Psychiatry & Psychotherapy Podcast - Eating Disorders: Empathy, Alexithymia, Reflective Function

Episode Date: August 16, 2024

Eating disorders are often understood through a medical or behavioral lens, focusing on symptom reduction. But what if we've overlooked something deeper—something rooted in the complex emotional lives of our patients? In this episode, Dr. Tom Wooldridge, a psychoanalyst and expert in eating disorders, joins Dr. David Puder to explore the psychoanalytic perspective on treating these conditions. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

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research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Tom Woldridge. He is a SID, he is the chair of the Department of Psychology at Golden Gate University, as well as a psychoanalyst who has published on anorexia, eating disorders, male anorexia, and I'm excited to have them on the podcast to discuss eating disorders, and yeah, welcome the podcast. Thank you. I'm excited for our conversation. Yeah, so tell me a little bit about how you approach eating disorders and how maybe it's different than most people in the field?

Sure, yeah, I'd be happy to. So my interest in eating disorders started when I was a doctoral student, and I, in one of my clinical placements, had a patient who was a young man with anorexia. And the way I was being trained to approach him was very much through a kind of symptom-focused, family-based intervention. And there was something about his journey, his plight, his suffering that really, I think, grabbed me emotionally. And so I decided to write a doctoral dissertation on male anorexia. And then, you know, as the years went by and I started a clinical practice, I'm located in downtown Berkeley. So I was near UC Berkeley and also Berkeley High. and so had the opportunity over about a decade to work with a lot of young people that had eating disorders.

And at that same time, I was on a path myself clinically of becoming more interested in psychoanalysis, developmental thinking. I trained as an analyst. And my effort has really been to bring the two together to apply developmental and psychoanalytic thinking to eating disorders, not certainly not as a sole treatment for eating disorders, but as a component of a larger treatment team. Okay, yeah. Tell me, what was it about that case that really inspired you or got you curious or interested? What was it about that particular patient, do you think? Sure, yeah. So the way I think I was being supervised to approach him at that time, It was not a strict, what would be called, an FBT family-based therapy model today,

but it was very much a kind of family-based intervention drawn from Salvador Mnuchin's structural family therapy. And so, you know, it was not at all interested in the kind of meaning of the symptoms or what lay beneath the surface. It was very much more interested in what can you do with and to the family to address the symptom very directly. and the symptom being low body weight and refusal of food. So can we restructure the family system such that it supports this young man in regaining weight and restoring his ability to eat, which of course is a very kind of noble and worthwhile goal? I mean, I'm not knocking that in the least. I think that kind of intervention can be life-saving.

And, you know, I felt that there was something about the way I was positioning myself that overlooked the deeper story. It was clear that there was more going on, you know, in the realms of attachment, in the realms of past trauma, in the realm of elaxithymia and reflective functioning. These were the words I'd put to it now that I didn't, you know, have so available then.

But it was clear that there was more than just the symptom that needed attention. Yeah, tell me about, like there's, we've talked about, and I've heard you write about kind of like this empathy gap that may exist if you purely go after the symptoms. Like what is the empathy that your approach gives to someone with eating disorder and the pain that's associated maybe underneath it? Yeah, yeah, yeah. I mean, I think this is all in the realm of thinking about our countertransference, right?

So when we're with somebody with an eating disorder, especially if it's severe and life-threatening, eating disorder, which it often is or has the potential to be. We're thrown into a realm, you know, in the countertransference that is hard to tolerate. And that can take different shapes for different people and depending on the individual patient that you're working with. But, you know, there can be fear, there can be panic or even terror that this person will die. There can be, you know, a kind of defense against that fear and terror in the form of very pressured action to do something to get them back up to the target weight really, really, really quick, which of course is important. But, you know, can you do that in a reflective way or is it in a pressured, you know,

way that's a response to an underlying feeling of panic? So, you know, we're always thinking about what's the countertransferential state of the clinician. And if we're in a place of, you know, fear, terror, panic, pressured intervention, it can be really difficult to kind of think and to understanding and feeling into the inner life of the patient, which, of course, I mean, I think we all agree is an important part of clinical work, not that we want to get lost in it, but that it at least needs to be one lens that we're holding. Yeah, okay, so you kind of, when I ask you about the empathy for the patient, first, I think importantly, talk about how we can, in our own fear, move more to, to out.

action and less to sitting with them in the midst of their pain and understanding their pain. It's like it's almost too much. Is that what that's what you're saying? And then yeah. So what have you found is the pain, you know, and then for this, maybe this individual and other patients as well. And how is a lexathymia or the lack of the ability to express an emotion? How is that, sort of intertwined in that pain? When we encounter a patient, if we have a psychoanalytic lens, I think that part of what we're holding in mind is that the place that they are today as they come to us is a result of a developmental process that came before.

