Psychotherapist https://nitter.cf/t.co/iPd5T9mEIX
Joined March 2026
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The return of my Substack articles! This week's topic addresses the types of criticisms that therapists face online and in media through the lens of object relations in an attempt to better understand where it comes from.
Shoutout to @NickTaber who I mention in the article. While I don't agree with all of his takes, I believe it's important for the field to have its critics, lest we lose perspective of what we're trying to address.
corygradlcsw.substack.com/p/…
Cory Grad retweeted
The boys will teach you more than grad school.
@DoctorPerin is a worthy TherapiX follow.
Cory Grad retweeted
You can only see so many patients before quality drops and that makes openings valuable. It’ll sometimes sound like bait to open them but limiting your caseload is a requirement to doing good work.
This is the experience of many early- to mid-career clinicians. An administrator without a clinical background is tasked with Running The Numbers. If you ask the clinician to articulate their case formulation for a client, they will seem baffled and gesture back to the measures.
One of the things left off that list in the screenshot is that it provides legitimacy for billing. The development of the PHQ-9 and GAD-7 was funded by Pfizer and led by teams of researchers that included Robert Spitzer, the man behind bringing the medical model to the DSM. They were initially intended to be used in primary care settings, since that’s where antidepressants are prescribed the most. It got rolled into therapy since it provided a nice concrete number that could be auto populated into the EHR.
It was far too naked to say that aloud, so the term “best clinical practice” gets thrown around. What it means is never defined.
Edit: I realize a certain irony in that the application of the measurement based care is actually being measured itself.
In grad school, therapists in training are told about the healing power of the therapy relationships, the importance of rapport and empathy.
Their first job is at a large organization that reduces treatment a to a series of metrics. PHQ9, GAD7, MH-QoL, along with a series of scoring systems populate a various dashboards that need to be checked regularly. Clinician success is tracked with intake to follow up conversation rate, documentation completion rate, and amount of monthly completed visits.
Emails regarding progress get sent out saying things like, "Case 244011 has had persistent PHQ9 for last several months. May be beneficial to explore distressing thoughts and strengthen coping, self-soothing, and hopefulness." Further clinical development comes in the form of self taught training modules online.
Client, clinician, and treatment have all been reduced to abstracts.
Cory Grad retweeted
Therapists are sources of iatrogenic harm. How frequently and in what ways, not well studied.
I imagine much of the harm is wasted time and money because of unethical boundaries. Others are probably overtreated and fragilized. A smaller percentage are harmed by greed or sexual misconduct.
“Therapy can sometimes create exactly the kinds of problems it’s meant to cure... Dubious theories spread among therapists and patients, then suggestion during therapy inadvertently creates false memories that confirm the theories.”
stevestewartwilliams.com/p/m…
Cory Grad retweeted
Overusing porn is bad for anyone. Porn is the Pringles of sex. Pringles are fine, but a steak is better.
Generally speaking, prioritizing sexual behavior with real people is way better for our mental health. Sex is more than physical gratification and procreation.
Sex is also: intimacy, friendship, play, exploration, revelation (of self/needs/interests), and discovery.
Cory Grad retweeted
Infanticide is common among mammals.
I don’t like it. I have chosen to be in relationships where that will never be an issue.
I don’t think we fully understand abortion and other types of infanticide behaviors in humans. Eugenics in this domain is really scary. We don’t know what we’re doing or why. But we’re excellent at rationalizing choices.
Cory Grad retweeted
When a diagnosis like autism or ADHD becomes a way to understand yourself, we have a problem.
Psychiatry was not created as a tool for self-development or self-knowledge. It applies the medical model to human behaviour and experiences and in doing so, frequently pathologises them. It categorises but it does not explain.
If you look to psychiatry to provide the answers as to why you are the way you are, you are inevitably going to be frustrated. That just isn’t what psychiatry can do.
