some pressure and they don't feel uncomfortable, then they won't get better. That's why it takes skill, training, experience, sensitivity, and thoughtfulness. It is also why when amatuers (or professionals acting outside their scope) pretend like they can do it, patients get worse or even die. Borderline PD has a 20% prevalence of death by suicide last I checked.

 

[borne_before]

An essential feature of beard stroking is the narrative fallacy?

Is Yalom a beard stroker?

 

[Sanman]

An essential feature of beard stroking is the narrative fallacy?

Is Yalom a beard stroker?

Actually, he had a very nice VanDyke (EDIT: apparently the D word is forbidden here). Great for rubbing the chin.

It is at this point that I think we need an operational definition of beard stroking because I do not group all psychodynamic or humanistic folks into this category. Certainly some really old school psychoanalytic types that can never be wrong, but also those that that just provide random insight and assume the problem is fixed. I feel as though others are generalizing more.

 

[smalltownpsych]

Actually, he had a very nice VanDyke (EDIT: apparently the D word is forbidden here). Great for rubbing the chin.

It is at this point that I think we need an operational definition of beard stroking because I do not group all psychodynamic or humanistic folks into this category. Certainly some really old school psychoanalytic types that can never be wrong, but also those that that just provide random insight and assume the problem is fixed. I feel as though others are generalizing more.

I agree that in this context, we are referring to the insight and assume that fixes things.

I do disagree with the random descriptor, often these beard strokers insights are accurate or insightful, still doesn't mean that it helps the clients. I think some of the dynamic is that the "brilliant insight" feeds the beard strokers ego and also leads to an idealizing transference from the patient that they have to fulfill by "getting better" and then have to split off or hide any negative experiences, thus leading to increased shame and fracture. Very bad stuff. Kernberg spoke of the importance of interpreting the hostility and integrating the good and bad perspectives of the therapist. When a patient like this is able to say you really helped me with this and that, but I was really pissed off or disappointed when you did this; then I know we have made some real progress.

Weathering through a few of the disappointments and fractures of rapport is way more important than my brilliant insights. (although I do like them and they impress me at times). One benefit of experience is reviewing successful treatments with patients. It is incredible how often what I thought was an important moment is not the same with them or vice versa. This helps keep my ego in check because even as much as I know, I still don't know what the heck is happening much of the time.

 

[tr]

I agree that in this context, we are referring to the insight and assume that fixes things.

I think that's a good succinct description of the beard-stroking phenomenon.

May I ask you something, as someone with psychodynamic expertise, how do you train another individual to do whatever it is that you are doing that is effective?

I was drawn to CBT because there was a clear way to assess progress and efficacy, and specific techniques that could be taught and learned, and that would reliably produce improvement.

My understanding is that there are many techniques ("common factors" if you will) that are parallel among all types of effective psychotherapy. I know psychodynamicists wouldn't use the paper-based forms but would use many verbal/interpersonal techniques similar to what I would call Reflection, Downward Arrow, What-If, Changing the Focus, etc.

My question is, *how is this taught to trainees in a systematic way within a psychodynamic framework?*

The two psychodynamically oriented supervisors I had in training seemed like they weren't teaching me anything at all. This doesn't mean they weren't effective with their patients, but whatever they were doing in their own rooms was opaque to me. I can completely understand how someone whose entire psychotherapy supervision experience was similar to those two supervision experiences I had early in my training, would emerge from their training with a Dr K. approach. What I don't understand is how effective psychodynamic psychotherapists train future effective psychodynamic psychotherapists.

 

[Shiori]

I have struggled to formulate my thoughts on why I find his appeal so unsettling and upsetting. As people have alluded to, his presentation is a often off-putting. With even a little more charisma, a person has the potential to really harm folks in the gaming community. I have seen a lot of therapists with varying levels of talent and skill on TikTok, and it gets ethically questionable quickly. The idea of some of them streaming live with a "client" and an audience makes me queasy.

I mostly play RPGs and played WoW for years (like I literally quit a couple of months ago). The ability to escape real life and embody an attractive hero for hours tends to attract some individuals with a lot going on in their day-to-day life. If someone is feeling lonely, misunderstood, and unloved, the blurry lines of this kind of pseudo-therapy sound like a disaster. Bad therapists used to transgress one client at a time. Now they can more easily do harm on a much larger scale. Ugh.

