HealthyGamerGG - Does Your Therapist Know If You're The Villain?

Episode Date: July 8, 2026

In this episode, Dr. K explores the hidden complexities of trauma, narcissism, and reality testing. He answers the highly requested question of whether therapists know when their patients are the "villain," breaks down the neurobiology behind the modern fentanyl crisis, and offers a profound look at how childhood abuse shatters identity to create disorganized attachment. What to expect in this episode: The Villain in Therapy: An exploration of whether therapists can tell when a patient (such as a covert narcissist) is actually the problem, and why utilizing supportive psychotherapy is sometimes necessary to bypass the "narcissistic defense" so the patient can eventually take accountability. Therapy-Speak Weaponization: How the modern democratization of mental health language (like "I'm entitled to my feelings") is frequently weaponized by people with personality disorders to justify inappropriate emotional reactions and mistreat others. The Power of Reassurance: Why providing constant reassurance is the neurological key to healing conditions like BPD and PTSD, acting as a "corrective emotional experience" that teaches the nervous system it is finally safe. Autism and "Invisible" Trauma: A look at research showing how non-traditional events—like the diagnostic process, severe bullying, or even vomiting—can cause severe PTSD in individuals on the autism spectrum because they lack the innate social scripts to buffer the experience. The "Fentanyl Fold": A clinical breakdown of the tragic Philadelphia zombie-drug crisis, explaining the pharmacology of Fentanyl and Xylazine ("tranq") and why this specific combination causes floppy abdominal muscles alongside rigid limbs and severe skin ulcers. Compassion vs. Behavior: Why having deep compassion for someone struggling with addiction or poverty does not mean you have to compromise your physical boundaries or enable their toxic behaviors. CPTSD and the Fractured Self: How chronic childhood abuse disrupts the formation of a cohesive identity, leaving a person with multiple, intensely contradictory self-narratives (e.g., "I am lazy" vs. "My extreme effort never works"). Disorganized Attachment: Understanding the two extremes of this attachment style: the "Oscillating" type (bouncing between intense anxiety and hostile avoidance) and the "Impoverished" type (walling off inner vitality to protect against a chaotic world). The Collapse of Cause and Effect: Why crying out for help as a child and receiving no response leads to profound "despair," an energy-conservation state where the brain unlearns the physics of effort and reward. Repairing the Attachment System: Practical steps for healing a broken relational system by explicitly mapping out your triggers across the four core components of connection: Attention, Expectation, Affect, and Behavior. Dr. K's NEW Guide to Love, Sex, & Relationships is here! Order now: https://bit.ly/4dO3x0VHG Coaching : https://bit.ly/46bIkdo Dr. K's Guide to Mental Health: https://bit.ly/44z3SztHG Memberships : https://bit.ly/3TNoMVf Products & Services : https://bit.ly/44kz7x0 HealthyGamer.GG: https://bit.ly/3ZOopgQ Learn more about your ad choices. Visit megaphone.fm/adchoices

Hey, chat, welcome to the Healthy Gamer Gigi podcast. I'm Dr. Al-Ocunoja, but you can call me Dr. K. I'm a psychiatrist, gamer, and co-founder of Healthy Gamer. On this podcast, we explore mental health and life in the digital age, breaking down big ideas to help you better understand yourself and the world around you. So let's dive right in. Welcome to another Healthy Gamer Gigi stream. My name is Dr. Aalok Kanoja.

Just a reminder that although I'm a psychiatrist, nothing we discuss on stream today is intended to be taken as medical advice. everything is for educational or entertainment purposes only. If you all have a medical concern or question, please go see a licensed professional. So, oh, nope, that's not what I want. Let's find chat. Okay. Yeah, one of my lights died.

And then it's like, it's way too dark without it. And even then it's a little bit dark with it, but that's okay. Uh, let's see. Okay, so, a couple of announcements. Um, let me see if I have all this. Okay, this is fine. This is fine. I know we've got a couple of things.

Where is my chat box chat? Hello, welcome to your first stream. Hey, sorry about that, guys. I was so, I was like ready to go. We went live at like, we went live on time today, you know? Yeah, this is so dark. Hold on, let me see if I can fix it. That works.

And then I'm going to adjust one other thing. Okay, chat, y'all let me know. The other one doesn't turn, so we're not going to mess with that. We're just going to go, we're going to go dark mode today, chat. Yeah, so welcome to another healthy gamer Gigi stream. Let's just get into it. So give you your depression back. FX3 loves low light.

Okay, great. So I don't know if you guys. saw, so we're going to be like covering a couple of posts today. But I don't know if you guys saw we, you know, launched a new series, which was one of the goals for our LSR launch. Let me just pull this up. So we have the LSR launch, Dr. K's Guide to Love Sex and Relationships. And since we were able to, since you guys were so kind to support us, right? So we sold about 8,000 copies of the guide.

You guys bought it. Thank you very much. The guide has the highest engagement of any guide that we've had. But we were able to do a couple of things. So we launched a new series called Love Maxing, which is like talking to people about dating. And I don't know if you guys saw this post or not, but someone was like, I'm not sure how I feel about the current state of Healthy gamer. He was interviewing my favorite streamers. I'm not sure I would have found his content with a lecture style format and less interaction.

That being said, over the last few months, I've gotten back and watched a lot of old interviews with creators. And I've come to the conclusion that they are superior to the content in their content and their ability to tackle my life. You know, anyway, so like people are like sort of missing interviews. And then it's interesting. I don't know if you guys saw this, but I think Gruthy down here actually posted. And so this was 14 days ago, and people were like, hey, I missed the interviews. So we did love maxing. So today, if you guys, if you all have seen the series, we did a series of three interviews about dating.

So if you guys liked that, like, let's chat about it. So today we're answering some questions about it. And then the other thing is, you know, a lot of people are asking, You know, should we do, Loll, I don't watch the interviews at all. Yeah, so that's the challenging thing, right? Some people are like, yeah, the interviews are the best. They should interview more.

And other people are like, yeah, I don't watch interviews. Yeah, and then some people, so Pampelmoose LaCroix is saying, interviews are really good. Following the conversation, oddly feels more personal. I love the lectures, though. So, yeah, so what do you? I mean, y'all tell us, right? So do you all have any interviews are the best?

I'm more into the educational content. And people are saying, you know, this is, I like the variety. Hello, Estelle. Okay. Not a big lecture fan. Yeah, so people are saying two greater than one, greater than three. Yeah, I think the point of doing multiple interviews is to get different, because not everybody's situation is the same. Yeah, so people are saying someone saying,

you know, Ogle Canton gal is saying, you know, less inquisitive. Yeah, I think, I think that depends on the person. So do you all have questions about love maxing? So just as a heads up, we've also got some other stuff too. Okay. Okay. Hold us. Do the reason? Can you interview yourself in front of the mirror? I don't know. You guys can check out the tram rant interview. Those are great. Will there be more?

Do I know that you're the villain? Would you do more if people want? So I want to just give you all a quick. We've got a couple of other things, okay, coming down the pipeline. So this is, this is not related to dating. So we've got, and then I don't know if you guys recognize the same. guy. Right?

So we've got more interviews coming down. We've got more of the style of content. So I miss it too. Oh, we're lagging again. Yeah, I miss it too, chat. TBH. So I love doing interviews. They got complicated for a couple of reasons, but

we can talk about that one day if you all want. But do I have individual clients' patients? Yes. Saw the one versus 20. Yeah, dude, the one versus 20. So here's the thing. A lot of people were like, man, they like cut people off. I don't think you guys understand.

Jubilee gave us so much time. So they're usually like really specific about when the buzzer hits they go. They gave us on average. So like, you know, people will have like 15 minutes per claim. They would give me 20 to 30 minutes per person. They normally have 15 minutes per claim. So it's a total of four claims at 15 minutes each. They gave us three times as much.

They let people talk for twice as long, three times as long as they usually do. And then you still have to cut it off at some point. Was it draining? Absolutely. Incredibly. Ah. Okay. Yeah, Jubilee people were saying, it seems like people like, I like the Jubilee thing too.

I think, you know, Jubilee, like I got to give them mad problems. for understanding they have a platform and like really trying to use that platform for something good. Okay. Yeah, I thought Jubilee was great. We have some content on schizophrenia coming out a little bit. I'm scripting something on that. Yeah, the Raj interview is good.

You guys recognize Raj. Okay. Okay, so you guys want to see some stuff about spirituality. I created a thread on some form about your content and you got a lot of hate. I don't know. I think the internet is a polarizing place. Hey, wonderful, human, you're helping so many of us just a small thank you. You're very welcome, user.

Okay, I saw this interesting. I think maybe we should get to it. Hold, I want to show you guys something because someone posted a question. So there's something about a COVID. Norseist. Yeah, so Dr. Kay broke up with my girlfriend who is a typical covert narcissist, extremely manipulative and emotionally abusive. I still hope she can change and be happy, but is it possible she won't ever admit it?

So this actually, this question segue is really good to something I want to talk about today. The most selfish person you know is at therapy being told they're allowed to be selfish sometimes. Somewhere out there, the worst person you know is being fed an Instagram graphic on their algorithm telling them it's okay to put themselves first. Right? So do therapists know when their patient is actually the villain? One of the most toxic people I know has been seeing the same therapist for about five years with no change in their behavior slash life, mind you. And I just have to wonder if this therapist secretly knows that her client is actually the problem. The person I know M is just truly awful to everyone around her,

but she's constantly raving about her therapist and how her therapist tells her that everyone else is the villain in her story, that her mom is a narcissist, her sister is a sociopath. I've never heard of a therapist casually diagnosing family members with personality disorders. Does this therapist likely know that M is actually the villain? So this is a really great question, right? So if you're a therapist, do you know when your partner, I mean, if you're a therapist, do you know when your patient could be the villain? It's kind of an interesting question, right?

Like, do we know? And this is where I would say a couple of things. The first is that I think it's like super scary, but I have had so many patients who have people in their life who are in therapy for years. And it appears that from my lens of working with my patient, that the person in their life is basically not, that their therapist is missing this person's personality disorder. And it's shocking, like I would say the most common example of this is I will be working with someone who is dating someone who has borderline personality disorder.

and that person is in therapy. But the therapist seems to think that they have severe anxiety. Bipolar disorder is a very common misdiagnosis of borderline personality disorder. And so it seems like they just are working with them for years and like nothing is getting better. Now, is that actually what's going on? Like, I don't know, right? Because the problem with that is in my shoes is my patient is in a relationship with someone with BPD. they have a therapist, and I'm like, oh my God, the therapist is misdiagnosing them.

But maybe it's my patient who is narcissistic or borderline or whatever and represents this other person in a bad light. So I'm going to go ahead and say that as a therapist, I believe that there are many therapists who misdiagnose their patients. Like they're not misdiagin, they misdiagnoses in their patients. Now, the other scary thing is that when I say therapy, do this, do I do this, almost certainly, right? So there's like no reason to think that I am impervious to what my colleagues may experience as well. But I think that there's, what I can say is that when I work with people, I oftentimes find personality problems. Like I see a lot of narcissism. I see a lot of sociopathy. I see a lot of borderline characteristics. And there are certain.

certain signs. So like if you, I mean, this is maybe me being arrogant here, but it's not just me. I think I was taught by many therapists to detect people who are narcissistic. Right. So one key thing that I've learned is that if I have a patient who is surrounded by people who are problematic, this person mistreats me, this person mistreats me, this person mistreats me, this person mistreats me. The patient is somehow responsible for that. Now, I want to to be clear about this because it doesn't necessarily mean that the patient is personality disorder. Okay, this person is abusive, this person is abusive. The key thing there is that it could be that my patient is narcissistic and thinks that everybody is abusive, or it could be

that this, my patient has certain relationship patterns where they enter into relationships with people who regularly abuse them. That when someone treats them kindly, they actually freak out, they don't know what's going on. They're waiting for the other shoe to drop and they run away from the good relationships in their life. So one of the key things that I sort of think about as a therapist is how is my patient responsible for their situation in life? Even when if it's someone who's like, let's say I have a patient who says, this person is taking advantage of me. In a weird way, I still kind of blame the patient in the sense that, okay, you are doing something that allows them to take advantage of you.

