Clinician Quotes

It’s estimated that AI could free up to 25% of clinician time across different specialties. This increased amount of time could mean less hurried encounters and more humane interactions, including more empathy from happier doctors. This is important because empathy has been shown to improve outcomes by boosting patient adherence to the prescribed treatments, increasing motivation, and reducing anxiety and stress.

Much of clinician burnout is due to spending time writing notes, placing orders, generating referrals, writing prior authorization letters, and creating patient communication. In other words, burnout is caused by physicians having to generate output! With the emergence of large language models that are used to train generative AI solutions, these use cases will be at the frontier of AI’s applications in healthcare.

The greatest clinicians who I know seem to have a sixth sense for biases. They understand, almost instinctively, when prior bits of scattered knowledge apply to their patients—but, more important, when they don’t apply to their patients.

One of the reasons I never became a clinician is because I was never convinced that life—its saving, its extension, its return—was definitively the best outcome. In order to be a good doctor, you have to think that, you have to fundamentally believe that living is superior to dying, you have to believe that the point of life is more life.

Clinicians have told me that our emotional is arrested at the age that an eating disorder takes control of our lives. After we recover, we pick up emotionally where we left off at that age.

If we could somehow end child abuse and neglect, the eight hundred pages of DSM (and the need for the easier explanations such as DSM-IV Made Easy: The Clinician's Guide to Diagnosis) would be shrunk to a pamphlet in two generations.

What’s the difference between shame and guilt? The majority of shame researchers and clinicians agree that the difference between shame and guilt is best understood as the differences between “I am bad” and “I did something bad.” Guilt = I did something bad. Shame = I am bad. Shame is about who we are, and guilt is about our behaviors.

First do no harm. -Hippocrates Second, do some good. -Anne M. Lipton, M.D., Ph.D.

Farmer liked to tell his Harvard students that to be a good clinician you must never let a patient know that you have problems too, or that you’re in a hurry.

Underlying the attack on psychotherapy, I believe, is a recognition of the potential power of any relationship of witnessing. The consulting room is a privileged space dedicated to memory. Within that space, survivors gain the freedom to know and tell their stories. Even the most private and confidential disclosure of past abuses increases the likelihood of eventual public disclosure. And public disclosure is something that perpetrators are determined to prevent. As in the case of more overtly political crimes, perpetrators will fight tenaciously to ensure that their abuses remain unseen, unacknowledged, and consigned to oblivion. The dialectic of trauma is playing itself out once again. It is worth remembering that this is not the first time in history that those who have listened closely to trauma survivors have been subject to challenge. Nor will it be the last. In the past few years, many clinicians have had to learn to deal with the same tactics of harassment and intimidation that grassroots advocates for women, children and other oppressed groups have long endured. We, the bystanders, have had to look within ourselves to find some small portion of the courage that victims of violence must muster every day. Some attacks have been downright silly; many have been quite ugly. Though frightening, these attacks are an implicit tribute to the power of the healing relationship. They remind us that creating a protected space where survivors can speak their truth is an act of liberation. They remind us that bearing witness, even within the confines of that sanctuary, is an act of solidarity. They remind us also that moral neutrality in the conflict between victim and perpetrator is not an option. Like all other bystanders, therapists are sometimes forced to take sides. Those who stand with the victim will inevitably have to face the perpetrator's unmasked fury. For many of us, there can be no greater honor. p.246 - 247 Judith Lewis Herman, M.D. February, 1997

If you submit an article to a major refereed clinical journal and it is accepted upon first submission without a single revision, let me know and I will take you to dinner the next time you are in Portland, Oregon.

When faced with choosing between attributing their pain to “being crazy” and having had abusive parents, clients will choose “crazy” most of the time. Dora, a 38-year-old, was profoundly abused by multiple family perpetrators and has grappled with cutting and eating disordered behaviors for most of her life. She poignantly echoed this dilemma in her therapy: I hate it when we talk about my family as “dysfunctional” or “abusive.” Think about what you are asking me to accept—that my parents didn't love me, care about me, or protect me. If I have to choose between "being abused" or "being sick and crazy," it's less painful to see myself as nuts than to imagine my parents as evil.

There is, however, a skill to it, a developed body of professional expertise. One may not be able to fix such problems, but one can manage them. And until I visited my hospital’s geriatrics clinic and saw the work that the clinicians there do, I did not fully grasp the nature of the expertise involved, or how important it could be for all of us.

This is why people who have experienced severe abuse and trauma often have difficulty explaining their experiences. They have a problem because clinicians, friends, and family often don’t have the concept of an immobilization defensive system in their vocabulary.

Such is the demographic paradox of a junior physician's relationship with his patients: I worry about how to extend their lives. This anxiety inevitably shortens my own.

Presence depends upon a sense of safety. The

Clinicians should be trained to identify any underlying conditions that may be associated with homelessness.

I will be the clinician of my own pathology.

The clinician, no matter how venerable, must accept the fact that experience, voluminous as it might be, cannot be employed as a sensitive indicator of scientific validity,

Somehow the disorder hooks into all kinds of fears and insecurities in many clinicians. The flamboyance of the multiple, her intelligence and ability to conceptualize the disorder, coupled with suicidal impulses of various orders of seriousness, all seem to mask for many therapists the underlying pain, dependency, and need that are very much part of the process. In many ways, a professional dealing with a multiple in crisis is in the same position as a parent dealing with a two-year-old or with an adolescent's acting-out behavior. (236)

This boy was likely to die soon, but he died yesterday - because of a doctor's arrogance, his unwillingness to seek a consult, his neglect to get a full and thorough history. Arrogance! We are clinicians, scientists. We observe time-honored procedures and analyses - that's how we are trained. And this is what happens when we subjugate that training to arrogance!

It seems both outrageous and irresponsible that so few mental health clinicians connect the epidemics of mental distress in industrial societies with the devastating impact of our suicidal destruction of our own habitat and ecocidal elimination of whole species. — Linda Buzzel and Craig Chalquist

I never had the ambition to do what clinicians call "integrate". Many clinicians think that until your mind comes into one piece, then you have not healed. But I don't care that much about what the experts say.