They've lived a life that's brought them to where they are now. And that life has had components in it that have shaped the journey to this point. And so, you know, whenever I'm sitting with a patient, I'm thinking about what have they been through? You know, what has shaped this expression, this symptomatic expression of pain? And that's what I think, you know, psychoanalyst mean when they talk about the meaning of the symptom. What's the developmental history that has gotten this person here today? And if somebody's doing something like starving themselves or, you know, binging to the point of physical pain, or, you know, binging and then vomiting, the underlying assumption is that that's, that's

an expression of some psychological pain that they haven't been able to work through, digest, make sense of, integrate into their personality, into a meaningful way. So that's always the question I'm holding in mind. The symptom is a way to forestall a developmental process that could move them through whatever it is that they're contending with. And depending on the patient, what they're contending with could really, really, really vary. I think that links to the idea of elixothymia because, you know, elixothymia is this idea that there's no words for feelings. There's something about the person's ability to translate their emotional experience into words or images, symbols, representations that is circumscribed or undeveloped. That's the lexathymia.

So, a lexothymia is highly correlated with eating disorders, and it's one component of what prevents the person with an eating disorder from using, you know, words and making use of another person to kind of express their psychological pain so that something different could be done. with it. That's good. Yeah, I love how you're really searching to find the depths of what's going on inside of them. How do people respond to that when you do that? Well, I think it depends, right? So, you know, as I kind of alluded to it at the beginning, I very much think of a psychoanalytic approach as one component of a larger treatment team. So, you know, people with eating disorders, they need multiple modes of intervention. There needs to be, I mean, you know,

depending on the individual situation, potentially a psychiatrist and eating disorders informed physician, a nutritionist, maybe a family therapist or a family-based therapist. So there need to be multiple modes of intervention. And, you know, how quickly you can get to the underlying emotional pain in a constructive way with a given patient,

I think it depends often, certainly on who they are, but also where they are in the recovery process. If somebody is at the depths of starvation, they're not really able to do psychoanalytic work because there certainly are developmental factors that can contribute to, say, elixothymia. But another thing that can contribute to elixothymia is physical starvation.

So, you know, if the person is, you know, severely undernourished, that is a place where I think, you know, a psychoanalytic mindset can help with case conceptualization. It can help with managing the countertransference. You know, it can help with thinking about what kinds of intervention might be helpful to this given person at this given moment, but there do need to be other things happening, you know, trying to help them restore weight at least to a point where they could make use of psychotherapeutic process. You talk about this, study where they looked at the Shedler-Westton assessment protocol for a group of patients with anorexia nervosa and bulimia nervosa and how the study really found three different groups of

patients and I think this is an important study to look at because I think often we think of these groups of patients as kind of in the descriptive lens of the DSM but I think that this study added something. Can you talk about that? Yeah, yeah. Thank you for that question because I think that that really does help unfold what is a, is a kind of essential point here, which is that, you know, nowadays with the DSM-5 or the ICD or whatever, our field is very oriented towards descriptive diagnosis, which really looks at surface-level operationalizable symptoms. And, you know, in that sense, a person with anorexia is is similar to another person with anorexia.

You know, they're kind of homogeneous categories in some sense, whereas I think the psychoanalytic sensibility is much more one of heterogeneity. You know, there are two people with anorexia. I wouldn't make assumptions about the kind of underlying psychological structure of those two people. I wouldn't assume that they're the same. I would assume that there are probably multiple developmental pathways that can lead, to that same DSM diagnosis. I guess that's the idea of equifinality

in psychiatric jargon. So this particular study, it was a study with the Shedler-Western assessment protocol of a swap. And it used that, that's an instrument that therapists complete themselves to assess their patients. And it looked at patients with DSM diagnoses

of anorexia and bulimia. And in the results of the swap, three different categories of patients emerged. So there was a high-functioning perfectionistic group, there was a constricted, over-controlled group, and there was an emotionally dysregulated, under-controlled group. So, you know, in a psychotherapeutic process, that has really important implications, because if you're just thinking in terms of DSM diagnosis, you've just grouped together, say, anorexic patients who are high-functioning and self-critical with other anorexic patients who are highly disturbed, constricted, and avoidant.