So I think very heavily from a lens of what is my patient's role in responsibility in their life. And even if other people are bad to you, you may be able to do something that can change that. Because ultimately, we can't control them, right? So the field that we play on is like what the two of us can figure out and how my patient can actually change. So that's what I come.

kind of focus on. The interesting thing is I do have a lot of patients that I think are, you know, have features of sociopathy, narcissism, BPD. And I see those things. I can see and like I'll give you guys a couple of examples of what this looks like. So number one is if I have a patient who has a very strong external locus of control, this is a big problem. So what is external locus of control. When I have a patient who comes in who says, the things in my life happen because things outside of me control my life. So that's an external locus of control. Where is the center of control in your life? Is it your society is this way? Your boss is this way. Your parents are this way. Your wife is this way. Your husband is this way. Where is the power in the relationship?

And now sometimes that can be narcissism, but it's not always. So that's kind of what I think about. Does the patient feel empowered? Or are they just a victim to everything going on around them? And then the second thing is, even if they sort of play the victim, I think this is a really important point to understand. A lot of people think that therapy is about talking about your feelings. So you come in and you talk about, oh, this person did this and this person did this, and I feel this way and I feel this way. And there are forms of psychotherapy that are like that. So something called supportive psychotherapy is an example of psychotherapy that's just supportive.

So patient comes in every week. You just try to do your best to support them. Now, sometimes this is what people need. Like if their life is genuinely falling apart and they have nowhere to turn to, they just need one place to go for one hour a week where they just vent everything out where we're not working on what's your responsibility. We're not working on what to change. They're just carrying so much weight that they need to unworked.

burden at some. They need to vent some. Then supportive psychotherapy is fine. The other thing is if you look at, you know, patients with a history of something like Down syndrome or patients who have lower IQ, supportive psychotherapy is one of the most effective forms of psychotherapy for those people. That doesn't mean that if it's effective for you, that means you have low IQ, but there are certain populations where supportive psychotherapy is very effective. But for me, when I work with people, people in their emotions, the goal is to decompress the emotion so that the emotion no longer clouds your thinking. And then you should be able to see the situation, right? So yeah, this person, you got, get this person a gift and they never give you a gift and that hurts. You feel angry,

you feel frustrated, so be it. Right? Let's get those emotions out. But then what? So what comes next? Now that we understand that you feel taken advantage of, and sure you're entitled to your feelings, but then what? What are we going to do about it? Are you going to, what, you know, what comes next? And there are some therapists who don't push for that. And this is the really tricky thing. So it's easy for me to say, hey, I don't think that that is effective, but that's wrong. See, this is important to understand.

I suck at that. I'm pretty bad at supportive psychotherapy. So one of the key things about being a therapist is you have to understand that just because you're not good at a modality doesn't mean that the modality isn't effective. Right? So it could be that, oh, it's like sushi is disgusting because I don't know how to make good sushi. So it's very possible that other psychotherapists are being supportive with their narcissistic clients and they are making progress.

So I had a brilliant supervisor who once told me, you know, it was after three years that we made a breakthrough. And my reaction was, what the hell were you doing for the verse two and a half? Why does it take three years to make a breakthrough? Because there's this presumption in especially fields like psychoanalysis and psychodynamic therapy that like therapy is kind of like a long-term, intense, slow, fertilized, growing kind of process. And I'm not saying that it isn't, but I have to wonder, like, from almost like a randomized controlled trial standpoint, out of those three years of therapy, like how much of that is really necessary. And there are therapists who are far more experienced than me, arguably far more clinically superior. I don't know, because I've never compared my outcomes to their outcomes, who will say, yeah, like, this is the way that it has to be done.

I'll be the first to admit that maybe this is the arrogance of having a little bit of information. okay but when it comes down to it i think that most of us know when our patient is the villain i think most of us can tell because there are conspicuous things that are absent from their stories right oh this person cut me off like this person blocked me this person complains about me this person um you know my boss doesn't recognize my credit or people at work or are ostracized me, I'm being bullied. And then if we tunnel down into it, is there something missing from that story? So what I really look for is like a sense of like do things stitch together in a way that is,

that makes sense. And one of the trickiest things is, you know, everyone says nowadays that people are entitled to their feelings. Like you're entitled to feel that way. This is where I got to respectfully disagree a little bit. I think some of the emotional reactions that we have, especially with narcissistic patients, are inappropriate to the circumstance. Like, I know this is wild, but this is a key, you know, teaching from Buddhism. So in Western psychology, we have this attitude that all feelings are healthy, all feelings are good.

You know, and this is like a good neuroscience evolutionary argument. Our brain has the capacity for anxiety. our brain has the capacity for shame and guilt. These are important, evolutionarily selected emotions. But if you look at sort of the Buddhist perspective, some of them are good and some of them are bad. Compassion and appreciation are superior to envy and jealousy, are flat out better than envy and jealousy.

And that ideally, it is not good to feel envy or jealousy ever. We want to get rid of that completely. Now, where I kind of settle is that in many of my patients, what I find is that they have what I would call inappropriate emotional reactions to situations. Now, this isn't their fault because they have a template where this emotion is activating, but they're actually like, that's not the right thing to feel. Right. So in a sense, like, we can't blame you for it, but I think something is really scary where a lot of the language that we're using around sort of the democratization of mental health, where like now everyone's being emotionally supportive and mental health aware and things like that. Like I think that's generally a good trend.

But I think it's really scary because you have this subpopulation of people who have become incredibly predatory, like the narcissists, who are now weaponizing the language of therapy to continue to traumatize other people. I'm entitled to my feelings. Well, like, sort of. Right? So like, yeah, I understand that you feel that way. but is that an appropriate feeling? Oh, this person lost weight and came to my wedding. How dare they?

I feel attacked. They're doing it to make me look bad. And that emotional reaction you're having that emotional reaction isn't an appropriate emotional reaction. If you feel bad, does that mean that someone is trying to hurt you? So one of the key things that I look for when it comes to like, is my patient the villain is something called theory of mind. So what we see in people who are narcissistic is the way that they feel projects out onto the people around them.

So if my friend lost weight and now I feel ashamed of myself, I feel hurt, I feel like, oh my God, my friend was able to do it, I used to be the attractive one, now they've become the attractive one. Over the last 10 years, I've let myself go, whereas they've, have really taken care of themselves. And that shines a light on my own failures and their successes. But then what I will do, what people who are narcissists, this is what I pay attention for is, do they attribute their hurt to the other person?

This person lost weight to make me look bad. That's the nature of narcissism. Everything that happens around me is pointed at me. Right? And then I'll ask a couple of questions. I'll be like, oh, so, you know, this person really tried to put you down. What did that look like? What did they say?

So I'll be inquisitive. Because I think this is the really important thing to remember. I like working with Cluster B patients a lot. My job is to help them be less narcissistic. Because narcissism causes an immense amount of suffering. in their life, screws up their relationships, screws up their mood, leads to as a high risk factor for substance use. So my job, like my goal is to help this person become less narcissistic,

to help them realize that the world is not all pointed at them, that they take things too personally. And so I'm on the lookout for those kinds of features, because if I miss that, then I'm doing my patient a huge disservice. And then we do the slow work. of sort of helping them understand, right? And like, that's what the work is. Do we know that our patient is the villain?

Oftentimes, yes. And then it's like, okay, let's understand what other motivations could this person have. How do you feel about their choices versus your choices? Because that's where the money is. This person did this to make me look bad. That's not helpful. Because what's the action then?

Are we going to cut this person out of their life? life, and then someone else shows up and makes you look bad, and then we're going to cut that person out of their life. And this is what happens with people who are narcissistic. They leave a trail of burned bridges behind them. And as a psychiatrist, like, my goal is to try to prevent that, unless that's what they really want to do. If they're acting with full awareness and they want to burn bridges right, left, and center,

like, that's their choice. My goal is to give them the choice. And then as we examine, okay, what does it feel like? when someone shows up and has really gotten their life together and you've let your life slide away, what does that feel like? What's the emotion there? How do you feel about yourself? Right? And this is literally the deficit in Cluster B personality disorders is a failure of mentalization. They're not able to separate out if I feel bad. Someone did it to me. No, I can feel bad and this person can be a completely independent, entity.

And it is literally in the failure of that understanding. Oh, and I hear this so much from like parents who have been cut off suddenly by their kids. With no warning, it came out of nowhere. My daughter blocked me and it came out of nowhere. And that's

what their experience is because their brain is not registering that when this person, a really good example of this is when someone complains to you, about something that you do, a narcissist does one really interesting thing.

If they don't agree with your complaint, they don't accept your complaint. They frequently think that people who complain towards them, hey, I think you're doing something wrong. They say, no, I am not. If they don't agree with it, if it doesn't make sense to them, the other person is wrong.

This is the key thing about narcissism. When you're narcissistic, if you don't understand something, that means it doesn't exist. Whereas someone who is capable of mentalizing spins around and tries to, okay, that's confusing to me why you would be upset about what I'm doing. Can you help me understand? Like, I'm lost. I don't see it, but that doesn't mean it doesn't exist.

So for a narcissist, if they don't understand it, that means it doesn't exist. Whereas if a non-narcicist gets some kind of feedback, it's not that it doesn't exist. it's that I have a blind spot. That's why I don't see it. There's a differential diagnosis for the things that I don't see, either that I don't understand. Either they don't exist or I have a blind spot. And so these are the kinds of things that we pick up on.

I want to say that most psychiatrists and therapists pick up on this stuff. But the tricky thing is I could have all kinds of patients that, you know, maybe I'm missing diagnoses on and I don't realize. And that's what's really hard about psychiatry is like, We don't always know. Make sense? But I think we know. Right.

So narcissists don't believe that they have blind spots. So this is really important to understand. They don't have a theoretical framework in their head for their lack of knowledge. It happens so fast. It's a failure of something called mentalization. I switch between a narcissist and a normal person. Yes. That is actually the most common.

Remember, there's something called the narcissistic defense. And the narcissistic defense can activate within all of us. People who have narcissistic personality disorder will employ that defense very often. How do you justify helping them not burn bridges when it oftentimes is utilized by narcissists to hurt others, even if unknowingly? Great question. So, if the bridge is... What do you think is the, so someone's asking like, hey, if you're like helping these people not burn bridges, they use those bridges to hurt people. So therefore, by maintaining the bridge, you are helping narcissists hurt the people around them.

Fair point. But let's be a little bit clear. In order for the bridge to be burnt, what happens? What has to happen? What do you all think? Oh, this is a good. Very good. Right? So somebody gets hurt. That's what causes the bridge burning. So the only way, not the only way, the best way, and the kind of way that we try to approach this, or I try to approach this, is if the bridge isn't being burnt and burnt, that means the other person is probably not getting hurt as much as they would have.

So maintaining the bridge comes hand in hand with stopping to hurt other people. How do we keep that bridge instead of burning it? we examine things in therapy so that the narcissist has a better understanding in a way, and we talk in a way that's emotionally validating, so it doesn't activate the narcissistic defense. We need to disable the narcissistic defense so that the person can look at their own problems and admit them. Right. So we have to be able to see problems without being hurt by them. And the reason that a psychiatrist is good at this is because we are professionally trained to help people. people walk that line to where it doesn't trigger the narcissistic defense. Whereas if you try to do it and you're like, hey, you did this thing, this thing is wrong.

Boom, narcissistic defense activates. That's where the emotional validation comes in. Right. So it's like, yeah, I can understand why you would feel that way. Right. It sounds like these people really are discriminating against you, ostracizing you, bullying you, cutting you out. How do you understand that? And then they'll say something like, that's, just the way the world is. Well, that's interesting. So this person that is ostracizing you, bullying you, whatever, your sister who's now cut you off, do you think that's the way the world is for her? Is everyone or a one around her bullying her? Austricizing her? No.