Clinicians and researchers have remarked that where the higher emotions are concerned, sociopaths can “know the words but not the music.” They must learn to appear emotional as you and I would learn a second language, which is to say, by observation, imitation, and practice. And just as you or I, with practice, might become fluent in another language, so an intelligent sociopath may become convincingly fluent in “conversational emotion.” In fact, this would seem to be only a mildly challenging intellectual task, quite a lot easier than learning French or Chinese. Any person who can observe human actions even superficially, or who can read novels and watch old movies, can learn to act romantic or interested or softhearted. Virtually anyone can learn to say “I love you,” or to appear smitten and say the words, “Oh my! What a cute little puppy!” But not all human beings are capable of experiencing the emotion implied by the behavior. Sociopaths never do.

As a clinician, I unapologetically believe that we must no longer identify our patients/clients with the addiction. While they may struggle with an addiction, the addiction itself is no different than any other form of medical ailment and disease.

I emphasize this because some of my colleagues, for whose academic attainments I have great respect, argue" 'You assume too much; this is not proved; this is not strictly scientific. We disagree with your neurology and your psychiatry is misleading, therefore you must be wrong.' My reply has been, with all humility: 'Yes, of course,' and I have returned to the labor ward to be greeted by happy women with their newborn babies in their arms: 'How right you are, Doctor, it is so much easier that way.' That is what really matters to the clinician. He should use the method that gives the best and safest result from all points of view until something better is discovered.

Having DID is, for many people, a very lonely thing. If this book reaches some people whose experiences resonate with mine and gives them a sense that they aren't alone, that there is hope, then I will have achieved one of my goals. A sad fact is that people with DID spend an average of almost seven years in the mental health system before being properly diagnosed and receiving the specific help they need. During that repeatedly misdiagnosed and incorrectly treated, simply because clinicians fail to recognize the symptoms. If this book provides practicing and future clinicians certain insight into DID, then I will have accomplished another goal. Clinicians, and all others whose lives are touched by DID, need to grasp the fundamentally illusive nature of memory, because memory, or the lack of it, is an integral component of this condition. Our minds are stock pots which are continuously fed ingredients from many cooks: parents, siblings, relatives, neighbors, teachers, schoolmates, strangers, acquaintances, radio, television, movies, and books. These are the fixings of learning and memory, which are stirred with a spoon that changes form over time as it is shaped by our experiences. In this incredibly amorphous neurological stew, it is impossible for all memories to be exact. But even as we accept the complex of impressionistic nature of memory, it is equally essential to recognize that people who experience persistent and intrusive memories that disrupt their sense of well-being and ability to function, have some real basis distress, regardless of the degree of clarity or feasibility of their recollections. We must understand that those who experience abuse as children, and particularly those who experience incest, almost invariably suffer from a profound sense of guilt and shame that is not meliorated merely by unearthing memories or focusing on the content of traumatic material. It is not enough to just remember. Nor is achieving a sense of wholeness and peace necessarily accomplished by either placing blame on others or by forgiving those we perceive as having wronged us. It is achieved through understanding, acceptance, and reinvention of the self.

Much of our work today has entered its own B-17 phase. Substantial parts of what software designers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone. Multiple fields, in other words, have become too much airplane for one person to fly. Yet it is far from obvious that something as simple as a checklist could be of substantial help.

The unique stigma of PTSD. The stigma of PTSD remains one of the most formidable barriers to effective care.

time meet a patient who shares a disturbing tale of multiple mistakes in his previous treatment. He has been seen by several clinicians, and

as the clinician gains maturity, he or she gradually begins to appreciate that there are staggering problems inherent in an empirical study of psychotherapy.

The key to clinical attunement is to be willing to say “I don’t know” and “tell me more.

By listening first rather than jumping in prematurely to explain or reassure in a way that missed the point, the clinician was able to get on the mother’s wavelength so they could connect on a deeper level. And having experienced being experienced, the mother will hopefully be able to extend a similar gift to her child. It’s a model for how we could all listen better.

The claim that patients can recover [from ME/CFS] as a result of CBT and GET is not justified by the data, and is highly misleading to clinicians and patients considering these treatments.

Our culture sees grief as a kind of malady: a terrifying, messy emotion that needs to be cleaned up and put behind us as soon as possible. As a result, we have outdated beliefs around how long grief should last and what it should look like. We see it as something to overcome, something to fix, rather than something to tend or support. Even our clinicians are trained to see grief as a disorder rather than a natural response to deep loss. When the professionals don’t know how to handle grief, the rest of us can hardly be expected to respond with skill and grace.

It is not unusual for subjects diagnosed with a Dissociative Disorder on the SCID-D to be surprised at having their symptoms validated by a clinician who understands the nature of their disorder.

Because of media portrayals, clinicians may believe that dissociative identity disorder presents with dramatic, florid alternate identities with obvious state transitions (switching). These florid presentations occur in only about 5% of patients with dissociative identity disorder.(20) How ever, the vast majority of these patients have subtle presentations characterized by a mixture of dissociative and PTSD symptoms embedded with other symptoms, such as post-traumatic depression, substance abuse, somatoform symptoms, eating disorders, and self-destructive and impulsive behaviors.(2,10)

Any effective treatment—effective beyond placebo that is—will generate a specific effect plus a placebo effect, provided that clinicians administer it with sufficient time, dedication, compassion and empathy.

In 2010, the psychiatrist Thomas Insel, then director of NIMH, called for the research community to redefine schizophrenia as “a collection of neurodevelopmental disorders,” not one single disease. The end of schizophrenia as a monolithic diagnosis could mean the beginning of the end of the stigma surrounding the condition. What if schizophrenia wasn’t a disease at all, but a symptom? “The metaphor I use is that years ago, clinicians used to look at ‘fever’ as one disease,” said John McGrath, an epidemiologist with Australia’s Queensland Centre for Mental Health Research and one of the world’s authorities on quantifying populations of mentally ill people. “Then they split it into different types of fevers. And then they realized it’s just a nonspecific reaction to various illnesses. Psychosis is just what the brain does when it’s not working very well.