And those two different patients are going to need very different kinds of developmental relationships with the therapists, most likely, to, you know, move towards healing. Okay, so the high, let's go one by one to kind of highlight this, these three different groups. Because I think for someone who's listening to this, who's maybe, you know, educated in a residency see like I was, you know, it seems like eating disorders are treated with DBT, very behavioral approaches, you get a nutritionist. You know, we had a partial program, a day-truin program for eating disorders at my, the place I trained. And I think these three categories really open up

something that is, that can kind of add to our framework. So let's slow down a little bit here. So there was a high-functioning perfectionistic group. Tell me a little bit about that group in particular, what you see, maybe what they look like when they come into your clinic. Yeah, I mean, you know, I think it's a good idea to slow down here because it's important to look beneath the surface. This idea of a high-functioning perfectionistic group, even just that phrase, you know, it might in fact refer to very different kinds of people all grouped under that category. But, you know, let's assume somebody comes in who's, you know, quote unquote high functioning. So, you know, high school student or a college student, they're doing really well at school. You know, maybe it's a student at Cal. They're taking, you know, five or six classes. They're getting straight A's. As you're talking with them about that, you find, you know, maybe it's even more than that. Maybe they're staying up until 2, 3 a.m. getting up at 8 or 9, sleeping very little, drinking a lot of, you know, coffee, pushing, pushing, push. grinding, grinding. So they're working really, really, really hard. So that says a lot to me, just in that. It says that, you know, they definitely have some intact ego structure because they're

able to kind of pull their life together in that way. That's a strength. That's a good thing. But something is leading them to kind of override whole other aspects of their person, you know, their need for sleep, their need for nourishment, their need for friendship, other interests that they might have, you know, what is it that's leading them to push in that way? Is it, you know, an internalized, harsh parental voice, you know, kind of super ego? That's one possibility, right? I mean, did they grow up in a family where expectations were incredibly high, where there was a lot of shame around failure, weakness, vulnerability, lack? That's, you know, one developmental pathway that could structure a person in that way, you know, were they kind of humiliated in moments

of weakness and failure by a parent, by someone else? We're thinking about the developmental history. What shaped the person to become like this? That's sort of the direction I would be taking it clinically as I'm sitting with this person. Not that you can always answer that question quickly. It often, you know, unfolds over months or even years. Okay. Yeah. And so There's that type. The second one you said was a constricted, over-controlled group. Yeah, yeah.

Tell me about that one. Yeah, which seems very, very related. I mean, you've got high-functioning and perfectionistic versus constricted and over-controlled. And maybe I kind of blended the two in the little case of India, I gave there. So if I think of someone who's perfectionistic, you know, they have a very, well, you know, one, One possibility is that they have a kind of ego ideal that's very difficult to attain. They have an image of who they should be that they're trying to live up to. Maybe they also have a very pronounced fear of failure.

You know, something around this kind of idea of image of who I should be, what I should live up to. If I think of the idea of constricted and overcontrolled, it's more of a kind of clamping down on something. you know, not wanting to kind of allow spontaneity or aliveness to be expressed. There's a kind of closing up of, say, emotional expression. And you can often feel that, right, in the countertransference. You know, this is a patient that comes in and, you know, different possibilities. But one is that they don't have a lot to say. You know, they come in and they kind of look to you to lead the session.

Or maybe they speak in a way that's very intellectualized. and kind of removed from their feeling. You know, those are just different possibilities. I think both of these first two, the high functioning and the perfectionistic and the constricted and over-controlled, you can really see a big contrast with the third group,

which was the emotionally dysregulated and under-controlled group, right? So that's a very different kind of patient that has very different kind of clinical implications for, you know, what they need from you. This is the person that was having a lot of trouble, regulating emotional expression. Maybe they are not really going to classes.

Maybe they're kind of binge drinking or binge eating. They're not functioning very well in their day-to-day lives. That's a very kind of different, a lot of interpersonal conflict, maybe. That's a very different kind of patient than one in the first two categories. Yeah, is it kind of like someone who's more obsessive, compulsive, versus someone who's more like borderline?