Oh, interesting. How do you understand that? Well, she's really good at manipulating people. Interesting. What does she do to manipulate people? herself look good. Now we're role-playing therapy with myself. And she makes, she makes herself look good and she makes the people around her look bad. So everybody wants to be her friend because she looks so good. She pretends like she has it all together. Interesting. And now there's a really good question. Will a narcissist ask questions about something that doesn't make sense to them? Absolutely not. That's why I do the question asking. How do you understand why your sister has friends? like, what's up with that? What are your cousins think?

Right? And is it a possibility that there's something else going on? Now we have to sort of like slow play it, right? So this takes a little bit of time where they're like, oh, the sister is manipulative. Right? They have an answer right away. But even then you've planted the seed. And then it's slowly like, okay, what does your sister do?

And sometimes it's like, well, why don't you have a conversation with your parents about what they think? think about it. You know, and then slowly, as long as the narcissistic defense, this is what's challenging, as long as the narcissistic defense is calmed, then these people can really make a lot of progress. But the moment that you trigger it by blaming them, by them protecting themselves from their shame, by them dealing with, so here's the real challenge of narcissism is that they know they screw up. But that thought is so devastating to them that they can't face it. So a big part of that is being able to diffuse that weight, carry it with them, to help them realize, okay, this is my fault. And that's okay.

Because the problem with a narcissist, and they have difficulty mentalizing, right? So they literally can't see, like, imagine what it's like to be in someone else's head. Imagine that for a moment. It's like trying to navigate relationships if you, like, if you're blind. Like, it's like navigating the world if you can't see. literally lack this capability. And so now the problem is if you say, okay, this is your fault. They're like, I don't have the tools to fix this. And people work really hard to avoid diagnosing problems that feel unfixable. There's no point in diagnosing a problem that has

no treatment. So another big part of this is equipping them with the tools. And then saying, okay, just because you haven't been able to fix it doesn't mean that you will be incapable for the rest of your life. The question is, do you want to give this a shot? Dr. Mario Master, thanks for the raid. Okay. What's the difference between it being okay and not okay? I don't understand what that means. I don't understand the question. So start RAS can, is mentalization explicitly a part of DBT, not so much. It's implicitly a part of DBT. Maybe it's explicitly, I don't know.

But I think MBT is a different modality. DBT is like Marshall Linnehan's baby. MBT, I think, is Fonagy's baby. But I may be misattributing it, for which I apologize. Cognitive flexibility is one of the skill. It's not the same. Cognitive flex, well, they overlap some. Mentalization is understanding that

any given thing is influenced by thoughts, emotions, even behaviors. That the reason that people do things are like complex. That what the result is, what's on the right side of the equation, is influenced by all these variables on the left side of the equation. That's what mentalization is. It's understanding that people do things for reasons. cognitive flexibility is being able to, if your mind has a certain conclusion, being able to move out of that conclusion. Is mentalization effective for building theory of mind in autism?

I don't know. I would think so. But this is where I'd have to see actual studies, because part of the problem in autism is that some of the tools that mentalization utilizes may be variably impaired. in autism. So mentalization works very well for personality disorders, but if we look at the brains of people with personality disorders, they're different from the brains of people with autism. So I imagine that mentalization as a concept will be helpful for autism, but you probably, this is the thing about autism, is you have to adjust whatever you're doing to the neurodivergent brain. I don't think it's like one to one. That's what's so frustrating about seeking mental health treatment as someone

on the spectrum is that all of the protocols that people will be trained in, unless they are specifically trained in an autism-specific protocol, won't apply to you 100%. And then the other problem is that a lot of the neurodiverse specific protocols and modalities that we use are for like low functioning autism. So there's a huge treatment gap in mental health treatment for

high functioning people on the spectrum. Because if you look at like ABA and all this kind of stuff, right? So like the, there's the biggest amount of expertise in more severe impairments. It's, it's really challenging. Do all of Clusterby have over

active, a humkara? Absolutely. That's why I love talking about a humkhar. That's what's so cool about using some of these meditation practices is that you start doing Shunya meditation and suddenly the narcissism seems to get better. It's really cool. All right, in combination with therapy. Okay. Let's move on. I want to show you all a couple of other things. Okay. This one I thought was funny. Let me just make sure that this is... Okay, so... Okay. Ear warning, okay, chat?

You guys may want to... I'm gonna play this twice, so you guys can turn it down if you need to. Hold on. Let's try this again. Assure me. Exhaustic. First of all, I love reassuring you and... Let's try this again.

Nope. Like, exhausting, how much you have to reassure me? Exhausting. First of all, I love reassuring you. And second of all, it's so easy. It's so easy. My job is so easy. My super hot fucking girlfriend wants to be told that she looks hot or she looks good.

Oh no. Oh no. The easiest is a bad bitch. And if you are with a bad bitch, you need to have a bad bitch mentality and nobody understands that. You are art. People need to see you. Okay. My job is to reassure you and feel proud when I'm out with you and everyone's to be. I'm out with you and everyone stares at you. I have the easiest fucking job in the world. Okay, so no, it's really not difficult.

Okay, so. Somebody said that it must be, like, exhausting, how much you have to reassure me. Exhausting. Second of all, it's so easy. It's so easy. My job is so easy. A super hot fucking girlfriend wants to be told that she looks hot or she looks good. Oh, no. Oh, no. The easiest is a bad bitch. And if you are with a bad bitch, You need to have a bad bitch mentality, and nobody understands that. You are art. People need to see you, okay?

My job is to reassure you and feel proud when I'm out with you and everyone stares at you. I have the easiest fucking job in the world, okay? So, no, it's really not difficult. Okay, so I think this is, this is, I'm so curious what you all think. What do you all think about this? I can't with the reassurement is exhausting. Is this healthy? Is she talking to, is pretty talking?

Okay, interesting. Based. I'm in physical pain. No. Okay. Ask her in three years. I feel a lot of mixed reactions. Nice.

Nice chat. I need more context. Good, good, good. I thought it was cute. Yeah, so, you know, I noticed that Tim Tointer had the same reaction I had, which is, okay. This is a case of someone asking reasons. reassurance about their need for reassurance.

Right? Like, that's what this is. It's like, hey, can you reassure me about how much I need to be reassured? So here's a couple of things to understand. When people are like, oh, reassurance is the easiest for women. I wonder why men think it's so hard. Okay. So I don't know why people have to bring gender into it, right?

But this is the internet where it's like, let's rage bait this by men. making it a men versus women think. So a couple of things to understand about needing reassurance. The first is that many people who need a lot of reassurance, there are two ways that this can go. Either this can get better or it cannot get better. So a good example of this is borderline personality disorder, where these people have a severe fear of abandonment.

And they need constant reassurance that this person is not going to leave them, not abandon them, et cetera. Whereas what we know, actually, is that people with borderline personality disorder, the vast majority of them, over 90% of them get better within 10 years of a stable relationship. 50% of them no longer meet criteria after two years of a stable relationship. So if you're someone who needs constant reassurance, the vast majority of humans who get reassurance will be better.

but it takes years. Okay? Like, it'll start to sink in after years of reassurance. And so this is one thing to understand, right? Like, it does seem to work. So one good example of this is, you know, I was working with a family that told me that they kept on finding, they had adopted a child,

and they said, you know, we keep on finding ants in the child's room. They basically have one behavioral problem. they always have ants. Why do they have ants because they have half-eaten food tucked away inside all their drawers and then the ants find it? And we've tried to explain, hey, you can't have food here. There's plenty of food in the pantry. Like, please stop keeping your food here. We have ants. We have to call the exterminator again and again and again. And again, the kid keeps doing it. Otherwise, the kid like listens to things. And so the kid grew up was in an environment where there wasn't food security.

and so we're talking like from the age of three or four or five learn how to hide food and then gets adopted at the age of nine and then tucks things away and the parents are like there's a pantry like they can go into the pantry and they can grab whatever they want we've shown him the pantry like 15 times it's not clicking exactly it takes some time to click and this is where if we look at um you know, this is kind of an interesting question of what does getting better look like in a situation like this? So there was a great question about, you know, why do some people develop PTSD from traumatic events when others don't?

And this is what's really interesting. If we look at, let me see if I can find this. Yeah. So if we look at one of the most protective factors from preventing the development of PTSD, it is social support. Okay, so basically this is what's really interesting. You can look at people who have been experienced some kind of trauma, like physical assault or emotional abuse, sexual assault, take your pick.

And not all of them end up with PTSD. And even then, what's kind of interesting is that the majority of people, who end up with PTSD. So probably the strongest, the highest indicator of trauma in some studies is a single instance of sexual assault is the most likely to result in PTSD. But what we see is that more than half of people who have PTSD will no longer have it at the end of one year, even if they've had sexual assault. This is the people who develop in the first place, okay, which is less than half of

people. So the question is how, right? How is it that some people do develop PTSD? Some people don't develop PTSD. Like, what's the difference? And for people who do develop it, what determines whether they get better or they don't get better? And this is where social support and specifically what I would call corrective emotional experiences are really, really, really important. And this is why reassurance works. So I want you all to imagine for a moment that someone has been sexually assaulted. They have early stages of PTSD. They've had it for about two months.

What does the process of healing over that PTSD look like? Since this was sexual in nature, when they are in a committed relationship with their partner and they start to get sexual, the trauma triggers. They start to clamp down. they go into a freeze mode. They, you know, it's like their body goes into survival mode instead of relaxing, being vulnerable with someone, being able to engage with someone. And this is the really important thing.

What happens next? If their partner is able to give them the space to breathe that way, and then they, you know, cool it for now, try again maybe an hour, try again a week later, not push it, then what we're starting to do is we're starting to do is we're we're starting to enroll exposure and response prevention. Because after a sexual assault, the body learns that sex is dangerous. So what does social support actually mean? Is it just having people around you?

No. It is being able to re-engage with the things that trigger your trauma and being safe despite the trauma signals being active in here. Really important to understand. the way that you heal from trauma is by teaching your body that the reaction that you have is actually the wrong reaction. It's natural, it's normal, but it is inappropriate. We don't need to react this way. It's safe. And the trauma is triggered, it's safe.

Trauma is triggered, it's safe. Trauma is triggered, it's safe. And this is what good social support literally does. So the child hides the candy bar. Parents come in and say, hey, you don't have to hide the candy bar. Child doesn't get it. No real consequence.

Okay, you feel that way? Okay, fine. We're going to take the candy bar because there's hands. You can hide another one. And this is really scary. You know, I was thought about this. I've told this story before. I never realized this.

No wonder the child keeps hiding the candy bar because it keeps on getting taken away by the parents. Wait, what? I just had a breakthrough. Man, talk about failing your patience. I don't know why. Did you guys realize that? Did you all pick that up?

Actually, we're doing it again. Did you guys see that? Seems obvious now, right? Right? So it's so interesting. What an epic fan. Anyway, the kid got better. So that's the good news is that you can miss some of these things

and you can still provide the right support without doing things precisely correct. Lull, right? But this is what we need. We need corrective emotional experiences, which was originally not related to trauma. I mean, that's been, that's a deep part of the psychoanalytic

and psychodynamic literature. Okay, about like even the childhood traumas that we have, we're looking for corrective emotional experiences through psychotherapy, through transference, countertransference, and all that kind of stuff.

But the way that we heal trauma is by, you know, we have one experience and then we learn, oh, this is scary. And then we have to have other experiences that show us this is safe. And the problem is that our brain is wired to wait negative more than positive. So we literally will wait a negative experience three to ten times as much as a positive experience. So if you guys have ever had a cat, right, you can pet a cat for one year and be friends with a cat, but if you have a single bad altercation with a cat, the cat will keep a grudge and remember.