A cesspool of past wounds has created men who have worked hard to protect themselves from revisiting emotional pain by learning not to feel. In fact, they have done such an excellent job in erecting protective walls they are not fully aware of the depth of their brokenness. But, if they believe their issue starts and ends with their addictive behaviors, they – and their clinicians – are sadly mistaken. -- "Why Men Struggle to Love

n sum, let us enter a plea for clinical clinicians who can distinguish unconscious depression from conscious despair, paranoia from adaptive wariness, and who can tell the difference between a sick man and a sick nation.

I see the quintessential task of the clinician as one of coming to know him-or herself sufficiently to be able to register the experience of the other in progressively more profound and also more useful ways. This process begins with our own discomfort at finding ourselves sitting in the chair that has somehow become designated as “the authority”: the person ostensibly in charge of something we haven’t even begun to comprehend. —MARILYN CHARLES (in press)

Instead of showing visibly distinct alternate identities, the typical DID patient presents a polysymptomatic mixture of dissociative and posttraumatic stressdisorder (PTSD) symptoms that are embedded in a matrix of ostensibly non-trauma-related symptoms (e.g., depression, panic attacks, substance abuse,somatoform symptoms, eating-disordered symptoms). The prominence of these latter, highly familiar symptoms often leads clinicians to diagnose only these comorbid conditions. When this happens, the undiagnosed DID patient may undergo a long and frequently unsuccessful treatment for these other conditions. - Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, p5

The metaphor I use is that years ago, clinicians used to look at ‘fever’ as one disease,” said John McGrath, an epidemiologist with Australia’s Queensland Centre for Mental Health Research and one of the world’s authorities on quantifying populations of mentally ill people. “Then they split it into different types of fevers. And then they realized it’s just a nonspecific reaction to various illnesses. Psychosis is just what the brain does when it’s not working very well.

It’s a moment every clinician has inhabited and, all too often, pulled back from—a threshold we fear crossing. We imagine ourselves, [...], and recognize a double bind, a new doctor’s dilemma: if we ask about [a patient's interest/personal information], we fall hopelessly behind in administrative tasks and feel more burned out. If we don’t ask about [it], we avoid the kind of intimacy that not only helps the patient, but also nourishes us and keeps us from feeling burned out.

And there is one thing that I really, really like to have company for. Watching TV. I'm not particularly needy in relationships, I actually demand a fair amount of space. But I really like to be in bed with another human being and watch TV. That's as intimate and reassuring and tender as it gets for me. I find dating exhausting and uninteresting, and I really would like to skip over the hours of conversation that you need just to get up to speed on each other's lives, and the stories I've told a million times. I just want to get to the watching TV in bed. If you're on a date with me, you can be certain that this is what I'm evaluating you for—how good is it going to be, cuddling with you in bed and watching Damages I'm also looking to see if you have clean teeth. For me, anything less than very clean teeth is fucking disgusting. Here's what I would like to do: I would like to get into bed with a DVD of Damages and have a line of men cue up at my door. I would station a dental hygienist at the front of the line who would examine the men's teeth. Upon passing inspection, she(I've never met a male hygienist, and neither have you) would send them back to my bedroom, one at time, in intervals of ten minutes, during which I would cuddle with the man and watch Damages. Leaving nothing to chance, using some sort of medical telemetry, I would have a clinician take basic readings of my heart rate and brain waves, and create a comparison chart to illustrate which candidate was the most soothing presence for me. After reviewing all the data from what will now be known in diagnostic manuals throughout the world as the Silverman-Damages-Nuzzle-Test, I will make my selection.

The apes are, after all, behind the bars of their cages, and we are not. Eager for the experiments to begin, they are also impatient for their food to be served, and they seem impatient for little else. After undergoing years of punishing trials at the hands of determined clinicians, a few have been taught the rudiments of various primitive symbol systems. Having been given the gift of language, they have nothing to say. When two simian prodigies meet, they fling their placards at each other.

In the course of therapy, we often witness clients’ capacities to report abuse stories with intellectualized, detached demeanors. And they are quick to add disclaimers that minimize their experiences such as “It wasn’t so bad,” “I probably deserved it anyway,” “I know my parents did the best they could,” “It didn’t have any negative effect on me,” or “That was a long time ago, and it can’t be relevant to my life now.” Many clients expend tremendous amounts of energy disavowing traumatic or abusive histories, believing that revisiting old feelings and thoughts will keep them stuck or are irrelevant to who they are today.

During one of these lectures, our teacher imparted a morsel of clinical wisdom. This is what he told us: “You will from time to time meet a patient who shares a disturbing tale of multiple mistakes in his previous treatment. He has been seen by several clinicians, and all failed him. The patient can lucidly describe how his therapists misunderstood him, but he has quickly perceived that you are different. You share the same feeling, are convinced that you understand him, and will be able to help.” At this point my teacher raised his voice as he said, “Do not even think of taking on this patient! Throw him out of the office! He is most likely a psychopath and you will not be able to help him.” Many years later I learned that the teacher had warned us against psychopathic charm, and the leading authority in the study of psychopathy confirmed that the teacher’s advice was sound. The analogy to the Müller-Lyer illusion is close. What we were being taught was not how to feel about that patient. Our teacher took it for granted that the sympathy we would feel for the patient would not be under our control; it would arise from System 1. Furthermore, we were not being taught to be generally suspicious of our feelings about patients. We were told that a strong attraction to a patient with a repeated history of failed treatment is a danger sign—like the fins on the parallel lines. It is an illusion—a cognitive illusion—and I (System 2) was taught how to recognize it and advised not to believe it or act on it.