Are those kind of, I don't know, are those categories, kind of what we're talking about here? I think definitely the emotionally dysregulated under-controlled group I would think of as more in the realm of borderline structure. The borderline, not necessarily, could be, but not necessarily the DSM borderline personality disorder,

but more of kind of what analytic thinkers would think of as a kind of borderline level of structure. And, you know, it certainly could be, I mean, if you're thinking in terms of personality organization, the high functioning perfectionistic person could be, you know, in the kind of obsessional category. There could also be a kind of narcissistic characterological component because, you know, could have to do with, you know, an ego ideal or self-image that they're trying to live up to.

Okay. Yeah. And so understanding this, how does that change kind of our conceptualization of this from the descriptive to this kind of descriptive way of understanding? Or this is this is beyond descriptive because now we're talking about like there's things that are leading to this. Yeah. Deeper, deeper, deeper things. Yeah, deeper things. Deeper things. You could think of that as a, you know, kind of personality structure. Maybe that's the depth component or a person's kind of history that's led them to where they are.

That's another component of depth. But it is, I think, much more than just the descriptive level. And, and, you know, why does that matter? I think it matters because, and, you know, again, I think this is the frame I bring to psychotherapy. It's not, I recognize it's not shared by all psychotherapists. But for me, the goal of psychotherapy is to create a relationship with a person. You call it a kind of developmental relationship that is going to facilitate their ongoing psychological development. I think of the symptom as something that has gotten in the way or forestalled their continued psychological development. And I'm now coming in, trying to create a relationship with them that will allow that

development to continue. By knowing who they are in this depth dimension, you're a much better position to form the kind of relationship that they need. Not that you can just, you know, kind of construct it from nothing, but if I know, for example, that a person is, you know, say they have a kind of narcissistic characterological structure, the way I speak with them and interact with them is going to be different than if they have an obsessional structure. If they're, you know, more kind of narcissistically organized, I'll be thinking a lot about the potential of shaming them, you know, where to shame live in their, where is shame live in their psychology? You know, what are they needing from me? Are they

needing to be, you know, seen in a certain way? How is that showing up in the countertransference? Whereas if somebody is more obsessional, I'm thinking about, well, you know, how are they using their intellect? How are they using their mind to kind of organize our time together? What's happening to the feeling? Where is that being kind of hidden away? Very different implications for the way we would be together. Okay, I like that. Yeah, so if someone's narcissistically, psychodynamically oriented,

there may be that shame that could spontaneously come out in the work that you have to be conscious of, like, okay, are they perceiving something I'm saying, as shaming? And that's kind of something you're paying attention to, is that right? Certainly, yeah.

I think, you know, shame would be, kind of central affect in a person like that, you know, for a person that's narcissistically organized, you know, there's, I mean, I guess there's different, there's different presentations, right? So there's somebody who's managed to kind of organize their self around, you could think of it as a kind of grandiose self-image. So they, you know, present themselves in a certain way that is a kind of defense against shame, you know, they present themselves as good and admirable and competent and, you know, all that. At times, you know, in a person with an eating disorder, this can be very much connected to body image, right?

So part of what people with eating disorders are often concerned about is how does their body look? And, you know, the appearance of the body, again, can have very different meanings depending on the underlying psychology of the person. One meaning it can have is that, you know, I want to have a body that is, you know, to be admired, that is desirable, that is, you know, you know, kind of within our culture thought of as a good body, that can be a kind of narcissistic concern. Another, you know, kind of narcissistic presentation is a much more collapsed and vulnerable presentation. So such a person hasn't been able to pull off the grandiose self, you know, in some way that hasn't been available to them. And so they're more in a kind of collapsed, vulnerable depression.

Maybe this is a person that, you know, is binge eating compulsively. You know, their only kind of avenue to find some soothing is in a binge. And then after the binge, they're left kind of a wash and shame. It can show up like that. Those would be two different kind of pathways, a narcissistic organization could go down. I like how you put like when you're working with someone who's more on the obsessive, they might use more intellectuals.