They don't keep a grudge that are just, you know, that's just how they work. They're now wary of you. Right? And it's like you can be married for 20 years, one instance of betrayal, heavily outweighs 19 or even 20, 19.9 years of fidelity.

That's just how we're wired. Hello. Oh, you're wired. Oh, you're wired. watching stream? Okay. Can you turn on the AC? Thank you. Sure. Okay. Um, so, what was I saying? This is so, like, even after we've been together for 20 plus years, I think, let me think about this, 20 years. Yeah, we've been together for 23 years. I still, sometimes when she is around and walks into the room and gives me a kiss, my mind just stops working. What was I talking about?

It used to be, I suppose that's romantic, but in this moment, it's like, man, don't I get used to this at some point? Doesn't this stop happening? Hold on. Let me think. What was I talking about? Exposure and response prevention. Yes. Okay.

ERP. Okay. Fidelity. Thank you, chat. Right? So the negative outweighs the, like, it's just like, I feel like my brain alter force a little bit. Um, so, yeah, it's, it's so weird. Like, this is such a strange experience because, like, I feel like the thoughts of my brain is a colander and it's all flowed out.

I was like in a flow. Um, okay, so I was talking about fidelity, but I feel like the spark is gone. Was, anyway, okay, let me get back there. Let me get back there, chat. Okay. So we're talking about fidelity. Negative outweighs the positive. Um, yeah.

So with, with people who heal from trauma, we have to have these. corrective emotional experiences. We have to have other data points that will help us put the negative thing in context. And because of, if we look at the example of fidelity, this is why people need so much reassurance, right? And this is why if we look at, I think, something like 96%, 95 or 90, 95 to 98% of people with BPD are in remission 16 years after diagnosis. So 50% at two years, 90% at like 10 years, 98% at 16 years. I think are the stats that I remember off the top of my head. Right.

So you need a lot of those data points. Now, here's why I think we're seeing a huge spike in trauma. Because those corrective emotional experiences, those social support structures, the repeated chances for salvation are disappearing. hearing from society. We live in a world where people get blocked. We live in a world where we're working remotely. We live in a world where once I get dumped and something bad happens to me, I go to places on the internet where we can have an experience like this. Right? And the top comment, literally the top comment, I'm not even logged in and look at what the top comment on

Instagram is. Is this because it's upvoted the most? Is this because Instagram knows this is going to get the highest level of engagement? But it's like, boom, rage bait. Rage bait. Right? It's like, what? So I think the reason we're really seeing a spike in trauma-related things is because

if you kind of screw up, you get punted off the escalator. And you kind of get left behind. And there isn't an opportunity for corrective emotional experience. This person says, oh my God, like, is it hard to reassure me? I want you all, and this is beautiful in heartwarming and whatever, right? So, fine. But I want you all to think about this person's response. And how easy or difficult is it to find someone like this to provide you with reassurance?

Right. And then we run into another problem, which is beauty is in the eye of the beholder, totally fine. But like, what happens if you're not the most beautiful person on the planet? Or even, not even, what if you're south of five out of ten? Then how hard is it to find a person like this? Right? And then we begin to see, not that this person is doing anything wrong or anything like that, and I'm not saying that this person is a ten or whatever.

I really do believe that beauty is in the eye the beholder. But it's like now we begin to see why everyone is so fucking traumatized all the time. Because the basic elements of what is required for correction do not, or harder to find. And it does require a large dose. So this person requires reassurance about needing to be reassured. Seems like they're getting it. We can put this in the W column. the challenge is that so few people, if we're talking about gender dynamics for a moment,

now there's a big movement, right, to like a man's emotions are no longer somebody else's responsibility, they have to handle them on their own. And I'm not disagreeing with the argument. I think that self-sufficiency is really, really, really important. But then the question is, like, who does the work? Who does the work of social support, trauma, healing, things like that? Right? And I'm not saying this is right or wrong.

This is just how things are. And as society changes, the first most important thing to do is to understand why things are changing. What is the mechanism? Good diagnosis precedes good treatment. Then we can figure out what comes next. Right? And this is another. So I was like looking at this.

This is really scary. So I was looking at, you know, this question of, let me see if this is the one. Nope, this is not the one. Yeah, here we go. So I was looking at this. This is super scary. Why do some people develop PTSD after from traumatic events when others don't? So I was trying to answer this question.

I came across this paper. Experience of trauma and PTSD symptoms in autistic adults. Risk of PTSD development following DSM and non-DSM five traumatic events. So basically, if you look at our diagnosis of trauma, we have a kind of event that qualifies for trauma. So here are the examples of things. Sexual abuse, physical abuse, serious injury, abduction, sudden death of close friend or family member, suicide attempt by close family or friend or family member, serious injury to another individual, learning, witnessing sexual abuse, threats to one's life from another individual suicide attempt. So in the diagnosis of PTSD, these are DSM-5 traumatic life events.

This is what causes PTSD. Okay? Here's what's really scary. Okay. Although rates of Criterion A, trauma exposure have been found to be 25% in individuals of ASD, we just looked at Criterion A. That's like the bad stuff that we normally think about with trauma. More than 50% of individuals with autism spectrum disorder were reported via parent report to experience at least one event in their lifetime, which was interpreted as traumatic.

Okay, let's find this data. 47% of all females and 70% of males reported having experienced a life event that they found to be traumatic, but which did not meet DSM-5 criteria. bullying, non-traumatic bereavement and traumas relating to mental health problems such as anorexia or breakdowns. In addition, abandonment by a significant other mother or wife and stress associated with social difficulties were also reported by multiple individuals. So here's what's really scary. These are the kinds of things that people on the spectrum will experience as traumatic. bereavement, police visit to the house, bullying, abandonment, death of a pet, psychological therapy. Therapy is in and of itself traumatic to some people on the spectrum.

Injury of family member, parents, divorce, ASD, the process of getting diagnosed with autism is in and of itself traumatic. Own violence to other, right? So when they lose control because they're behaviorally dysregulated and hurting someone, boarding school, their own illness, just having autism. Vomiting is huge. Grossly underappreciated source of trauma for people on the spectrum. Social difficulties. So I was like, okay, why do people recover?

How do people not recover? What I stumbled into is actually way scarier, which is that if we look at specifically people on the spectrum, their capacity to experience trauma is elevated. There are lots of experiences that non, I was about to say normal, neurotypical human beings experience that are not traumatic. And let's understand why. Because when I get bullied, I have a brain that knows how to form social connections.

I have a brain that empathy is more easily accessible. I have a brain that doesn't need a script, a strategy, or a game plan for social interactions. I can feel my way through life. And when I'm capable of feeling my way through life, my capacity for social support is increased. So on the spectrum, we have two challenges. The first is that the experiences that other people may have, which are not traumatic, are traumatic for us. us. And that's because of the way that our brain processes this information. The amount of emotional activation that we get when we get bullied, the persistence of bullying, the frequency of bullying.

And then we lack the social support that is necessary to protect us from the trauma, to stabilize us afterward. And so one of the things that I stumbled into, which I was really kind of like honestly proud about and also happy about was the realization that when you get diagnosed with ADHD, when you get diagnosed with ADHD late in life, you also have a mood disorder until proven otherwise. See, as a psychiatrist, I used to think, okay, this person's diagnosis is ADHD. And they may have depression. They may have bipolar, but that was like a maybe.

Now my thinking has shifted. If they have adult diagnosed ADHD, I am a. assuming the burden of proof has now changed in my mind. They have depression until I'm sure they don't. It's not a possibility. It is true until it has proven otherwise. And having worked with people on the spectrum, what I'm now realizing after seeing this paper,

it clicked for me. I was like, oh, these people have trauma until proven otherwise. I'm going to operate under the assumption, 47% of women and 78% of men who are on the spectrum, staggering percentages, are traumatized by things that we do not usually assess for in an intake. Because literally, when I'm, I have a script, when I'm reviewing, evaluating someone for trauma in the emergency room,

have you ever been physically abused, emotionally abused, sexually abused, what was growing up like? I don't ask, have you ever seen a therapist and found yourself feeling, traumatized by that process? Have you been bullied? Have you ever lost a pet? Right? And I don't know that these need to be screening questions because that was one person that said the loss of a pet.

Right? And this is the important thing. Losing a pet is hard for everyone. But it has a greater likelihood of becoming PTSD if you're on the spectrum. Right? That's what's really scary about this. 48% for women. that's what this study shows. I wouldn't say that this study is like, you know, absolutely true. This is just one study.

What was the paper? Here, I'll show you the paper. Experience of trauma and PTSD symptoms in autistic adults. Risk of PTSD development following DSM-5 and non-DSM-5 traumatic life events. Right? So here's the lay study. I mean, lay summary. Explore the experience of trauma and rates of probable PTSD in adults

autism spectrum disorder, we asked 59 small sample size. Autistic adults to complete online questionnaires about their experiences of stressful or traumatic life events and related mental health difficulties. Autistic adults experienced a wide range of life events as traumatic, with over 40% showing probable PTSD within the last month and over 60% reporting probable PTSD at some point in their lifetime. Many of these life events experienced as traumas would not be recognized in some current diagnostic systems, raising concerns that autistic people may not receive the help they

need for likely PTSD. Right? And it's like, this is what's so devastating about it is like, this is kind of what I see is a clinician, is you have this idea, right? Because like, people on the spectrum are following like scripts oftentimes. Like that's how they navigate life because they're not quite as empathic. So they're like, okay, these are the things that qualify as trauma. I do not have those things. Therefore, I do not qualify for PTSD. But I still have all of the impairments of PTSD. Therefore, there must be something really wrong with me. I'm pathetic. I'm a loser. I'm broken. I'm unfixable. Things are hopeless, right? Because they actually fall under this category, which they don't understand they fall under. And we don't understand they fall under. And this is what so is tricky about being on the spectrum is like, unless you have a good,

explanation, unless you understand why you have difficulty, what you end up blaming is yourself. And isn't just people on the spectrum, it's true of everybody. Now that I think about it. I see it a lot more in like ADHD. Like there's something wrong with me. Like, I know I'm not stupid, but I can't study. I can't focus. I just can't do what other people are able to do.

Huge. You guys can just Google it. It's in the public domain. Okay. Let's do something wild chat. I don't know if you guys. seen this. The random thing.

So I just wanted to talk about it. So have you guys heard what's happening in Philadelphia? Hold on... Wait, wait, wait. Look, this guy is sitting on this dude. Okay, so this is the fentanyl fold. Okay?

Fentanyl fold, boys and girls. Okay. Okay. So what our earth is going on here? So I saw people were asking about this. They're like, what is going on here? A lot of people have answers, but I don't think they're the correct ones. So first thing is like, this kind of hits close to home.

Okay? So in 2016, I had a phone call with some of the psychiatric leadership at the American Psychiatric Association. And I said, hey, I'm really worried about tech addiction. I was like, I think this whole video game, social media, pornography thing, I think this is really, really, really bad. This is 10 years ago, okay? I was like, what are we doing about this? Like, this is what I'm interested in. How can I get involved?

What is the APA got going on? And they were like, there's an opioid crisis. That's what we're trying to focus on. And I remember at that point being a little bit frustrated. I was like, these guys don't get it. Oh, the arrogance of youth. And now I'm in the arrogance of middle age. Right? Because this is what they were talking about.

Like, think for a moment. Now I sort of understand. I never quite understood, right? So when this is the problem that you're dealing with, you're like, kids are watching too much porn. Like, look at this. Like, no wonder, right? That's what they were like, this is what we're focused on.

And the deaths were skyrocketing, things like that. So what is going on? Okay. So, first thing to understand, the fentanyl epidemic is, so, the opioid epidemic is not really the right word. Okay, so there's an opioid epidemic. That was probably triggered very heavily by pharmaceutical industry. So what happened is we started developing Oxycontin, MS. Contin. We started developing all of these synthetic opioids,

which normally morphine is injected, right? So if we look at like heroin and morphine, something really important about those, which is that they're methamphetamine. They have to be injected into the bloodstream. If you orally take heroin, it does not affect you in the same way. So it has to be snorted, absorbed through the nasal mucosa, or it has to be injected into the bloodstream. Because here's why. So when you eat heroin, it gets broken down by the stomach acid. And then also the blood vessels in your GI system go straight to the liver.

