The Carlat Psychiatry Podcast

Dr. Carla Sharp is a leading expert in Mentalization-Based Treatment (MBT), developmental psychopathology, and the treatment of personality disorders. She is the John and Rebecca Moores Professor of Clinical Psychology at the University of Houston, where she serves as Associate Dean for Faculty and Research and directs the Developmental Psychopathology Lab and the Adolescent Diagnosis, Assessment, Prevention, and Treatment Center. A prolific scholar with more than 380 peer-reviewed publications and eight books, she has made substantial contributions to the development and dissemination of mentalization-based approaches and is a certified supervisor and licensed trainer in MBT for both adults and adolescents. In this episode, Dr. Sharp offers a comprehensive introduction to MBT as a treatment for BPD — from what mentalizing is and how it develops through early “serve-and-return” interactions, to how disruptions in this capacity contribute to the difficulties characteristic of BPD. She takes clinicians inside an MBT session, explaining experience-near exploration, empathic validation, affect elaboration, and the mentalizing loop. She also unpacks the three pre-mentalizing modes — psychic equivalence, teleological mode, and pretend mode — and discusses the therapist’s use of self, the importance of maintaining a curious “not-knowing” stance, and how clinicians can recognize when a patient’s capacity to mentalize is strengthening.

Learning Objectives

After completing this educational activity, participants should be able to:

• Define mentalizing and explain how disruptions in its development and functioning contribute to borderline personality disorder.
• Describe how MBT uses experience-near exploration, empathic validation, and the mentalizing loop to strengthen a patient’s capacity to reflect on the mental states of self and others.
• Identify the three pre-mentalizing modes — psychic equivalence, teleological mode, and pretend mode — and recognize when mentalizing has broken down in a clinical interaction.
• Apply the MBT mentalizing stance, including curiosity, uncertainty, and therapist use of self, to support reflective functioning in patients with borderline personality disorder.

Topics Covered in This Interview

• What mentalizing is and its role in psychological functioning
• How mentalizing develops throgh early “serve-and-return” interactions
• Mentalizing difficulties in borderline personality disorder
• Strengthening mentalizing as the core treatment target of MBT
• What an MBT session looks like in practice
• Experience-near exploration and the mentalizing loop
• Empathic validation and managing emotional arousal
• Affect elaboration and working with underlying emotional experience
• Mentalizing relationships with others and with oneself
• How patients and therapists determine the focus of an MBT session
• The three pre-mentalizing modes: psychic equivalence, teleological mode, and pretend mode
• Recognizing when mentalizing has gone offline
• The therapist’s use of self in MBT
• The mentalizing stance: curiosity, uncertainty, and “not knowing”
• Recognizing progress and the generalization of mentalizing outside therapy

Prescribing stimulants outside of ADHD is not illegal, but what Done did sent the clinical leader to jail. We look at what went wrong and what the charges were, and end with a research update that improves access to psychiatric care the honest way.

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Published On: 09/28/2026

Duration: 15 minutes, 25 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Done paid clinicians by the refill, not the visit. We trace how a telehealth company built its business model around stimulant prescriptions. Along the way you’ll learn why amphetamines are the #1 stimulant in America, but rarely used outside the US.Plus: a research update on tapering and switching sleep medication.

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Published On: 09/21/2026

Duration: 26 minutes, 00 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

This activity includes brief excerpts from interviews conducted by the faculty member with informants. The interviewees provided historical information and/or commentary as source material only. They did not participate in planning, developing, reviewing, editing, or approving the educational content of this CME activity and have no role in controlling its content. The faculty member independently selected, contextualized, and incorporated the interview excerpts into the presentation. 

A Silicon Valley founder built a telehealth company to make ADHD treatment as easy as ordering takeout, until federal prosecutors traced 37 million pills of Adderall back to the clinic. We follow Done from venture-backed startup to criminal conviction, and ask what the case means for how we diagnose and treats ADHD. Plus: a new FDA approval adds a third option to the ADHD reuptake-inhibitor family.

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Published On: 09/14/2026

Duration: 13 minutes, 34 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Today, we’re tackling a deceptively simple question that comes up all the time in clinical practice: When should we prioritize medication, when should we emphasize psychotherapy, and when can we recommend both? This question comes up especially often with patients who are new to treatment. They’ll ask, “Do I need a medication?” or “Can I just do therapy?” And while it’s tempting to answer in generalities, the evidence actually gives us much clearer guidelines, depending on the substance that the patient is using. 

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Published On: 09/07/2026

Duration: 10 minutes, 57 seconds

Noah Capurso, MD, and Suzanne Decker, PhD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Dr. Donn Posner is a leading expert in Cognitive Behavioral Therapy for Insomnia (CBT-I), founder and president of Sleepwell Consultants, and an adjunct clinical associate professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. He is co-author of Cognitive Behavioral Therapy for Insomnia: A Session-by-Session Guide, and he has trained and consulted with clinicians nationally and internationally across nearly four decades of clinical practice. 