They might try to organize away from using emotion or looking at their emotion. So you're going to look for emotion, right? That's what you said. Yeah. And, you know, I can't say too much about this because it's not something I feel I know a lot about. But I think there is a kind of implicit recognition of this. And say, you know, you mentioned DBT earlier being a kind of intervention that, you know,

you were familiar with for people with eating disorders. Well, we've now got, you know, R.O.D.T. Right. Radically open DBT, which is, you know, you know, you're not. much more, it's a very, a very different form of intervention that's much more organized to people like that. It's very much about, you know, promoting a kind of openness and, you know, kind of working against constriction instead of, like, say, DBT, working to increase regulation. So I think it's recognized in other forms of intervention, this difference we're pointing to.

It seems like one thing I've pulled from your work is Alexa. Thymia seems to be a theme that I hadn't really thought about with eating disorders per se. How did you stumble upon this connection there? And how has that helped you in treating this population? Yeah, yeah, yeah. I think, you know, for me, I stumbled upon it in two ways. I mean, it's certainly something that is spoken about in the literature on eating disorders. It's been recognized for a long, long time, at least back to the work of, you know, Hildebrook in the, what, 60s, 70s. But certainly it's noted in the empirical literature now over and over again, this correlation between eating disorders and Alexisthemia.

Alexeiemia is also associated with attachment and security. It's associated with, you know, histories of trauma, abuse, et cetera. So there's a lot in the kind of empirical literature. there that's important. It's also an important idea in the history of psychoanalysis that we can talk about if you want to. But just to ground it clinically for a moment, I think, you know, Alexa Thymia became an important idea for me because I'm trying to make sense of what I'm encountering with patients. And if anybody, you know, anybody that's worked with eating disorders has had this experience, I think, of not every patient, but many patients, especially with certain

eating disorders, say anorexia, with the end example, who comes in, you know, they sit down, maybe they've chosen to come to treatment, maybe they're being brought by their parents, but, you know, as the therapy gets rolling, there's often such a feeling of emptiness, of foreclosure, of, you know, speaking for the patient, I don't know what to say, I don't have anything to say, I don't need anything from you, I don't want anything from you, there can be long silences, there can be such a, feeling in the therapist of ineffectiveness, of not having the patient with you as a kind of full participant in the process. There can be a real sense that there's incredible pain here, but there's

just no way to get it into words. There's no way to talk about it. There's no real problem, except maybe that, you know, the patient wants to lose weight or, you know, they're thinking about calories or food. I mean, you know, very kind of circumscribed concrete places where you can get traction. And so, you know, there's a feeling of lack, I guess, would be one way to put it in the countertransference. And Alexis Thymia, I think, is one way of thinking about that. It's really helpful. I think I'm curious about your work with male patients with anorexia, specifically, are there unique differences from female clients? Are there unique, you know, obsessions, what have you found as the difference? What are the similarities?

Yeah, yeah. Yeah, I mean, that's something I've been interested in for a while now. And I think, you know, when I first became interested in anorexia and males in particular, you know, there was there was very much a feeling of a kind of under recognition of the fact that men can get anorexia. And that was reflected in, you know, the data that was passed around, you know, 10% of people with anorexia are male. And, you know, now I think we know that that's a significant underestimate. It's more like 20 or 25%. Maybe more. You know, there was very much a feeling that so many cases of male eating disorders are myth, you know,

in a primary care physician's office, and a psychotherapist or psychiatrist's office. that is just not thought of in the differential diagnosis because anorexia is thought of as a female problem. So, you know, there was a very strong feeling that I wanted to work against that. I wanted to increase recognition that this is a potential problem men can suffer from so that it would be recognized.

I think there was also a sense that men face or boys face, you know, an incredible stigma in seeking treatment in the first place. Because anorexia is thought of as a women's problem, there can often be increased shame around seeking help for it. And then there may also be things about, you know, male, how would you put it, what it means to be a man or a boy in our culture that are at odds with seeking help in the first place, just more generally. So what I'm getting at is that there may be additional obstacles to getting treatment as a male. So those were some of my kind of initial concerns. And then, you know, I think there's also the fact that eating disorders in general in men may tend

to present differently. So, you know, for a woman, for example, with anorexia, you know, there's a seeking of a kind of thin body. There's a, you know, kind of body ideal that's very much reflected in our culture of, you know, a very thin kind of insubstantial physicality. And that certainly can be the case for a boy or a man. There are definitely, you know, men or boys with anorexia who seek out that kind of body. But there are also a lot of young men who are much more oriented towards a lean, hypertrophic, muscled physique. And this is what you'd see in like muscle dysmorphia. And so, you know, how, muscle dysmorphia and anorexia are related is a really complex question, but it may be that there's