I’d always wondered why there had been no mention of psychopaths in the DSM. It turned out, Spitzer told me, that there had indeed been a backstage schism—between Bob Hare and a sociologist named Lee Robins. She believed clinicians couldn’t reliably measure personality traits like empathy. She proposed dropping them from the DSM checklist and going only for overt symptoms. Bob vehemently disagreed, the DSM committee sided with Lee Robins, and Psychopathy was abandoned for Antisocial Personality Disorder.

Speaking to BBC Newsnight in 2020, Taylor was explicit. ‘If you try to set out to please or comply with someone, whether you’re a parent or a clinician, then you won’t be helping them.’ It is vital for clinicians to keep an independent perspective, he added.

In fact, they turned out to be unprecedented. In America and across the Western world, adolescents were reporting a sudden spike in gender dysphoria—the medical condition associated with the social designation “transgender.” Between 2016 and 2017 the number of gender surgeries for natal females in the U.S. quadrupled, with biological women suddenly accounting for—as we have seen—70 percent of all gender surgeries.1 In 2018, the UK reported a 4,400 percent rise over the previous decade in teenage girls seeking gender treatments.2 In Canada, Sweden, Finland, and the UK, clinicians and gender therapists began reporting a sudden and dramatic shift in the demographics of those presenting with gender dysphoria—from predominately preschool-aged boys to predominately adolescent girls.

According to the most outspoken and vituperative Skeptics, therapists specializing in recovered memory therapy operate in a neverland of fairy dust and mythic monsters. Woefully out of touch with modern research, engaging in “crude psychiatric analysis,” guilty of oversimplification, overextension, and “incestuous opinion citing,” these misguided, undertrained, and overzealous clinicians are implanting false memories in the minds of suggestible clients, making “therapeutic lifers” out of their patients and ripping families apart. This

An uncritical scientist is a contradiction in terms: if you meet one, chances are that you have encountered a charlatan. By contrast, a critical clinician is a true rarity, in my experience. If you meet one, chances are that you have found a good and responsible doctor.

Frosh (2002) has suggested that therapeutic spaces provide children and adults with the rare opportunity to articulate experiences that are otherwise excluded from the dominant symbolic order. However, since the 1990s, post-modern and post-structural theory has often been deployed in ways that attempt to ‘manage’ from; afar the perturbing disclosures of abuse and trauma that arise in therapeutic spaces (Frosh 2002). Nowhere is this clearer than in relation to organised abuse, where the testimony of girls and women has been deconstructed as symptoms of cultural hysteria (Showalter 1997) and the colonisation of women’s minds by therapeutic discourse (Hacking 1995). However, behind words and discourse, ‘a real world and real lives do exist, howsoever we interpret, construct and recycle accounts of these by a variety of symbolic means’ (Stanley 1993: 214). Summit (1994: 5) once described organised abuse as a ‘subject of smoke and mirrors’, observing the ways in which it has persistently defied conceptualisation or explanation. Explanations for serious or sadistic child sex offending have typically rested on psychiatric concepts of ‘paedophilia’ or particular psychological categories that have limited utility for the study of the cultures of sexual abuse that emerge in the families or institutions in which organised abuse takes pace. For those clinicians and researchers who take organised abuse seriously, their reliance upon individualistic rather than sociological explanations for child sexual abuse has left them unable to explain the emergence of coordinated, and often sadistic, multi—perpetrator sexual abuse in a range of contexts around the world.

Having worked as a clinician for almost 40 years, I have seen some young adults, who had the classic, clear and conspicuous signs of Asperger’s syndrome in early childhood, achieve over decades a range of social abilities and improvements in behaviour such that the diagnostic characteristics became sub-clinical; that is, the person no longer has a clinically significant impairment in social, occupational, or other important area of functioning. There may still be very subtle signs of Asperger’s syndrome, but when the diagnostic tests are re-administered, the person achieves a score below the threshold to maintain the diagnosis. There is now longitudinal research that is starting to confirm clinical experience that about 10 per cent of those who originally had an accurate diagnosis of Asperger’s syndrome in childhood no longer have sufficient impairments to justify the diagnosis (Cederlund et al. 2008; Farley et al. 2009).

This extreme treatment was among the proliferating regimens developed in response to the stunning increase in nervous disorders diagnosed around the turn of the century. Commentators and clinicians cited a number of factors related to the stresses of modern civilization: the increased speed of communication facilitated by the telegraph and railroad; the “unmelodious” clamor of city life replacing the “rhythmical” sounds of nature; and the rise of the tabloid press that exploded “local horrors” into national news. These nervous diseases became an epidemic among “the ultracompetitive businessman and the socially active woman.

With an increased need to connect, missed moments of joining can quickly turn from misunderstandings to painful withdrawal into a shame state. While this is possible for anyone, those of us with difficult early histories filled with shame may be at highest risk of feeling the pain of missed connection and amplifying our reactions.

The difficulties in diagnosing DID result primarily from lack of education among clinicians about dissociation, dissociative disorders, and the effects of psychological trauma, as well as from clinician bias. This leads to limited clinical suspicion about dissociative disorders and misconceptions about their clinical presentation. Most clinicians have been taught (or assume) that DID is a rare disorder with a florid, dramatic presentation. Although DID is a relatively common disorder, R. P. Kluft (2009) observed that “only 6% make their DID obvious on an ongoing basis” (p. 600). - Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision, p4-5

The main reason why clinicians may not diagnose personality disorders is that they think that doing so supports therapeutic pessimism. Recent research has shown this is not true; most patients get better, either with time or with treatment, that the prognosis is actually better than in many patients with severe mood and anxiety disorders.

Many clinicians told Sinha of the homophobia they witnessed: how young people appeared to be experiencing internalized homophobia and how some families would make openly homophobic comments… some parents appeared to prefer the idea that their child was transgender and straight than that they were gay, and were pushing them towards transition.