So it travels straight to the liver where the liver processes it and breaks it down. So you can't get high by eating heroin in the same way. So then drug companies developed something really cool, okay, which is like an oral formulation of an opioid. Now we can take a pill. And this automatically changes the ball game for how easy it is to take a medication. And then there's a lot of stuff about how they knew its addictive potential. They kind of lied about it.

obfuscated it, whatever. And they had a bunch of drug reps go out. And for a long time, a lot of doctors were prescribing pain pills all the time. And so as pain medication became really this highly addictive, became widely acceptable, boom, we have an opioid crisis. Then what happens is we realized, hey, as doctors, we shouldn't be prescribing pain pills right, left and center. Okay? So then we crack down on prescribed opioids. But there's also a big demand now, right?

People are hooked. So they're looking for alternatives. And along comes fentanyl. So fentanyl is super scary. It's a synthetic opioid that is way more powerful than morphine. The really scary thing about fentanyl is that like a couple of granules is enough. Okay? So the amount of fentanyl that you need to take.

take is way lower than a pain pill, which then leads to more overdose, because if you take even a small quantity, like a pellet, that can be enough for an overdose. The other thing is that in terms of getting it in, the volume of what you're smuggling in is vastly different, right? Like, we can smuggle in like granules. Like, think like grains of salt. That's enough to get high off of. So now we have this fentanyl problem. And what we're seeing here is not just fentanyl. It's fentanyl and xylazine. Okay? And what this does, it does a couple of really interesting things.

When you combine these two medications, let me. You get some really scary effects. New choking epidemic trends in psychoactive drugs. The zomifying combination of fentanyl and xylazine cause overdoses and little hope of rehabilitation. Okay. So what's going on?

Why is it that these people are like turning into zombies? This is fascinating from a neurochemistry standpoint, pharmacology standpoint. So first thing is when you combine these two medicines, what's really interesting is that they have differential effects on different muscle groups. This is the first thing. So if we look at the mechanism of action, we're going to get a bit scientific. Fentinol's blockade of potassium channels contributes to wooden chest syndrome. So this is something you all have to understand. Potassium is really important for muscular rigidity and muscular relaxation.

Okay. So fentanyl alters potassium channels, which does, and when combined with xylazine, it does two different things. The first is that it weakens our truncle and back muscles. So it has different effects on different muscle groups. So what literally happens is our abs and our back become completely full. floppy, which is why we see that fold, because the truncle muscles have no activity. They can't lift themselves up. It's like your abs are completely gone. So if you lose your truncle rigidity muscles, you lose your abdominal muscles,

what posture will you adopt? You'll flop over, like literally. Second thing that it does is it increases rigidity in other, some peripheral muscles. So in the arms, in the legs, and if we kind of go back and look at this. Okay. So let me just. right so if we look at this like you guys see this this is you see this right here this is a stiff arm with weakness in the neck

right so weakness in the neck and let's look so once again this is rigid this is floppy this seems rigid this is rigid this is rigid this is rigid right this becomes rigid

this is rigid. And we can look at different people and we'll see this. Like the legs are rigid, but the trunk is floppy. And that's because of the differential effect of calcium channels. I mean, sorry, potassium channels. The other thing that happens when we have fentanyl and xylazine is it knocks people out in a very special way. So these people are not conscious, but they feel bliss.

They're like in this beautiful haze of like semi-conscious bliss. And it's apparently the best feeling in the world. I would not recommend trying it. There are some drugs that you guys should honestly never, never, never, ever, ever, ever, ever, ever touch. And fentanyl and xylazine is at the top of the list, along with meth and cocaine and all the hard drugs. Like they're hard for reason.

Y'all should stay the hell away, let alone the other stuff is bad too. Better if you don't touch alcohol, don't touch weed, don't touch anything. That's the best. Caffeine may be okay. Then the really scary thing about this is that, so remember we talked to the, they lose some things, but then muscle rigidity is also a cause of fentanyl usage, right? And specifically, muscle rigidity, including jaw clenching and chest rigidity.

So this is what's really interesting is like there is, let me see if this kind of says, Yeah, I don't know if we know exactly Laryngeal spasms occur in 50 to 100%. This is really scary. Okay, let's see if they... Okay, I don't think... I don't know if we know... Yeah, we don't know what's caused by this.

My money's on something with potassium and calcium, but you never know. And so what's scary about the fentanyl stuff is that not only are you floppy, but you also are going to have rigidity. And when you have rigidity, that rigidity is so severe that it can cause like tightening of your throat and tightening of your chest.

So your muscles in your chest clamp down so much that you literally your rib cage cannot expand when you breathe in. Okay? And so then what we end up with is a situation where like basically, oh my God, I'm lagging so much. What we end... Now I'm having rigidity.

Hello, chat. You having some rigidity with me? Okay. Good. That seems to have cleared it up. You just have to pay the OBS gods. Yeah, but it's really scary because there's, there's, yeah, there's like, there's muscle wall rigidity too.

And that's what causes the fentanyl fault. It's this wombo combo of xylazine and fentanyl, and y'all should stay the F-O-A. Okay. Yeah, you two, I don't know what the deal is with lag. We go, we're like trying to fix the PC. As someone who did it, don't. Good. They're like calzone folded in half.

So scary, dude. Does Adderall have similar side effects? Hell no. Adderall has side effects, but they ain't nothing like this. Yeah, so this is another good point. Zylazine can cause respiratory and central nervous system depression. is not affected by Narcan. Can a heavy drug user ever fully recover?

I think so. I think most people can functionally recover. Yeah, so Zylazine also rotted my skin. So this is kind of disgusting. Let's see. There is something, yeah. This is scary, but... Zylazine is also called a zombie dog

due to its heavy sedative effect in associated severely infected skin ulcers. Right? So this does cause like really bad skin problems. Causes hypotension, social nervous system, depression, respiratory symptoms, bradycardia. Right? And someone said xylosine is not an opioid, naloxone will not reverse its breathing effects. So maybe flumazinol will work. I'm not 100% sure about that, though. You'd have to ask any, I'm rusty about my emergency room psychiatry and haven't kept up with whether flumazinol will work. But yeah, it causes like skin ulcers too. Scary, man.

Scarlet rot, yeah. This is this right here, Philadelphia is becoming, what's that place? Man, I can't believe I'm blanking on it. That red zone? What is it, chat? The place that has the meteor staff, Kalid. Mess him. Philadelphia is becoming modern day Kalid, dude.

Thank you, chat. Okay. Yeah, Kayla, dude. Yeah, I live in Baltimore, but it's arguably just as bad there. Yeah, so much like the Scarlet Rot, it spreads. I mean, it's bad in, like, Maine. Really bad. Like, some of these, like, states in New England that are a little bit smaller, it's so bad there.

Yeah. I am fentanya. Fentilenea. Blade of Zyelosa. Yeah, dude, it's bad chat. Yeah, the housing first stuff, so one of our members of our scientific advisory board,

you guys may remember Dr. Shue, he works at the VA and was talking a lot about housing first. There are a lot of cuts to that program. Let's chase the dragon together. No, thank you. Yeah, it's in Europe now.

Yeah, so how do I, have compassion for these zombies when I keep having unsafe experiences around them. It seems everyone who does works with them, but it's different when I'm just trying to get home. I'm with you. You know, it's interesting how my experience with the homeless has changed once I've had kids. So I think one of the things about like compassion for the homeless, which I'm a huge fan of. And, you know, one of the most transformative experiences for me in residency was something

called Boston Street team. Super cool. But basically like a team of clinicians will go and literally wander the streets of Boston to find patients and help them with their mental health problems, a lot of primary care too.

And I think one of the things that we forget is that when you're in a medical situation, how many safeguards you have in place? Right? So the biggest safeguard is that the people know you. so like i mean i remember remember like you know if if a homeless person in boston gives you a problem and you're like on the street team like other homeless people will show up and they'll like put

that person in line and then you also have the the safeguard of having other people around you you have numbers that you can call everyone knows where you are they they know what your route is you huddle in the morning you're like okay i'm going to take the west side of this highway you guys take the east side like we like split everything up, right? We have a huddle. And what's scary about, you know, homeless people is that if you're by yourself or even with other people, like you never know, some of them could be violent, some of them can be quite demanding. Like, it's just a whole different ballgame. I was, I was stunned by how having worked with these people for like, let's say, one to three months

very intensively, and then four years in the emergency room. five years in the emergency room. You know, how different it feels when I'm a citizen. And a lot of that compassion still sits there and stuff like that because I can appraise things. I can sort of tell, okay, is this person dangerous or not dangerous? Right? We're trained in that. But without that assessment, like, it's really scary.

And I think an important thing to remember is that compassion and tolerance are not the same thing. So it's possible to have compassion. towards someone and still say no and still move away, run away, avoid them. It's possible to have compassion. Compassion is the way that you feel, not what your behavior is.

And a simple example of this is sometimes, you know, I remember one time I got a call for someone who was like, hey, I'm trying to do physician-assisted suicide through an organization called Dignitas in, I think, Sweden. And I need a psychiatrist to do an evaluation on me. Would you be willing to do that evaluation? I'm desperate.

I don't want to live anymore. I've talked to a bunch of psychiatrists around here. You're into holistic stuff and reincarnation. Will you do this? And I had immense compassion for the person. I'm like, sounds like you're really suffering. But that's not something that I can do. It's not something I'm familiar with.

I don't know what this evaluation is. You know, it sounds like things are very hard for you. I can't imagine what it's like. And like, I have compassion for you, but I can't do that. And it's not even like, so it, you know, it, it's not what I was taught, what I, what the, the ethics of my profession are, which could be up for debate, fair enough, but I'm certainly not like clinically familiar enough to understand how to assess whether you're mentally ill or not, I don't know how to grapple with this.

And similarly, we can have compassion for people and have that genuine compassion without behavioral caving. And this is what's so hard. Like, if you guys have people in your life that take advantage of you and you, like, have compassion for their circumstances, like, this is that tightrope to walk, which is, I genuinely feel for you, the answer is still no. And here's what they try to do, right? They try to, like, tie those two things together.

If you really loved me, then you would. They tie a behavior to love or something else. If you were my friend, then you would do this. They're defining the friendship in that way. And one of the hardest things, you know, we've had to do is, like, when I have, you know, parents who have kids that have severe addictions and they steal your stuff do you let them come home after rehab are you going to send them to a halfway house right when they come begging i used to work at a rehab that was very expensive and you know we'd have quite wealthy people prominent

people come there and sometimes they had kids who were like used to having a three million condo in Manhattan. And then, like, said person has a trust fund has $50,000 a month that they have access to that they spend mostly on drugs. And then, like, it's like, yeah, sorry, you got to go to the halfway house. And it's so difficult to navigate that journey. So it's okay to have compassion. right separate out your compassion from your behavior and do whatever you can with your compassion like let your compassion influence what it can let it shape your words right like really pay

attention to what's dictating if if someone approaches me is like hey can you have can i have five dollars what's your response can you really not afford cash are you lying what's the deal do you want to give it do you not want to give it you know like think through it it's challenging Okay, one other thing I want to talk about. What's the halfway house? Someone in chat is asking. Who's going to answer for them? Okay.

50K on drugs, that's a lot of marijuana. Okay. So a couple things to understand. When you're spending $50,000 a month on drugs, usually there are two things that are happening. First thing is you ain't use a lot. in marijuana. Okay?

You're using designer drugs. Things like MDMA, things like cocaine, things that are sold to rich people. And you have a dealer that is vastly inflating prices because

you're now addicted and you're a rich kid. And so they're going to sell you $6,000 of cocaine. That'll last you 24 hours. you know, and it's not even too much cocaine. Okay?

