Dr Beech 🌤

Confused About Mental Health? Start here: A Simple Guide for Complex People open.substack.com/pub/toosimplet…

“The more narcissistic version of masochistic personality dynamics, sometimes called moral masochism, applies to people who equate self-renunciation and suffering with virtue. Self-esteem is tied to deprivation and suffering: the greater the deprivation, the greater the sense of virtue. Such people hold the conviction, often unconscious, that their suffering makes them morally superior. They may self-righteously seek to demonstrate their moral superiority to others… Moral masochism is relatively prevalent in the mental health and other helping professions. These professions offer ample opportunities for self-sacrifice, for example, by attending to others’ needs at the expense of one’s own. Disavowed sadism is often revealed through intolerance, harshly critical attitudes, or outright aggression toward others who fail the moral masochist’s purity tests. Thus, moral superiority, self-righteousness, self-sacrifice, and sadistic cruelty can coexist.” —N McWilliams & J Shedler, Psychodynamic Diagnostic Manual, 3rd edition (PDM-3; 2026)

@ShaneMLantz Minneapolis setlist

To anyone who has seen Springsteen in concert- what are the albums I should dive back into before I see him live for the first time? I know and love his work already, I just want to get a good idea of what songs and albums he will likely play and focus on those. #Springsteen

I prescribe meds to 4 different groups of people…(not by design or intention, but this is how it salts out in practice.) A: probably doesn’t need meds, but really wants to try it, based on research or reports of close others B: meds might be helpful, & reasonable to try- but psychotherapy alone is appropriate, at least to begin C: strongly recommend adding meds; significant chance of symptoms worsening, and decrease in function without meds, and a good chance that meds will help D: meds are a must; chances very high of deterioration and danger without meds. Most people fall into B or C. Core symptoms of sleep problems and appetite disturbance often tilt the balance toward meds. Repeated observations over time also helpful in making this decision.

@chetbff I don’t know but this article might provide some perspective: open.substack.com/pub/toosimplet…

Anybody on SSRI’s? My therapist wants me on them badly. What’s your experience? I’ve never heard a good think said about them.

🧵 I think therapy gets devalued in these ways, by people in the field and outside it, because the skill involved is often “invisible” to the naked eye. If the average person was a fly on the wall for a portion of a therapy session with a skilled therapist, they may not “see”

This proves little. The survey is 15+ years old, things have changed a lot. Linehan’s personal experience with the system was more than a generation ago. You are confusing the “label” with the condition; if the survey had asked how many clinicians would prefer to avoid patients with unstable self-image, volatile interpersonal relationships, recurrent self-harm, the survey would have gotten very similar results without even uttering the words “BPD.” Even now, there is very little incentive to put BPD as an official diagnosis on chart in US when clinicians recognize it; most people who meet criteria don’t actually carry that chart diagnosis, but that doesn’t mean the clinicians are blind to it. There is no systematic exclusion of BPD or other personality disorders from mental health services in the US. Inpatient units do not refuse to admit BPD patients because they have BPD, community mental health agencies do not discharge patients because of diagnosis. In fact, services are strongly incentivized to diagnose them as bipolar disorder or treatment-resistant depression. Most Mood Disorders Programs are heavily DBT focused because it’s taken for granted (correctly) that a lot of patients have personality psychopathology as a comorbidity. Believe it or not, far more people are suffering from unrecognized and unaddressed character disorders than those suffering because of a label given to them, and this is obvious to most competent MH clinicians in the US.

@DrAnnieHickox @PGtzsche1 (in a strong field of competitors).

There is no serious danger of leaving depression in pregnant women untreated with antidepressants. Absolutely none. The clinical effect is far below what is clinically relevant and the drugs double suicides and have many other serious harms. It is naive to think that clinicians can weigh benefits and harms. If they did, no one would use antidepressants.

If you are truly interested in trying to make the case that “personality disorders” don’t exist or talk of PD isn’t valid, you should engage with the DSM alternative model of personality disorders (AMPD) and the psychodynamic diagnostic manual, and show us that a) dimensions of personality psychopathology do not exist, b) that it makes little sense to talk about levels of personality organization, and c) that personality dimensions do not form prototypes of personality styles as described in the PDM. Criticizing heterogeneity of BPD polythetic criteria isn’t going to cut it, not by a long shot.

“I charge > $3000 for brain scans that look interesting, but give no specific actionable info. I then give the same advice to every person re nutrition, sleep, exercise, & cognitive training (regardless of scan data) but give them a pretty picture + an illusion of specificity.”

We don’t treat an “organ.” We are more often treating the mind, not the brain. Psychiatry’s biggest mistakes comes from confusing psychological meaning and biological mechanism.

"The real danger is not that computers will begin to think like men, but that men will begin to think like computers." Sydney J. Harris, journalist, 1964

This is just absolutely smart and beautiful. @KemtrupTweets X doesn't deserve you.

@j_cshrink @DoctorPerin

@DoctorPerin Without taking a simple post too seriously, i think it would be "be judgemental, then curious", considering that our pre and unconscious judgements happen before we can be actively curious (imo!)

Skilled psychotherapy is yin and yang, head and heart, tough and tender, warm acceptance and cold reason, in continual counterbalance. Without one, there’s no connection. Without the other, there’s no change. Today’s therapy culture has lost the balance.

Please stop calling chatbots therapists. That’s lying. The therapy relationship is necessary for being a therapist. The therapy relationship requires -amongst other things- mutual, reflexive feeling, eg I feel that maybe you feel, this about me. LLMs don’t have feelings 1/

@nadeemhasanpsyd @j_cshrink 😂

@j_cshrink @DrDBeech

Simply adding the qualifying phrase "for some people" or the limiting word "sometimes" at the beginning or end of claims would probably prevent about 90% of the acrimony in the social media health space.

@JeremySFrench You had me at "asks generic questions."

@DrDBeech I think if it was, you'd have found it easy to describe how to do it. From my experience, even with a particular ability to read people, I haven't found any faster way than to attend sessions for 2-3 months before I can confidently say. "Yep. This guy's just a charlatan."

You're driving. The less skilled therapist already knows where you need to go, sits beside you in the front seat with a map & tells you where and when to turn. The highly skilled therapist sits in the back seat, curiously looking out the window: "You said you got beat up the last time you were in this neighborhood. I wonder why you're driving down this street again. We should try to understand that better."