...[S]o many people look only to their bank balance for peace or to fellow human beings for models to follow. Clinicians, academicians, and politicians are often put to a test of faith. In pursuit of their goals, will their religion show or will it be hidden? Are they tied back to God or to man? I had such a test decades ago when one of my medical faculty colleagues chastised me for failing to separate my professional knowledge from my religious convictions. He demanded that I not combine the two. How could I do that? Truth is truth! It is not divisible, and any part of it cannot be set aside. Whether truth emerges from a scientific laboratory or through revelation, all truth emanates from God.

Our friend and colleague Marsha Linehan often says, “Emotions love themselves.” Feeling down tends to elicit actions that are consistent with feeling down.

Attunement requires presence but is a process of focused attention and clear perception. We

To state this more succinctly, awareness of the body’s state influences how we organize our lives. Knowing your body strengthens your mind.

When such resonance is enacted with positive regard, a deep feeling of coherence emerges with the subjective sensation of harmony. When

One last bit of bad news. We’ve been focusing on the stress-related consequences of activating the cardiovascular system too often. What about turning it off at the end of each psychological stressor? As noted earlier, your heart slows down as a result of activation of the vagus nerve by the parasympathetic nervous system. Back to the autonomic nervous system never letting you put your foot on the gas and brake at the same time—by definition, if you are turning on the sympathetic nervous system all the time, you’re chronically shutting off the parasympathetic. And this makes it harder to slow things down, even during those rare moments when you’re not feeling stressed about something. How can you diagnose a vagus nerve that’s not doing its part to calm down the cardiovascular system at the end of a stressor? A clinician could put someone through a stressor, say, run the person on a treadmill, and then monitor the speed of recovery afterward. It turns out that there is a subtler but easier way of detecting a problem. Whenever you inhale, you turn on the sympathetic nervous system slightly, minutely speeding up your heart. And when you exhale, the parasympathetic half turns on, activating your vagus nerve in order to slow things down (this is why many forms of meditation are built around extended exhalations). Therefore, the length of time between heartbeats tends to be shorter when you’re inhaling than exhaling. But what if chronic stress has blunted the ability of your parasympathetic nervous system to kick the vagus nerve into action? When you exhale, your heart won’t slow down, won’t increase the time intervals between beats. Cardiologists use sensitive monitors to measure interbeat intervals. Large amounts of variability (that is to say, short interbeat intervals during inhalation, long during exhalation) mean you have strong parasympathetic tone counteracting your sympathetic tone, a good thing. Minimal variability means a parasympathetic component that has trouble putting its foot on the brake. This is the marker of someone who not only turns on the cardiovascular stress-response too often but, by now, has trouble turning it off.

The modern world is drowning in information. We have more data than we can possibly use regarding nearly every picayune matter of society, economics, and politics. Science has contributed to this tsunami of facts and figures, but Riley's reports demonstrated that the tidal wave of minutiae is hardly unique to our time. In every age the challenge has been to move from information to knowledge. And the value of experts lies in their capacity to extract meaning from the reams of facts. Rather than being swamped by raw data, the connoisseur, craftsman, engineer, clinician, or scientist is selectively and self-consciously blind. Knowing what to ignore, recognizing what is extraneous, is the key to deriving pattern, form, and insight.

My own studies on the natural history of DID indicate only 20% of DID patients have an overt DID adaption on a chronic basis, and 14% of them deliberately disguise their manifestations of DID. Only 6% make their DID obvious on an ongoing basis. Eighty percent have windows of diagnosability when stressed or triggered by some significant event, interaction, situation or date. Therefore, 94% of DID patients show only mild or suggestive evidence of their conditions most of the time. Yet DID patients often will acknowledge that their personality systems are actively switching and/or far more active than it would appear on the surface (Loewenstein et al., 1987). R.P. Kluft (2009) A clinician's understanding of dissociation. pp 599-623.

survivors attempt to negotiate adult relationships, the psychological defenses formed in childhood become increasingly maladaptive. The survivor’s intimate relationships are driven by a desperate longing for protection and love, and simultaneously fueled by fears of abandonment and exploitation. From this place, safe and appropriate boundaries cannot be established. As a

The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. . . . What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort.

I don’t see any placebo there at all,” says Moerman. “What I do see is a clinician wearing a uniform of some sort.” Instead of focusing on fake pills, he argues, we should be looking at those trappings of medicine that make us expect to feel better—whether it’s the white coat, stethoscope, and gleaming hospital equipment of a Western physician, or the incense and incantations of a traditional healer.

Even harder to admit is how depressed I was. As the social stigma of depression disappears, the aesthetic stigma increases. It’s not just that depression has become fashionable to the point of banality. It’s the sense that we live in a reductively binary culture: you’re either healthy or you’re sick, you either function or you don’t. And if that flattening of the field of possibilities is precisely what’s depressing you, you’re inclined to resist participating in the flattening by calling yourself depressed. You decide that it’s the world that’s sick,, and that the resistance of refusing to function in such a world is healthy. You embrace what clinicians call “depressive realism.” It’s what the chorus in Oedipus Rex sings: “Alas, ye generations of men, how mere a shadow do I count your life! Where, where is the mortal who wins more of happiness than just the seeming, and, after the semblance, a falling away?” You are, after all, just protoplasm, and some day you’ll be dead. The invitation to leave your depression behind, whether through medication or therapy or effort of will, seems like an invitation to turn your back on all your dark insights into the corruption and infantilism and selfdelusion of the brave new Me World.

attachment figure—someone who provides a safe haven where the other can be deeply seen and feel safe and secure. At other times we are the expert on the mind, and perhaps on the brain and relationships too, and on the notion of health and unhealth, ease and disease. Yet our patients are also experts in their own right, deeply knowledgeable in other domains. Our patients are certainly expert in being themselves.

The thesis that DID is merely a North American phenomenon has been refuted in the past decade by research reports based on standardized assessment from diverse countries, such as from The Netherlands, Turkey, and Germany (Boon & Draijer, 1993; Gast, Rodewald, Nickel, & Emrich, 2001; S ̧ar et al, 1996). Clinicians and researchers should be careful to avoid categorizing a universal human condition as culture-bound.