Okay. This was, things that I did not expect to see in chat. Getting sharked on cocaine. Who was that? This is getting sharked on cocaine. It's crazy. Yeah, but I mean,

I hope it's okay that we're talking about this stuff. You know? And we've got to talk about substances, y'all. Yeah. Succession, Kendall, Roy, that's what I'm talking about. Yes. A lot of that stuff is based in reality chat.

Okay. Ooh, what's my opinion on free will? Maybe we'll have a collab with someone who's into philosophy and then we can talk about it. I wanted to talk about this before we wrap for today. The consequences of relational trauma are truly devastating. I really don't feel like most people understand the lifelong devastation, the actual destruction of the attachment system, the truly profound effect. the truly profound effect that relational trauma can have on a person. Everyone has different nervous systems and experiences things differently.

I consider myself to be quite sensitive. I think there was a bit of a perfect storm that led to my C.PTSD, and it is quite remarkable to truly think about what had to be done to a person to create a nervous system response where they never feel safe near human beings. Okay? To take a creature whose entire existence is rooted in connection and strip them, of the ability and capacity to connect. It's mutilation and nobody can see it.

I wish they'd taken my arm, my leg, rather than my spirit. My mother locked me in a bathroom and forbid me from playing, humming, self-soothing of any kind. She removed every other adult from contact with me. She convinced me that everyone aside from her was out to get me. She violated me to the degree of feeling dehumanized. She'd abandoned me just for the fun of it, just so she could watch me beg for her back. The number one risk factor for developing PTSD after trauma is a lack of social support. I don't want to protect her now.

I really don't, but God to think if I had one then, maybe I could have endured my household if I had people outside of it. If I hadn't been pulled out of therapy after six weeks as a child, if I'd been taken to a doctor when things were clearly wrong, if my elementary social school had social workers like they do now, if my father had been home an hour, earlier by surprise. If I'd been braver if someone had cared. It doesn't make sense. I don't understand. What I do now is that life is about, what I do know is that life is about people.

It's about connection. It's about love. It's about being of the world. That was taken from me. I will spend so much of my life if I can endure it, trying to get back what never got to be. It's not just hardship. It's not just what happened.

It's not trauma. It's carnage. So, we're going to, going to talk about the relational consequences of severe trauma. I've done a lot of lectures on attachment styles. 50% of people have secure attachment, 25% of people have anxious attachment, 20% of people have avoidant attachment, and 5% of people have something called disorganized attachment. And I've avoided kind of talking about it because the prevalence is so low, you know, it's only 5% of people.

But it's something that we get requests on a lot. And I think there is a rise. I think the attachment literature doesn't capture, I think, how big of a 5% it is. The rates of C PTSD are climbing. And people just have a lot of trouble with connections. And I think if we tunnel down into disorganized attachment, in order to understand disorganized attachment. It's the hardest attachment style to understand because it's disorganized. We have to understand the basics of how a relationship forms. Like what are the components of connection?

And so while it's the hardest to understand, I think paradoxically, understanding disorganized attachment will be the most useful for all people. In the same way that if we want to understand how the brain works, we gain that understanding through understanding stroke syndromes. A left-sided MCA middle cerebral artery stroke looks like this. A right-sided MCA looks like this. A vertebral, a basilar artery stroke looks like this. A posterior communicating artery stroke looks like this. An anterior-communicating artery stroke looks like this.

Left-sided is this way. Right-sided is this way. So it is through pathology that we understand how things work. And so today we're going to tunnel down into disorganized attachment. Okay. So let me start with some basic stuff. I just realized we have a problem. Saved.

Save to chat. Okay. So first thing that we got to do is understand the relationship between trauma, C, PTSD, and disorganized attachment. So I'd say C-PTSD is over here. And disorganized detachment is over here. Actually, it's probably a little bit more like this. No. Did I think about it?

A. and Dr. K. lecture without some terrible drawing. Okay, so this one is like this, and this one is like this. Oh my God, that's so bad. Okay, chat. I'm going to just start this over. Can Dr. K draw circles? I may be good at all kinds of things, but... Let me do it this way.

This is better. C-P-T-S-D. Disorganized attachment. Okay? So first thing is what is C-P-T-SD? So if I am an adult human, I am fully formed. Okay? I have a sense of identity.

I know who I am. I have a story or narrative about myself. the world and how these two things connect. Right? So there are good days and there are bad days. The world sometimes is unfair,

but if you put your head down and you kind of focus on working and you learn about yourself and you focus on growth and you try to form connections and things like that, you can navigate life and life is okay. Who I am, I'm someone who's not perfect,

I had some trouble, but I'm on the upswing. I'm doing a little bit better now. You know, I want to find connection. I want to find joy. I want to find love. I want to have a fulfilling and peaceful life. I want to travel to East Asia and spend some time in some Zen monasteries.

This is who I am. And a traumatic event happens. The system is formed. And this kind of takes a chunk out of the system. But then eventually the system kind of recovers. Right? If we kind of go back to this, you know, the natural recovery of trauma, most people get better, right?

Percentage of trauma survivors with PTSD, we can see that within one year, 80%, 75% of people who have PTSD will come down to 40%. So people will get better. And then in non-intentional trauma, like a natural disaster, if something bad happens to you, 30% of people will have trauma, PTSD at one month, and that basically sinks down to about 10%. Like, this is true of like physical assault, things like that. Okay?

childhood trauma also gets better over time. Okay? So, C-PTSD is different because these parts of our identity are still forming. And if we have chronic trauma, so PTSD happens with one or maybe a handful of events, complex PTSD is when the trauma is a regular part of your existence. So we see this in cases like people who are in the concentration camps, during the Holocaust for years at a time. Or when children are growing up in abusive environments.

The parts of us don't form properly. We just did a membership lecture about dissociative identity disorder and kind of a deep dive into how that works. There was recently a YouTube lecture uploaded about depersonalization, dissociative identity disorder and soul derealization. So if you guys want, y'all can check those out. but instead of forming like a unit, CPTSD makes a fractured self

with a hyperactive nervous system. And this can sometimes result in disorganized attachment. So what does disorganized attachment mean? There are two types of disorganized attachment. Okay. But let's take a look at a definition. Okay. So, the construct of disorganized attachment has remained amorphous in adults, and as a consequence is lacking in utility.

So people are like, look, it's disorganized. It doesn't have particular features. That's what makes it hard to define. But I like this model, which is disorganization and lack of structure. So type 1 incoherence is high intensity. high affect with multiple shifting mood-dependent states of mind. So what does this mean? This means high highs and high lows that shift very high, very quickly.

I'm incredibly angry. I'm incredibly ashamed. And it shifts. It's like there is not a... The way that disorganized attachment works is for someone who has a well-calibrated nervous system. we have spikes, the line is connected. In disorganized attachment, we're over here, and then we're up here, and then we're down here, and then we're over here,

and then we're up here, and then we're up here, and then we're up here. Except these are emotions. So instead of this, we need a feelings wheel. Right, where this is like anger, happiness, hope, sadness, guilt shame and then time point one is over here time point three is over here time point four is over here

time point five is over here time point six is over here time point seven is over here time point eight is over here time point nine is over here it's just it's just bouncing all over the place okay so high intensity of affect mood dependent states of mind narrative contains multiple unmonitored

contradictions. So this is what really messes people up, is when you ask me, who am I? I am able to say, I am this. I have good parts and I have bad parts. Hey, my name is Dr. Kay. I'm a recovering video game addict who failed out of college, went to become a monk, and became a psychiatrist. You guys have heard this story a thousand times. Right, but I have a synthesis of narrative. I am am one person who contains both good and bad things. In disorganized attachment, you have multiple contrary contradicting identities. I am an absolute loser who never does what they're supposed to do. And I'm so impotent.

I try so hard every day and nothing ever works. I exert so much effort, but the world around me is impenetrable and opaque. So my effort is useless. And I'm a lazy person that never does anything. Do you guys see how these are fundamentally contradictory? Wait, are you exerting effort and does it not work? Is the world a cruel place? Or are you lazy and not exerting effort?

Like these two things are contradictions. But the whole point of disorganized attachment. So remember that our sense of identity develops through the feedback of the people around us. And we'll get to how this identity forms in a little bit. Right. So I believe that I'm addicted to video games. Why? Because I'm addicted to video games.

But then I also fail Spanish class. I noticed that my friends are like, hey, bro, like where have you been? My parents are like, hey, alok, you need to do something. This is not right. You are off off track, me. you are off track. So I get like feedback, right? Oh, like I'm addicted to video games.

My friend from high school is like finishing residency and I'm applying to medical school. It's like, okay, this is who I am. But as you guys see, like this may sound bad. Like being addicted to video games, not good. Causes problems in life, yes. But I have the benefit, the luxury of consistent feedback. Everyone around me agrees,

hey, bro, you're playing too many video games. Now, in disorganized attachment, we'll get to this, right? So what they have is their sense of identity is fragments, right? Which one am I? I don't know. Some moments I'm this and some moments I'm this and some moments I'm this. They get differing feedback. They get the feedback that, hey, you're pathetic, right?

So if we go back to this for a second, like look at this. Right? So locked me in a bathroom, forbid me from playing. Removed every other adult. Convinced me that everyone aside from her was out to get me. Abandoned me and watched me beg back. So she could watch me beg for her back. Now, think about this for a second, right?

So when you're this person, what do you want? Do you want to be free of this person? Or do you want this person to never leave you? And the answer is like both. a really contradictory way. So this is what's so confusing. So if this is what your life has been like, how do you develop a strategy for moving forward?

Is my problem that I'm lazy and I'm trying, I'm not trying hard enough? Or is my problem that the world is stacked against me and no matter how hard I try, effort is useless? And you guys see how like, okay, is effort useless or do I need to quadruple my effort? Like, does it help or does it not help? And we don't know.

I don't know. It's like, I don't know. And so these people are paralyzed because there are two things that are contradictoryly true. But they're both true. And so it's like, damned if you do, damned if you don't. There's no way out of it. Okay? May show evidence of oscillating between extreme attachment styles may oscillate between

hostility and helplessness in describing caregivers. Okay? Boom. Look at this. Like, I didn't make this up. We didn't select this post. We found the post first, then found the paper. Oscillating between helplessness and anger.

Okay? So this is what's so difficult about this kind of disorganized attachment. I'd kind of call this the amplified type 1 incoherence, which is like there's too much of everything. Okay? There's like way too much. Too much feeling that's contradictory, hard to make sense of it,

hard to be able to move forward. Next type of incoherence. Low intensity, low affect with diffuse, vague, confusing, or inadequate states of mind has not struggled with or is prematurely foreclosed on career romantic relationship. Okay, let's start with this.

Low intensity. Low affect, with the views vague, confusing, or inadequate states of mind. So type 1 incoherence, yeah, this really does not like when I switch some buffering problem or something going on. Okay. So type 1 incoherence is too much that is contradictory. Type 2 incoherence is not enough of anything. How do you feel? I'm not sure.

Are you motivated? Eh. I just don't feel like doing anything. Like I want to do something. What do you want to do? I don't know. What do you feel like doing? What excites you?

I'm not sure. Right. So in one case, the nervous system has been like wired in a particular way where it's like hyperactive. And I'm dominated. I'm like a weird wolf. Like I turn into a weird wolf and I turn into a human. Do I love you? Yes.

Do I want to tear you to shreds? Yes. Both. So the other way that the nervous system, when dealing with all these contradictory things, the other thing that I can do is shut down. We become dissociative, depersonalization, de-realization. In order to preserve ourselves, we wall off our vitality. Okay, so this is a big part of the lecture, which you guys can find about.