Cory Grad retweeted
DSM has been oversold & overbought. It is not:
1)applicable to most people in general population
2)meant to be used in self diagnosis
3)a golden path toward self understanding
4)a self help manual
5)an encyclopedia of human behaviors
It is a:
1)valuable, but fallible, way to sort psychiatric symptoms
2)vehicle of clinical communication
3)necessary guide to treatment planning
4)tool for clinical & epidemiological research
I agree completrly with:
When a diagnosis like autism or ADHD becomes a way to understand yourself, we have a problem.
Psychiatry was not created as a tool for self-development or self-knowledge. It applies the medical model to human behaviour and experiences and in doing so, frequently pathologises them. It categorises but it does not explain.
If you look to psychiatry to provide the answers as to why you are the way you are, you are inevitably going to be frustrated. That just isn’t what psychiatry can do.
Cory Grad retweeted
Speak of people, even in your notes and supervision, as people. Describe the woman who cannot bear to be left, not “the borderline.” Describe the man who needs to be admired in order to feel real, not “the narcissist.” The longer phrase keeps the person in view.
Cory Grad retweeted
Thinking of leaving your clinic? Perhaps for private practice, perhaps for another city, perhaps for another modality that seems cleaner and less exhausting? Perhaps for another field altogether? I will never tell you not to go. Sometimes the change is right. Some clinics really are crushing, and some cities really are too expensive to practice in.
Cory Grad retweeted
Evidence Based is a marketing term.
Never an honest assessment of what therapy is, how it works (and does not work), and how relatively effective it is.
unavailable
Cory Grad retweeted
People do not realize how grateful they should be for society and it's rituals that afford us this amazing life. Maybe we can learn how we individually can contribute to it rather than run from it.
Cory Grad retweeted
A therapist loses a treatment in five ways:
-he overrides the patient’s capacities
-he only sides with one power in the patient’s life
-he brings in a third-party payer
-he is not present
-he leaves nothing behind in the patient between sessions
If you work in a Big Box Therapy place and you do couples and family therapy, be prepared for the following:
1. These are forms of therapy that can be intimidating, especially for an early-career clinician. They will probably shovel most of those cases onto you simply because you offer it, not because of fit. These places would rather grind the clinician into sawdust than refer out.
2. Be prepared for the therapy frame to be challenged before session one. One spouse or only part of the family may attend the intake session. If it's done over telehealth, don't be surprised if couples therapy is sprung on the other unwitting spouse. ("Honey, get in here! I booked us couples therapy!" … "What?!")
Other examples include family members trying to come in and out of family therapy because of work or other obligations (no session can happen in that case), or people trying to do couples therapy as they're driving to work in separate cars (again, therapy cannot happen in that instance).
One of the reasons this happens is that the intake process is nearly nonexistent in Big Box Therapy places. The only requirement to book a session is to provide your insurance info and a credit card number.
Cory Grad retweeted
PSA:
Generally speaking, acronym therapies are commodified products.
CBT, ACT, DBT, ERP, etc.
They are dumbed-down, shortened, enshittified and simplified versions of therapy designed to be sold for profit. The acronym itself is a result of this process.
Acronym therapies are born in academia because they're measurable. When it comes to the human mind, the more measurable something is the less its actually capturing something meaningful and truthful.
Then health insurers, large companies, etc. adopt these acronym therapies because they're easily marketable for the same reasons they're easily measurable.
Most people who've benefitted from acronym therapies are unaware they've simply received the best help from a line-up of inferior services with no high-quality service to compare it to.
TLDR, 'evidence-based' is functionally equivalent to a coffee shop that advertises 'the world's best cup of coffee'.
Cory Grad retweeted
Hey all. We had a spooktacular chat on today’s podcast.
Grateful to everyone in the chat: @angpeacock1111 @CoryGrad_LCSW @DFMagee @sfowler and others!
A bit of a rant on EHRs and EMRs.
(Full episode w/context ⬇️)
Cory Grad retweeted
Couples who protect their date nights like they would an important business meeting, and their sex life like a treasured thing, give their marriage a much better chance of staying warm, connected, and worth protecting.
Cory Grad retweeted
Every morning, before the first patient, consider that this may be your last session with each of them. This helps to stay present. Patients leave without warning. They may move, lose their insurance, get better, give up, die. Say what needs saying in a form they can use that day.