In my series, five percent presented self-diagnosed. In most cases, this was not believed by the initial clinician. I had the following unnerving experience. Prior to my first multiple personality disorder case, I did not think the condition existed. I saw a young woman who claimed to have multiple personality disorder, and dismissed her claim. She never mentioned it again. Seven years later, while doing research in multiple personality disorder, I asked her to be a control subject for a new multiple personality disorder screening protocol, since I believed she was a medication-controlled paranoid schizophrenic. A protector personality rapidly took over, cursed at me for disbelieving the patient in the first place, introduced me to other personalities, resumed control, and chastized me vehemently at great length. Thereafter, she left, never to return.

I define workaholism as an obsessive-compulsive disorder that manifests itself through self-imposed demands, an inability to regulate work habits, and overindulgence in work to the exclusion of most other life activities.

As a child I had been taken to see Dr Bradshaw on countless occasions; it was in his surgery that Billy had first discovered Lego. As I was growing up, I also saw Dr Robinson, the marathon runner. Now that I was living back at home, he was again my GP. When Mother bravely told him I was undergoing treatment for MPD/DID as a result of childhood sexual abuse, he buried his head in hands and wept. Child abuse will always re-emerge, no matter how many years go by. We read of cases of people who have come forward after thirty or forty years to say they were abused as children in care homes by wardens, schoolteachers, neighbours, fathers, priests. The Catholic Church in the United States in the last decade has paid out hundreds of millions of dollars in compensation for 'acts of sodomy and depravity towards children', to quote one information-exchange web-site. Why do these ageing people make the abuse public so late in their lives? To seek attention? No, it's because deep down there is a wound they need to bring out into the clean air before it can heal. Many clinicians miss signs of abuse in children because they, as decent people, do not want to find evidence of what Dr Ross suggests is 'a sick society that has grown sicker, and the abuse of children more bizarre'. (Note: this was written in the UK many years before the revelations of Jimmy Savile's widespread abuse, which included some ritual abuse)

DO YOU HAVE OR HAVE YOU EXPERIENCED IN THE PAST SIX MONTHS . . . — PART A — ■ A feeling you’re constantly racing from one task to the next? ■ Feeling wired yet tired? ■ A struggle calming down before bedtime, or a second wind that keeps you up late? ■ Difficulty falling asleep or disrupted sleep? ■ A feeling of anxiety or nervousness—can’t stop worrying about things beyond your control? ■ A quickness to feel anger or rage—frequent screaming or yelling? ■ Memory lapses or feeling distracted, especially under duress? ■ Sugar cravings (you need “a little something” after each meal, usually of the chocolate variety)? ■ Increased abdominal circumference, greater than 35 inches (the dreaded abdominal fat, or muffin top—not bloating)? ■ Skin conditions such as eczema or thin skin (sometimes physiologically and psychologically)? ■ Bone loss (perhaps your doctor uses scarier terms, such as osteopenia or osteoporosis)? ■ High blood pressure or rapid heartbeat unrelated to those cute red shoes in the store window? ■ High blood sugar (maybe your clinician has mentioned the words prediabetes or even diabetes or insulin resistance)? Shakiness between meals, also known as blood sugar instability? ■ Indigestion, ulcers, or GERD (gastroesophageal reflux disease)? ■ More difficulty recovering from physical injury than in the past? ■ Unexplained pink to purple stretch marks on your belly or back? ■ Irregular menstrual cycles? ■ Decreased fertility?

Beginning with a genuine sense of care and interest by the focus of the other’s careful attention, resonance extends this positive interaction into a fuller dimension of the other being changed because of who we are. This is how we feel “felt,” and this is how two individuals become a “we.

Coupling the relaxation and sense of safety associated with that imagery with the sensations of the body can ground a person in the visceral reality of tranquility and clarity. It is this grounded place that can serve as a vital resource of safety and strength during the explorations ahead.

Clinicians like Anna Hutchinson and Melissa Midgen have posited that ‘there are multiple, interweaving factors bearing down on girls and young women’ that help explain why so many are experiencing gender-related distress. They say they have witnessed a ‘toxic collision of factors: a world telling these children they are “wrong”; they are not doing girlhood (or boyhood) correctly’, girls struggling with their emerging sexuality, and girls who ‘struggle in puberty because it is uncomfortable, weird and unpredictable (particularly heightened if they happen to be on the autistic spectrum)’.

You will from time to time meet a patient who shares a disturbing tale of multiple mistakes in his previous treatment. He has been seen by several clinicians, and all failed him. The patient can lucidly describe how his therapists misunderstood him, but he has quickly perceived that you are different. You share the same feeling, are convinced that you understand him, and will be able to help.” At this point my teacher raised his voice as he said, “Do not even think of taking on this patient! Throw him out of the office! He is most likely a psychopath and you will not be able to help him.

noticing not just their words but also their nonverbal patterns of energy and information flow. These signals are the familiar primarily right-hemisphere sent and received elements of eye contact, facial expression, and tone of voice, posture, gesture, and the timing and intensity of response. The

Those who were gay were told they were ‘too close’ to the work, and, according to one former senior clinician, anyone who spoke out was ‘made to feel hysterical’ in some way. ‘The more anxious and worried you became, the more it was framed that you weren’t really someone who could handle it.’ It was ‘a brilliant way to divert it away from what we’re actually doing, which was changing children’s bodies’, they say. It is not credible to explain away the concerns of so many experienced clinicians either by accusations of transphobia or allegations that they are simply not up to the task at hand.

This is what he told us: “You will from time to time meet a patient who shares a disturbing tale of multiple mistakes in his previous treatment. He has been seen by several clinicians, and all failed him. The patient can lucidly describe how his therapists misunderstood him, but he has quickly perceived that you are different. You share the same feeling, are convinced that you understand him, and will be able to help.” At this point my teacher raised his voice as he said, “Do not even think of taking on this patient! Throw him out of the office! He is most likely a psychopath and you will not be able to help him.

you come to rely, more than anything else, on first sight. You walk into the room and you think, sick or not sick. Not sick goes home as fast as possible. Sick, you watch. You draw blood, you order X rays, you give them fluids. You are careful, because a little bell went off in your head when you walked into the room and saw them.