Does my girlfriend with multiple personalities have one soul? Which I thought it was super fascinating question. right not super clinically relevant but fascinating so basically what happens is in order to protect ourselves our body walls off the good part of us like because basically what's happening is I have joy right I get excitement oh yay mommy's home and then mommy locks me in the bathroom and calls me a piece of shit and then that's like what do I do better not get excited about anything let's take that capacity for excitement and protect it at all costs let's form a wall around it so that it never touches the external world

because the external world is a chaotic and dangerous place. It's an act of preservation, self-preservation. But now the problem is the zest in life, the vitality in life has been walled off. So we have these vague feelings. And then we go to therapy, and then we feel like fucking dumbasses. Because people ask us, how do you feel?

How does that make you feel? How does that make you feel? What are you feeling? What are you feeling? What do you feel? What are you feeling? What do you feel? I don't know how many feelings.

I don't know how I don't know how to answer that question. And then I feel, all I know is I feel like an idiot. How's that for a feeling? Okay. So that's number one. Second thing, has not struggled with or has prematurely foreclosed on career romantic relationships and or social relationships. This is fascinating. Has not struggled with and therefore has premature closure.

Okay. What does that mean? Okay. So when you're trying to figure out what you want to do in life, you run into a problem. Most people run into this problem, which is that I feel like doing this. But the world is like, that's dumb, bruh. It's like, what do you want to do? I want to paint, right?

My favorite career, I saw this meme earlier. Hopefully I can find it. God, can I find it? Come on, Reddit. Help me out. Top. Yes. What's your dream job?

My dream job is being unemployed with a mysterious source of income, right? What do you want in life? I want a mysterious source of income and just be unemployed. That's what I want. That's my career. So we have, like, things that we want to do. And then the world, like, says no. And then what happens is we have this negotiation.

We have this conflict with the world where we like we end up with some stitched together, compromise, mildly dissatisfying or majorly dissatisfying. Like we come to terms with the world. We grapple with the world and we wrestle some kind of life out of it. We carve out from life, the shit that life gives us, gives us a bunch of lemons. We start making, we start squeezing lemons. We add water. We get a little bit of sugar.

you've got lemonade and then we're kind of okay. But I want y'all to understand, in order to do that, is it a painful process to people complain about it, sure. But it's actually really healthy. It's like this is how I wrestle meaning out of life. It's not just given to me on a silver platter. If you're unemployed, you have a mysterious source of income, then you wind up being the person who's spending $6,000 a day on Coke

because you're a trust fund baby and you've got no purpose in life. Worked with those guys. They're great. Okay? really fantastic human beings. Directionalist. Just like me or you, the only difference is they've got a trust fund, which you may think is a blessing,

until you have access to so much cocaine that you have an MI at the age of like 32, and then your exercise capacity is permanently reduced by 40% for the rest of your life. And you become an old man at the age of 32. So be careful what you think is an advantage. I'm not saying that money on the whole isn't an advantage. Security is huge for,

stability, lowering your cortisol level, happiness in the dating worlds. There are lots of advantages. But anyway, that's life. Not as simple as people think. That's my experience as a psychiatrist. Way more complicated, way more nuanced. But here's the thing. In order to wrestle, you have to have access to that inner voice, right?

You have to, like, go to work and be like, this job sucks. I want to do something else. and you think that that's a bad thing because you're suffering, but actually it's like a really important signal. Your dissatisfaction with the world around you is your compass. Like literally. So I once was doing group coaching, and it was beautiful. Like I love doing group coaching.

And so there was a group of the group that I was working with, many of them were into making music. And a big theme was like, okay, we're very dissatisfied with the quality of music that we make. Because we want to make music like this, but we suck at it. So we end up making music like this. And then one of them about week 12, week 14, was like, I realized finally that actually like my dissatisfaction with my music is my sense of taste. And my sense of taste is amazing. And that's what I need.

It's not that I'm dissatisfied with my music. like the goal is to be satisfied with it. The goal is to work and grind until I can make something that I can be proud of. And if I was not such a harsh critic, I would be incapable of making something that is truly great. Beautiful. I was like, ah, inspired. Dr. Kay is inspired by this. Oh, my God.

It's so good. This is like five years ago. Like literally five years ago. I still, the moment still sticks with me. I was like, damn, son. You go. Let's go. Okay, so that voice within you is what causes you to strive, which is a good thing, is what causes you or allows you to not accept things laying down.

But if that voice is walled off, what do you end up with? Not this guy. Premature closure on career. So I already settled on this job. I'm with this person. I don't really know if I love them or don't love them. Social or they're just my people. there's lack of concern about impoverished ideas of self and others

is not pondered the minds of self and others. They don't understand themselves. They don't understand other people. They just kind of like exist. He's a second kind of disorganized attachment. Okay, so there's an impoverished kind, and there's an oscillating kind. Okay, let me just see if there's other things.

So I'll just read this out. to you all just to, so the disorganized oscillating class, that's the first one, exhibited a major theme of high affect that means a lot of emotional intensity, contradictory disorganization, and a strong trait of preoccupied attachment, but also significant hostile, controlling, and dismissive behavior. So this is why it's so confusing about it, is that they're very anxiously attached. So they're worried about being abandoned, they're worried that someone doesn't like them enough, they're worried that they're not good enough, and then they flip to being. controlling and dismissive.

It becomes a protective mechanism. They actually loathe their own weakness. They're like, why am I like this? Why am I so into this person? I hate being so powerless. So let me kick this person out and toughen up. The disorganized, impoverished class,

right? There's oscillating and there's impoverished. It was characterized by a major theme of vague impoverished disorganization, in which dismissive attachment represented the only other significant elevation. Okay, so this is kind of a data-driven sort of thing. Oh, let's wait for the lag to resolve.

Do do, do, do, do, do, do. Maybe I just check in the chat while we're waiting. Describing your ex, yeah. Okay. So, right? So then, like, the vague people, like, eh, I don't, like, are you into this relationship, eh? We've been dating for six years.

My partner wants me to get married. Like, I don't really know. Eh, me, eh, it's kind of the feeling. But it's not like a chill. It's kind of like this weird, desperate, like something is missing, existential dread. It's like there's some burbling. It's not like an earthquake, but there's like a lot of tectonic activity under the surface. It feels very destabilizing and it's still disorganized.

It's not consistent. It's like, but the disorganization is so vague. Does that kind of make sense? it's like vaguely in this direction and vaguely in this direction and vaguely in this direction and then people like, I don't even know what this is. I just don't feel like doing anything, but I kind of feel like doing stuff,

but I don't even feel like doing the things that I feel like doing. It's kind of like asking a blind person, what does a sunset look like? Well, they're like, well, I feel that the sun is kind of warm and then it kind of moves down a little bit and then it's less warm, but then it's more warm and it starts to get cold and then like,

but the sun moves up then, right? So then it gets warmer again. I'm not kind of, I'm not sure. I don't understand. But it's not, I can't make sense of it, but something isn't right. A second kind. Impoverished. And this is what's so tricky about it.

I don't know if this makes sense. See, sometimes when we have like these impoverished experiences of self, like we're alexathymic, which means we're emotionally colorblind. We think we need to figure out what we feel. I need to figure out what I feel. But it's not that you need to figure out what you feel. What you feel is vague. You have an accurate experience of vagueness.

Right? So it's like I forget which comedian said this. Have you guys ever wondered maybe Bigfoot is just blurry? Like it's not a blurry video. The Bigfoot itself is. blurry. How would you know the difference between a bad video, a blurry video of a clear object, or a clear video of a blurry object? And so people who have impoverished internal experiences don't have a clear sense of self. I don't really know who I am. I don't really know what I'm

doing in life. I'm kind of doing this. I don't know what I feel. You're actually accurate, but the picture is blurry. Like the object is blurry. Okay? So, yeah, it's like if you guys ever wondered, like, what if Bigfoot is blurry? Okay? So now we're going to get a little bit into what does, let me just make sure that I have. Okay, we're going to just touch on this. So how does the disorganized attachment form? So the general model proposed by Hess and Maine is that parents having an unresolved state of mind display frightening or a,

typical behavior. Parenthold frightening or atypical behavior leads to disorganized attachment, and therefore an unresolved state of mind is associated with disorganized attachment through the mediating pathway of frightening or atypical behavior. So what does this mean? So remember, we get our sense of identity from the people around us. And so what happens in disorganized attachment is we have caregivers that themselves are disorganized. So mom is one day abandoning me and on the other day isolating me from everybody else and making me dependent on her. So mom is not organized or consistent. And then it's sort of like, you know, I want you all to imagine what the world would be like if there was no consistency with weather and there was no consistency with night and day.

Like just imagine. Yeah, there's three days of sunlight every, not even every. these 18 days, there's three days of random sunlight, there's rain, there's clouds, there's hurricanes, there's sun, there's great weather, there's beaches, there's mountains, and everything is just chaotic. Like, how are you going to plan for anything? What are you where today? I have no idea. Could be sun, could be rain, could be nighttime, could be daytime.

And the rest of the world goes with it, by the way. So it's like, oh, there's 15 days of nighttime. That means that everything is closed, except for the late night places. So it's like Taco Bell is open two hours a day for 15. days. Like, what? There's no grocery stores. Like, it's just such a disorganized way of living. That's what, imagine for a three-year-old when you have a disorganized parent, that's what the world, the world is your parent. It makes no sense. There's no way to form a system to interact with this because it's so chaotic. And then that becomes frightening because there's no consistency.

It's like, when I cry, I get held. When I get, when I cry, I get slapped. Should I cry? I don't know. Right? And so then that this ends up in one of two ways. Either the highly oscillating, one day I'm crying, one day I'm not. Let's just roll the dice and hope it works out well.

Or the impoverished state, no more crying ever because we don't know what the hell is going on. We don't know. The world doesn't make sense. Which then wires our nervous. to be on high alert. Okay? But then let's get to the relationship stuff. Okay?

So if you are in this state, here's where to start. I think therapy is good, by the way. This is not like a due coaching thing. Okay? You guys have disorganized attachment. Coaching is great for a lot of things. So if you guys are like somewhat amotivated, somewhat electsothymic, want to figure out purpose and direction,

coaching will help with that. But if you've got C.PTSD and disorkewarmated, organized attachment, I'd definitely start with therapy. Okay. So, here are the components of a relationship. Attention, expectation, affect, and behavior. Okay? So if you want to understand, like, how to fix a relationship, this is what I love about

studies on disorganized attachment. We understand what the fundamentals are. When the thing is really broken, when I have an engine that has been completely disassembled and is non-function. At least I know what the pieces are. So the first aspect of a relationship is attention. And I don't mean how much attention you get from your partner. I mean literally what does your brain attend to?

So I remember I did an interview with a guy named Coco B. A couple years ago was one of my favorite interviews. And he had an abusive father. And I asked him, how long did it take you to understand when you're, when your dad walked in the door from coming home from work, how long did it take you to understand if you were going to get beat that day? And he was like within seconds. Like within the first second or less than five seconds, he knew.

So literally, if you look at if you have trouble in a relationship, pay attention to your attention. What does your mind focus on? Does it focus on the response time to text? or does it focus on the content of text, right? When someone says, hey, I love you, I want to be in this relationship forever, what does your mind do? Is it able to hear those things or does it shift to this person is just being nice? They're just saying that.

Right? So instead of your attention being on the same. stimulus from the world, it shifts to some kind of internal anxiety. Boom. Fear. Right? I don't deserve this. You don't really mean that.

The second thing is expectations. So what are the expectations of a relationship? What are the expectations on you? What are the expectations on the other person? Right? If someone says they love you, are they a love? allowed to one day say they no longer love you, right? What is the, what is the script? What is the rule book for a relationship? And literally when I work with people who struggle with these things,

this is what I will do. I will say, okay, let's pay attention to where your attention is. What makes it hard for you to receive the signals that your partner is sending? And then we'll get to their expectations. Well, because my mom told me that she loved me. and then that meant really bad things. So instead, I'm not receiving that signal. I'm so impoverished. I feel nothing when they tell me they love me. I don't feel anything.