 

[smalltownpsych]

I think that's a good succinct description of the beard-stroking phenomenon.

May I ask you something, as someone with psychodynamic expertise, how do you train another individual to do whatever it is that you are doing that is effective?

I was drawn to CBT because there was a clear way to assess progress and efficacy, and specific techniques that could be taught and learned, and that would reliably produce improvement.

My understanding is that there are many techniques ("common factors" if you will) that are parallel among all types of effective psychotherapy. I know psychodynamicists wouldn't use the paper-based forms but would use many verbal/interpersonal techniques similar to what I would call Reflection, Downward Arrow, What-If, Changing the Focus, etc.

My question is, *how is this taught to trainees in a systematic way within a psychodynamic framework?*

The two psychodynamically oriented supervisors I had in training seemed like they weren't teaching me anything at all. This doesn't mean they weren't effective with their patients, but whatever they were doing in their own rooms was opaque to me. I can completely understand how someone whose entire psychotherapy supervision experience was similar to those two supervision experiences I had early in my training, would emerge from their training with a Dr K. approach. What I don't understand is how effective psychodynamic psychotherapists train future effective psychodynamic psychotherapists.

Great question. My first thought is that those supervisors might have been beard strokers. The reason it is a good question is because answering it helps separate the truly knowledgeable from the beard strokers. My answer is that I use several different frameworks that integrate and support each other. I especially emphasize the neurobiological and I also integrate DBT and CBT and direct them to the research any time they have a question. My students tend to get overwhelmed with the knowledge that I am trying to cram down their throat. Many of my students have divergent philosophies of treatment so we will examine conceptualizations and interventions from both perspectives.

I also tend to focus on a developmental and interpersonal perspective and so we will talk quite a bit about the neurobiology of attachment and self-regulating other. When I am talking about development and the interpersonal, I definitely blend in standard behavioral principles. Relationships are reinforcers and patterns develop. Examining and understanding how those patterns develop guides what the different behaviors are to break the pattern. I firmly believe in learning theory as the foundation of what I do and use those principles all day long. I don’t see them as separate from understanding things from a psychodynamic perspective.

Another aspect of the question is helping the supervisee understand what they should do. In my mind, conceptualization or case formulation is what drives the intervention. The therapist is the instrument, the choices we make as to what to attend to, what questions to ask, how we react or don’t react, how we feel emotionally and whether or not to bring that to the patient are all part of the equation. Self awareness combined with other awareness combined with knowledge of principles of development, neurobiology, and learning tells you what to do or say at any given moment. Maybe the biggest reason that I am psychodynamic is that my emphasis is on the interpersonal more so than the technique of treatment, but it doesn’t mean that I am not going to do exposure therapy with my trauma patients or use DBT with my patients who self-harm and when I have had training in it, I find that it is completely in line with what I do.

 

[smalltownpsych]

Also, I encourage both patients and supervisees to always be asking the question of what are we doing and how is it going to work. Don’t believe in retreating to some mystical black box as a deflection.

edit to add: I forgot to answer about observable and measurable outcomes of progress. I don’t use scales as much as observable or reported behaviors which could include SI, self-harm, less self-deprecating statements, dealing with interpersonal conflict, less nightmares, less observable or reported CNS arousal, better grades, getting a job, holding down a job, etc

 

[borne_before]

I have struggled to formulate my thoughts on why I find his appeal so unsettling and upsetting. As people have alluded to, his presentation is a often off-putting. With even a little more charisma, a person has the potential to really harm folks in the gaming community. I have seen a lot of therapists with varying levels of talent and skill on TikTok, and it gets ethically questionable quickly. The idea of some of them streaming live with a "client" and an audience makes me queasy.

I mostly play RPGs and played WoW for years (like I literally quit a couple of months ago). The ability to escape real life and embody an attractive hero for hours tends to attract some individuals with a lot going on in their day-to-day life. If someone is feeling lonely, misunderstood, and unloved, the blurry lines of this kind of pseudo-therapy sound like a disaster. Bad therapists used to transgress one client at a time. Now they can more easily do harm on a much larger scale. Ugh.