[In a] recent PubMed and PsychAbstracts search... as we could not find a single reference for recovered memory therapy apart from those writing about its dangers. Our experience suggests that an overwhelming majority of clinicians do not assume or suggest to clients that they must have buried traumas from their past. It is also our experience that most clinicians are careful not to assume the literal veracity of reported traumatic memories, whether newly remembered or not." Cameron, C., & Heber, A. (2006). Re: Troubles in Traumatology, and Debunking Myths about Trauma and Memory/Reply: Troubles in Traumatology and Debunking Myths about Trauma and Memory. Canadian journal of psychiatry, 51(6), 402.

If for example you are diagnosed with depression, then your clinician might prescribe therapy to reduce your depression and or recommend anti-depressant medication. As we have discussed previously though, reducing the symptoms of mental illness does not seem to reduce the probability that someone will make a suicide attempt. Two treatments in particular, dialectical behavior therapy DBT and cognitive behavioral therapy for suicide prevention, CBT-SP, have demonstrated the ability to reduce the probability of suicidal behaviors in multiple studies conducted by multiple research teams. Other treatments that share many of the same characteristics and components as these treatments via attempted suicide.

Data show that the more patients actually know, the less they want of our treatments at the end of life. A study of 230 surrogate decision makers for patients on breathing machines demonstrated that the better the quality of clinician–family communication, the less life support was elected. Another study showed that people were less likely to want CPR after they learned what it actually entailed. Most people dramatically overestimate the likelihood of survival after CPR. When they learn the real numbers, they are less likely to want it by about 50 percent. In short, when people have a more robust understanding of the benefits and burdens of the treatment they are actually getting, they want less of it.

Because DID requires the presence of amnesia, DID patients are, by DSM-5 definition (American Psychiatric Association, 2013), unaware of some of their behavior in different states. Progress in treatment includes helping patients become more aware of, and in better control of, their behavior across all states. To those who have not had training in treating DID, this increased awareness may make it seem as if patients are creating new self-states, and “getting worse,” when in fact they are becoming aware of aspects of themselves for which they previously had limited or no awareness or control. Although some DID patients create new self-states in adulthood, clinicians strongly advise patients against so doing (Fine, 1989; ISSTD, 2011; Kluft, 1989).

Whatever proponents of false memory syndrome may claim and however persuasively they tell their stories and anecdotes, dissociative amnesia typically involves fragmented recall of trauma and is rather a retrieval inhibition than a forgetting (Spiegel et al., 2011). It may also involve complete loss of recall for sexual and physical abuse but most commonly, dissociative amnesia is partial, variable, and coexists with memories of trauma (Dalenberg et al., 2014). Studies addressing the accuracy of recovered abuse memories show that these memories are no less accurate than continuous memories for abuse (Scheflin & Brown, 1996). Memory is reconsolidated each time it is accessed and therefore potentially distorted (Bridge & Paller, 2012). Evidently, this does not disprove the possibility that some clinicians are too suggestive, one way or another, pushing their patients to adopt views that serve to confirm the therapist’s own perspective and beliefs.

This hall of epistemological mirrors was just one of the many challenges facing the researchers who wanted to bring LSD into the field of psychiatry and psychotherapy: psychedelic therapy could look more like shamanism or faith healing than medicine. Another challenge was the irrational exuberance that seemed to infect any researchers who got involved with LSD, an enthusiasm that might have improved the results of their experiments at the same time it fueled the skepticism of colleagues who remained psychedelic virgins. Yet a third challenge was how to fit psychedelics into the existing structures of science and psychiatry, if indeed that was possible. How do you do a controlled experiment with a psychedelic? How do you effectively blind your patients and clinicians or control for the powerful expectancy effect? When “set” and “setting” play such a big role in the patient’s experience, how can you hope to isolate a single variable or design a therapeutic application?

I am well aware that certain exercises, tasks setup by the facilitator, can practically force the group to more of a here-and-now communication or more of a feeling level. There are leaders who do these very skillfully, and with good effect at the time. However, I am enough of a scientist-clinician to make many casual follow-up inquiries, and I know that frequently the lasting result of such procedures is not nearly as satisfying as the immediate effect. At it's best it may lead to discipleship (which I happen not to like): "What a marvelous leader he is to have made me open up when I had no intention of doing it!" It can also lead to a rejection of the whole experience. "Why did I do those silly things he asked me to?" At worst, it can make the person feel that his private self has been in some way violated, and he will be careful never to expose himself to a group again. From my experience I know that if I attempt to push a group to a deeper level it is not, in the long run, going to work.

In 2013 a study published in the Journal of Patient Safety8 put the number of premature deaths associated with preventable harm at more than 400,000 per year. (Categories of avoidable harm include misdiagnosis, dispensing the wrong drugs, injuring the patient during surgery, operating on the wrong part of the body, improper transfusions, falls, burns, pressure ulcers, and postoperative complications.) Testifying to a Senate hearing in the summer of 2014, Peter J. Pronovost, MD, professor at the Johns Hopkins University School of Medicine and one of the most respected clinicians in the world, pointed out that this is the equivalent of two jumbo jets falling out of the sky every twenty-four hours. “What these numbers say is that every day, a 747, two of them are crashing. Every two months, 9/11 is occurring,” he said. “We would not tolerate that degree of preventable harm in any other forum.”9 These figures place preventable medical error in hospitals as the third biggest killer in the United States—behind only heart disease and cancer.