And why is that? Well, then we get into it. And then it's like, okay, well, your mom used to tell you she loved you, and then she would hit you. So you've learned how to filter that out. You've learned to expect that people who love you are going to hurt you. Okay? And we'll get to this in a little bit more detail.

detail. Then we get to affect, which is the emotional experience. So what are your emotional experiences in this relationship? Literally just listing them is a great place to start. I feel angry, I feel sad, I feel happy, I feel this, I feel really disorganized, I don't feel much. Just naming it as the first step, right? Oh, my God. And then you have to be a little bit careful because then where does your attention go? Oh, my God, the moment that you start naming all these emotions, you think I'm such a mess. This is terrible. I'm never going to fix myself. All these other people are normal.

Do you see what happened? We were naming our emotional experiences, but then we have this attentional shift, which goes back to shame or whatever. So your mind, like, runs away with it. That's what we have to slow down, right? We can even notice, oh, this is an emotional experience. There is an emotional experience that I have when I look within. That is shame. Anytime I look inside myself, they're shame.

And then suddenly, this is a win. Because now, out of this disorganized, impoverished landscape, we've got one thread, which at least is consistent. And then we can start pulling on that thread. And that'll open the door to all kinds of other stuff. That's our direction. Then we have the behaviors in the relationship. A relationship is composed of these four things. One of the actions that I take.

when I get a birthday gift, what do I say? Do I hug? Do I kiss? Do I call? Do I text? When they say, hey, I know you have a video game night tonight, but I'm in labor. Can you come to the hospital? What do you do?

Because there are all kinds of people on the internet who are saying like, oh my God, leave this person. They're terrible. They're terrible. What if you're that person? Because the internet is telling everybody to break up with everybody else. What if you're the one who's in the wrong? How do you fix this? You start by breaking your relationships down into these four quadrants and listing out these things explicitly.

What does your mind focus on? What are your expectations? What are your partners' expectations? What are your emotions? What are your partner's emotions? And remember, little cheat code here, not cheat code, little walk through, little pro tip. Your emotions are allowed to be blurry and vague. That is what you feel.

Okay? Now, what we're going to do is talk a little bit about how this ends up messed up. So, there are three things that mess up that disorganize this system. The first is something called threat conflict. Okay? The first is where an expected source of safety is also clearly associated with threat. This both tells us how we have. end up this way and how to fix it.

So if we go back to this post, right? So abandon me and beg. So this is what we see. Right? So you look at your life, you look at like read random Reddit threads. Let's do the Reddit study, the HG Reddit, CPD, Disorganized Attachment Study. Really, basic thing that messes people up.

The source of safety, is the threat. Just imagine for a moment how much that messes people up. It's like, if I'm drowning, do I go for the shore or do I go for the ocean?

Can you imagine for a moment if the shore drowned you, what do you do? Like, what do you do? Like, you don't, there's like nothing to do. This is what happens with people who are disorganized detachment, right?

That's how we end up oscillating because, I don't know, I guess I'll go for the shore oh shit, that's not working. Best, I better swim out to sea. Shit, that's not working. Let me be hopeless.

Might as well just drown. And on the flip side, we end up impoverished because like, okay, shore doesn't work, ocean doesn't work, eh, premature closure. I'll just do whatever is happening. I'll become, you know what I'm going to do? I'm going to become just like a cork

in the ocean and let it carry me whatever happens is going to happen. This messes people up so much when the thing that is supposed to be safe is the thing that is threatening. The source of danger, a source of safety is the same. So there's another weird version of this, which is so traumatic. So I've worked with some people that have a condition called cyclic vomiting syndrome, which is what it sounds like.

And then they end up in this really terrible situation where food makes them vomit. and they're starving, then what do you do? I'm so hungry, I'm nauseous. But if I eat, I'm nauseous, then what do you do? It's so traumatizing. It's like, it's so, it fucks people up. Like, that's like my kids sometimes asking, my daughter asked me yesterday, literally yesterday. Why do you use bad words?

And I explained to her, I said, look, words are used to communicate. So some words are used to communicate certain things. There are some bad words that I never say. the words that are hurtful towards a particular person, like racial slurs and things like that. But fucked is the best word in my vocabulary to describe this state. Literally, I cannot think of a better word. And I've been trying really hard to cut down on my profanity.

But when I think about my patients who have experienced this stuff, and I think about that person in the emergency, not in the emergency room, hospitalized, you're sitting on their hospital bed who can't eat anything is nauseous all the time. No amount of Zophran or an Anacetron or whatever is working. Like nothing works. Eating doesn't work. Not eating doesn't work.

They're just fucked. And that's the source of threat is the source of safety. Source of safety is what is threatening, really scary. Second way. Okay? When a strong motivation was intensely activated for a long time without assuagement, such as the child's desire for their care. in the context of institutionalization.

Okay? In print, he wrote, as the sum of such disappointment mounts, in hopes of reunion fade, behavior usually ceases to be focused on the lost object. Instead, despair sets in and behavior, and behavior lacking an object towards which to be organized becomes disorganized.

I'll explain what this means. Strong motivation was intensely activated for a long time without assuagement. We're going to stop right there. Second way in which disorganized attachment develops is when I want something a lot, and I strive for it a lot, and I don't get it. I'm really motivated towards this thing, and I don't get it. This fundamentally messes with people. I'm crying, I am hurting, I am scared, I am alone, and no one is there.

I send signals, help, help, help, someone please help, someone, please. help someone please help I get nothing in return fundamentally messes with people's ability to engage in the world because in the world we take these things for granted unless you've been traumatized then this was so hard to understand about if you haven't been traumatized it's hard to understand what someone who is traumatized with disorganized attachment just how hard life is for them and the simplest thing is most of us live in a world where if I send a signal, I will get a response. Like, that is part of the basic interaction on the planet.

If I wipe my ass, my ass is clean. Right? If I make a deposit in my bank account, I have money in my bank account. The simple principle of cause and effect that the whole of society and especially human relationships is based on. I give you a gift, you give me a gift. I do the dishes, you pay the bills. Doesn't fucking matter what the sequences or whether it's balanced or not balanced. I do everything, you do nothing. The more I do, the more responsibility I take, the lazier you become. That's still cause and effect. Like, it may not be a good cause and may not be a good effect,

but at least we're operating within the system of physics. Right? Physics is still working. It may not be good, but it works. My coworker, I do all the work, co-worker takes all the credit. At least there is uniformity. At least there is consistency. At least we can be organized about it. Just join.

Join a Dr. K stream. Hear about Dr. K's wiping his ass and whether it's clean or not. Like, cause and effect. What are you tuning in for? Nobody knows. the line does not wipe with people are like, what?

I thought this is supposed to be about narcissism and mental health. What is this guy talking about? Right, but there's consistency. Even within the stream, when you join up, if you join late, we make no promises that you're going to have any idea what the fuck is going on.

There's consistency around that. Okay? Okay? So if you disrupt, this basic thing where children have a strong motivation, right? The hungrier I get, the more I cry. If I do not get assuaged, if that signal does not get anything in return,

it messes me up, okay? And then what happens is disappointment mounts. Behavior usually ceases. Despair sets in. So the human response to the principle of cause and effect, no longer working, is despair. So if we look at what is despair really? Despair is the loss of your ability to engage in physics. If I exert effort, nothing happens. So what is despair? Despair is actually an energy conservation emotion. Don't bother. Don't waste your time.

Don't waste your energy. Right? This is a consistent thing. Even animals experience despair. There are studies that we all, it's really cruel, drop mice in a pool and a little bucket of water where there's a little pillar that is beneath the surface that they can stand on.

Okay, so mice, mouse swims around, finds the pillar and it's like, oh, thank God. Then we do the next version, which is we drop them in another bucket with no pillar. And then we see how long do they swim until they give up. We don't let them drown. We pull them out, but they engage in despair. And then when we have models of depression and whether medications work for depression, we basically see how long does a mouse swim before it gives up and lets itself drown.

And depressed mice give up right away. Undepressed mice will keep swimming for a very long time. They're fighters. Okay? So when it comes to, when it comes to despair, it's a loss of causing an effect. Okay. Next thing. Let me just make sure. How loud is that leaf lower, by the way, chat?

Is it super loud? Yeah. Yeah, it's a leaf lower. Okay. Let me see. The first. Hold on. One of the fabulous

Okay I'm trying to find Okay Okay Okay, the second situation is where Okay So we sort of talked about this The first situation

Was where a source of safety Is also clearly associated with threat We termed that this is threat conflict A second situation is where Signals about safety are ambiguous Even without cues for threat We termed this safe haven ambiguity Okay, so we didn't talk specifically

about that, but it's very similar. It's like where when I get a signal that things are supposed to be okay, I'm not reassured by that. So if mom tells me everything is going to be okay, so not only is like mom sometimes the source of danger, but when people try to assure me, reassure me, I can't rely on that. And so this is what sort of, this is what we end up with, right is someone who doesn't know what's safe and doesn't know what's dangerous we end up with somebody else another situation is when the world

is trying to tell me hey things are going to be okay we're not able to receive that and when we send out signals there's no response so I don't know what's safe I don't know what's dangerous I'm not able to be reassured, right? So that social support, which protects us from trauma, I'm blocked against. And I don't get to participate in cause and effect like the other humans. So when I'm working with people like this, what I try to do is target those things, right? And I didn't

even understand this model back when I used to do this kind of work. But, you know, when I'm working with people with NPD or BPD, there's a lot of overlap with complex trauma. And so the questions that we ask ourselves, and I use tools like a humkata and Alexothymia and things like that, which move us in the same direction. But practically, what you need to do is, first of all, define those four things, right? Get treatment. I think this is definitely a treatment kind of thing. But define those four things.

Right, what is attention, expectation, affect, and behavior. And second thing is look for these three patterns. Is it difficult to understand what is dangerous and what is safe? Is the source of what you want also the source of your suffering? So then do you move towards it or do you move away from it? Second thing is, are you able to be reassured? Just pay attention, right? So the attention is the key thing here is like, look at what your mind does with positive signals.

because as long as your mind is filtering out, reassuring data, then it's very hard to get better. So we see this in imposter syndrome where people with imposter syndrome do a very important thing. When somebody else does a good job, they filter that as being this person is hardworking. When they do a good job, their mind adds a filter which says, I got lucky. Other people succeed because they're hardworking. I succeed because I got lucky. I succeed because somebody helped me out. I succeed because I can't own that credit, but other people get that credit.

So look at that kind of filter. And the third thing is working on cause and effect. Right? Instead of thinking to yourself, hey, if I do this, it doesn't matter. Nothing matters. Watch yourself exert influence on the world around you. Right? whether that's making a cup of tea every morning that you sit down and enjoy for 15 minutes amidst the chaos of your life,

or whether it's, you know, getting somebody a gift and receiving a gift in return, like whatever. Oh, I knew that was going to happen eventually. There goes the light. Signals the end of stream. So that's what we need to focus on, right? Those three things. And now I'm so much darker. Hold on a second.

Let me see this works. On my face. Okay? Let me just make sure that I got through everything. Yeah. That covers it, chat. All right, we're about 45 minutes over time. I know we got started.

Link our stream. Tell me about it. Right? There's cause and there's effects. There's the efforts that we put in. Not everything goes our way. And that's okay, chat. So thank you guys for coming today.

Thanks for coming. We got to roll with the punches. There's that which you control and, life and that which you do not control in life. And don't, don't confuse the two. Huge source of suffering. All right. Thanks a lot for coming, everybody.

We'll see you guys. We'll see you guys. I think I'm doing a membership stream tomorrow on Weird Stuff Part 4, which is going to, we're going to cover Brana. And then we're going to cover, we're going to do Puere Crea part two. Okay? So it's going to be heavily practice focused tomorrow. Take care, everybody.

Do I still get angry? Hell yeah, bro. Wait till I play a game of Dota. Then see how angry I get. Thanks for joining us today. We're here to help you understand your mind and live a better life. If you enjoy the conversation, be sure to subscribe. Until next time, take care of yourselves and each other.