Does this build the case of gamers or a subset of gamers as a special population?

Personally, I think behaviorism does a wonderful job of explaining a ton of gaming behavior. You've got intermittent reinforcement, avoidance, social connection, beautiful graphics, etc., and if life isn't very reinforcing for the individual, then of course they are going to opt out.

I have reading a lot of Eli Lebowitz's work on parental accommodation in the context of anxiety and failure to launch (highly dependent adult children). A common thread is excessive gaming and internet usage. You'd be surprised how motivated people are to get a job and move out if parents cut off the internet.

I guess I do worry about gamers and very online people, as a I work with adolescents with autism and other socially challenged groups. The media already does a good job about talking about radicalization pathways through the alt right to q-anon highway and it makes a ton sense to me people who spend a ton of time online are yearning for meaning and purpose and thus more susceptible to weird online communities. This happens on the left, too. But, it's less obvious and often involved very online gender focused communities. Not lumping all gamers together, but how many shooters first escaped their lives and gamed and then went online.

Hell, I even have a brother, a very successful brother, who got radicalized online. I'm actually a little paranoid that he was targeted by Russians because of his success. He was already a contrarian, but got involved in r/the_donald and actually ended up going to the January 6th thing. He didn't go in or break any laws. But this is a dude with many millions of dollars who left a family vacation to travel there and meet up with some friends and veterans he knows. This brother has no social equals (very narcissistic) and all (or most) of his relationships are transactional.

All I'm saying is that gamers, excessive twitter users, and very online people might be best looked at as a special population.

 

[cara susanna]

Does this build the case of gamers or a subset of gamers as a special population?

Personally, I think behaviorism does a wonderful job of explaining a ton of gaming behavior. You've got intermittent reinforcement, avoidance, social connection, beautiful graphics, etc., and if life isn't very reinforcing for the individual, then of course they are going to opt out.

I have reading a lot of Eli Lebowitz's work on parental accommodation in the context of anxiety and failure to launch (highly dependent adult children). A common thread is excessive gaming and internet usage. You'd be surprised how motivated people are to get a job and move out if parents cut off the internet.

I guess I do worry about gamers and very online people, as a I work with adolescents with autism and other socially challenged groups. The media already does a good job about talking about radicalization pathways through the alt right to q-anon highway and it makes a ton sense to me people who spend a ton of time online are yearning for meaning and purpose and thus more susceptible to weird online communities. This happens on the left, too. But, it's less obvious and often involved very online gender focused communities. Not lumping all gamers together, but how many shooters first escaped their lives and gamed and then went online.

Hell, I even have a brother, a very successful brother, who got radicalized online. I'm actually a little paranoid that he was targeted by Russians because of his success. He was already a contrarian, but got involved in r/the_donald and actually ended up going to the January 6th thing. He didn't go in or break any laws. But this is a dude with many millions of dollars who left a family vacation to travel there and meet up with some friends and veterans he knows. This brother has no social equals (very narcissistic) and all (or most) of his relationships are transactional.

All I'm saying is that gamers, excessive twitter users, and very online people might be best looked at as a special population.

Special population, sure, but not one that needs their own dedicated treatments. I also would think that you could categorize the people you mentioned in other special groups (alt right or right wing extremists, incels, etc). I mean, anyone who plays video games is a gamer, despite what the online community thinks.

 

[Shiori]

I do think there are interesting factors related to an excessive online presence. Gaming has a lot of interesting cultural nuances, which I think is at least some of how Dr. K. was able to establish such a strong hold on people without a lot of skills related to psychotherapy. I have had several clients where we had several cross-matches, but I instantly received more credibility and engagement when they found out I was also a gamer. I would get the usual quiz question to make sure I was the "right kind" of gamer because it is a very gatekeep-y community. Being a match didn't make me a better clinician, but it allowed them view me as more like them. It was 0.5% of therapy, but it was enough to blow open the door. Reflecting back, my ability to play video games made a very big difference for some folks, which is worrying.