I have practiced psychotherapy, family therapy, and hypnotherapy for over 25 years without a single board complaint or law suit by a client. For over three years, however, a group of proponents of the false memory syndrome (FMS) hypothesis, including members, officials, and supporters of the False Memory Syndrome Foundation, Inc., have waged a multi-modal campaign of harassment and defamation directed against me, my clinical clients, my staff, my family, and others connected to me. I have neither treated these harassers or their families, nor had any professional or personal dealings with any of them; I am not related in any way to the disclosures of memories of sexual abuse in these families. Nonetheless, this group disrupts my professional and personal life and threatens to drive me out of business. In this article, I describe practicing psychotherapy under a state of siege and places the campaign against me in the context of a much broader effort in the FMS movement to denigrate, defame, and harass clinicians, lecturers, writers, and researchers identified with the abuse and trauma treatment communities….

Yet skill in the most sophisticated applications of laboratory technology and in the use of the latest therapeutic modality alone does not make a good physician. When a patient poses challenging clinical problems, an effective physician must be able to identify the crucial elements in a complex history and physical examination; order the appropriate laboratory, imaging, and diagnostic tests; and extract the key results from densely populated computer screens to determine whether to treat or to “watch.” As the number of tests increases, so does the likelihood that some incidental finding, completely unrelated to the clinical problem at hand, will be uncovered. Deciding whether a clinical clue is worth pursuing or should be dismissed as a “red herring” and weighing whether a proposed test, preventive measure, or treatment entails a greater risk than the disease itself are essential judgments that a skilled clinician must make many times each day. This combination of medical knowledge, intuition, experience, and judgment defines the art of medicine, which is as necessary to the practice of medicine as is a sound scientific base.

Psychoanalysis has suffered the accusation of being “unscientific” from its very beginnings (Schwartz, 1999). In recent years, the Berkeley literary critic Frederick Crews has renewed the assault on the talking cure in verbose, unreadable articles in the New York Review of Books (Crews, 1990), inevitably concluding, because nothing else really persuades, that psychoanalysis fails because it is unscientific. The chorus was joined by philosopher of science, Adolf Grunbaum (1985), who played both ends against the middle: to the philosophers he professed specialist knowledge of psychoanalysis; to the psychoanalysts he professed specialist knowledge of science, particularly physics. Neither was true (Schwartz, 1995a,b, 1996a,b, 2000). The problem that mental health clinicians always face is that we deal with human subjectivity in a culture that is deeply invested in denying the importance of human subjectivity. Freud’s great invention of the analytic hour allows us to explore, with our clients, their inner worlds. Can such a subjective instrument be trusted? Not by very many. It is so dangerously close to women’s intuition. Socalled objectivity is the name of the game in our culture. Nevertheless, 100 years of clinical practice have shown psychoanalysis and psychotherapy not only to be effective, but to yield real understandings of the dynamics of human relationships, particularly the reality of transference–countertransference re-enactments now reformulated by our neuroscientists as right brain to right brain communication (Schore, 1999).

Should you operate upon your clients as objects, you risk reducing them to less than human. Following the culture of appropriation and mastery your clients become a kind of extension of yourself, of your ego. In the appropriation and objectification mode, your clients’ well-being and success in treatment reflect well upon you. You “did” something to them, you made them well. You acted upon them and can take the credit for successful therapy or treatment. Conversely, if your clients flounder or regress, that reflects poorly on you. On this side of things the culture of appropriation and mastery says that you are not doing enough. You are not exerting enough influence, technique or therapeutic force. What anxiety this can breed for some clinicians! DBT offers a framework and tools for a treatment that allows clients to retain their full humanity. Through the practice of mindfulness, you can learn to cultivate a fuller presence to the moments of your life, and even with your clients and your work with them. This presence potentiates an encounter between two irreducible human beings, meeting professionally, of course, and meeting humanly. The dialectical framework, which embraces contradictions and gives you a way of seeing that life is pregnant with creative tensions, allows for your discovery of your limits and possibilities, gives you a way of seeing the dynamic nature of reality that is anything but sitting still; shows you that your identity grows from relationship with others, including those you help, that you are an irreducible human being encountering other irreducible human beings who exert influence upon you, even as you exert your own upon them. Even without clinical contrivance.

As the result of some observations I have made in recent years, I propose to add two new and previously undescribed varieties to the various forms of insanity with fixed ideas, whose underlying phenomenology is essentially phobic. The two new terms I would like to put forth, following the nomenclature currently accepted by leading clinicians, are dysmorphophobia and taphephobia. The first condition consists of the sudden appearance and fixation in the consciousness of the idea of one’s own deformity; the individual fears that he has become deformed (dysmorphos) or might become deformed, and experiences at this thought a feeling of an inexpressible disaster… The ideas of being ugly are not, in themselves, morbid; in fact, they occur to many people in perfect mental health, awakening however only the emotions normally felt when this possibility is contemplated. But, when one of these ideas occupies someone’s attention repeatedly on the same day, and aggressively and persistently returns to monopolise his attention, refusing to remit by any conscious effort; and when in particular the emotion accompanying it becomes one of fear, distress, anxiety, and anguish, compelling the individual to modify his behaviour and to act in a pre-determined and fixed way, then the psychological phenomena has gone beyond the bounds of normal, and may validly be considered to have entered the realm of psychopathology. The dysmorphophobic, indeed, is a veritably unhappy individual, who in the midst of his daily affairs, in conversations, while reading, at table, in fact anywhere and at any hour of the day, is suddenly overcome by the fear of some deformity that might have developed in his body without his noticing it. He fears having or developing a compressed, flattened forehead, a ridiculous nose, crooked legs, etc., so that he constantly peers in the mirror, feels his forehead, measures the length of his nose, examines the tiniest defects in his skin, or measures the proportions of his trunk and the straightness of his limbs, and only after a certain period of time, having convinced himself that this has not happened, is able to free himself from the state of pain and anguish the attack put him in. But should no mirror be at hand, or should he be prevented from quieting his doubts in some way or other with rituals or movements of the most outlandish kinds, the way a rhypophobic who cannot get water to wash himself might, the attack does not end very quickly, but may reach a very painful intensity, even to the point of weeping and desperation.