In this second of two episodes, the conversation turns from what CBT-I is to how clinicians actually learn and deliver it. Dr. Posner reviews the available training pathways and what proficiency really requires, and explains why sleep hygiene — the advice most patients have already heard many times over — does not treat chronic insomnia, even though it has a place later in the work. He identifies the high-yield principles any clinician can apply immediately, including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping. He then examines sleep effort as a perpetuating factor and CBT-I as fundamentally a therapy of acceptance, describing how he prepares patients for a treatment that will make them feel worse before it makes them better, and how cognitive work addresses the fear and resistance that follow. He closes with what clinicians should expect from a course of treatment — typical length and spacing, responder and remitter outcomes, and the durability of gains — along with how he handles sleep medication and why guidelines place CBT-I ahead of hypnotics.

Learning Objectives

After completing this educational activity, participants should be able to:

• Explain why sleep hygiene is ineffective as a monotherapy for chronic insomnia, and describe the more limited role it plays within a full course of CBT-I.
• Identify high-yield behavioral sleep medicine principles — including a fixed morning wake time, early light exposure, and getting out of bed when not sleeping — that clinicians can apply before completing formal CBT-I training.
• Describe sleep effort as a perpetuating factor, and summarize how the cognitive and acceptance-based components of CBT-I address the dysfunctional beliefs and resistance that arise during treatment.
• Summarize the expected course and outcomes of CBT-I (including typical session number and spacing, responder and remitter outcomes, and durability of gains) and explain why guidelines position CBT-I ahead of hypnotic medication.

Topics Covered in This Interview

• Pathways to training in CBT-I and behavioral sleep medicine
• Board certification in behavioral sleep medicine
• Why sleep hygiene alone does not treat chronic insomnia: the dental hygiene analogy
• Where sleep hygiene does belong within CBT-I
• Available CBT-I training programs and online options
• How clinicians become proficient: consultation, community, and case experience
• High-yield behavioral sleep principles any clinician can apply
• Sleep regularity, fixed wake times, and morning light exposure
• Why getting out of bed is the hardest intervention for patients to accept
• Sleep effort as a perpetuating factor
• What good sleepers do — and do not do — to fall asleep
• CBT-I as a therapy of acceptance
• Preparing patients for the work: “I'm going to make you worse before I make you better”
• The cognitive component: uncovering and debunking dysfunctional beliefs
• Common patterns of resistance, and exposure as the remedy
• Typical treatment length, session spacing, and pacing
• Responders versus remitters, and what the outcome data show
• Durability of gains and the role of sleep self-efficacy
• Managing and tapering sleep medication alongside CBT-I
• Why guidelines position CBT-I ahead of hypnotic medication

Dr. Donn Posner is one of the most active educators in CBT-I. He's founder and president of Sleepwell Consultants, adjunct clinical associate professor in Psychiatry and Behavioral Sciences at Stanford, and spent twenty-five years before that as director of behavioral sleep medicine at the Sleep Disorders Center of Lifespan Hospitals.



In this first of two episodes, Dr. Posner explains that chronic insomnia is a disorder in its own right — not just a symptom of something else — driven by perpetuating factors that become the targets of treatment. He covers:

• How insomnia disorder is defined, and what a proper CBT-I assessment looks like
• The sleep diary as the clinician's version of an X-ray
• The two core behavioral components — sleep restriction (more accurately, time-in-bed restriction) and stimulus control — and the mechanisms each one targets: homeostatic sleep drive and conditioned arousal
• Why sleep can't be willed — it's never under a patient's voluntary control
• How far the protocol can flex for individual patients
• The evidence base showing CBT-I works even alongside depression, anxiety, PTSD, or chronic pain — and that those conditions don't need to be treated first

Length: 28 Minutes

How to separate adult ADHD from other causes of cognitive problems like bipolar disorder, sleep apnea, medication effects, brain injury, temperament, and malingering.

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Published On: 08/17/2026

Duration: 15 minutes, 35 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

The modern DSM began as a short list of 12 well-validated diagnoses. But the list expanded as the authors changed the goals from validity to reliability. Lost in this history is a missing page that helps separate adult ADHD from its mimics.

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Published On: 08/10/2026

Duration: 14 minutes, 39 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Nine studies have tried to find out whether ADHD can start in adulthood, we dig into the data and find some answers to the controversy.

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Published On: 08/03/2026

Duration: 13 minutes, 07 seconds

Chris Aiken, MD and Kellie Newsome, PMHNP have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.