something about, you know, the male gender that leads people down the muscle dysmorphia path, whereas if they were female, they might go down the anorexia path. I don't know that we fully know the answer to that. Do you find, like, how does someone like that, like let's say they're more into the big muscles, you know, I'm wondering how do these people, people even come to seek treatment, because you wouldn't necessarily identify them as, you know, this person is too slender? Yeah, well, I think they're, you know,

again, are different presentations, but if I think about some of the young men I've seen, you know, say they're 14, 15, 16, somewhere in that range, you know, they've started to do a number of things that come to the attention of their parents, for example. So, you know, they've become very rigid in their diet. You know, they're only eating, you know, lean protein and vegetables. They're not, you know, going out with the family for ice cream anymore.

They used to love, you know, tacos. But, you know, nowadays they just get the, you know, the meat with the lettuce. Maybe they've started to use, you know, creatine or maybe even steroids. You know, they've gotten hold of some kind of supplement or substance that's oriented towards muscle growth. you know my kid he used to be so happy you know carefree but now he goes to the gem every morning and every night for two hours you know so there's an increasing sense that they're becoming rigid and controlled and driven and you know maybe depressed and the parents you know hopefully might you know pick up on that and then that might lead them to treatment okay yeah i think

there's a thin line between good aspirations and excessive aspirations. There was one guy on my rowing team in college who comes to my mind when you talk about this. He would only eat like tuna and lean chicken and vegetables, you know. And I think it was too, he was too obsessive to the point of being undernourished at times for the amount of work that we're doing, you know? Yeah, yeah. Yeah, it's a good point, right? Because, I mean, I think, I mean, again, as you said,

sports and exercise, those things are great. But, you know, there are sports that because of the practices that they incorporate, you know, say making weight or things like this, you know, where you have to cut for the sport or, you know, sports that hold out certain kinds of body ideals is very disqual. desirable, that certainly are risk factors for eating disorders. And then, you know, I think with young men, just to stay with that, you know, often there's a kind of pre-morbid, overweight. You know, maybe this kid, 12, 13, was a little pudgy or had some, you know, belly fat or whatever.

And maybe they got teased for that. You know, that's often something you see that there's a kind of history of teasing. And so, you know, they decided to try a ketogenic diet. you know, maybe, maybe dad had had a lot of success with a ketogenic diet. And so now they're going to try a ketogenic diet. And that, you know, is the kind of entryway into starting to mess around with the body and with eating. So, you know, there's, again, there's a developmental history that got them to this place. Yeah. And one of your articles, you talk about the value of rough and tumble play, but you also talk about when it goes wrong.

Is this specifically something you've seen in male anorexics, or is this something in general? Yeah, yeah. So the ideas about rough and tumble play, they were part of a very kind of nuanced and in-depth way I was trying to think about anorexia and, you know, maybe other eating disorders. So it's not so much about just rough and tumble play in itself. though, you know, there is research that rough and tumble play can potentially be very facilitative for children. But just to kind of lay out that idea. So, you know, beginning with Hilda Brook, there's this idea that people with anorexia emerge from families that have certain dynamics in place or can emerge from certain families that have certain dynamics in place. And I think this is a very contested idea because, you know, we don't want to stigmatize families.

we certainly don't want to hold up some idea of like an anorexogenic family, you know, that doesn't look at many other factors at play. People can develop anorexia from many, many different pathways. And, you know, it's really a kind of perfect storm, a biopsychosocial, perfect storm. But, you know, there is a kind of clinical observation that's been made again and again and again. And my experience does often hold up, though not always, that people with anorexia, are struggling with the process of separation and individuation. Often, because of the culture we live in and the way families are structured, separation and individuation from mother.

So they're struggling to establish a sense of self that is separate and independent from the family. Anorexia often shows up around, you know, puberty, which is a kind of second separation individuation. You know, a child around three or four really starts to establish a sense of independence. you know, can go out and explore the world and then return for refueling. And then around puberty, there's another kind of movement away in establishing ties with peers and, you know, establishing more of a life outside the family.

And that's often when the anorexia shows up and really undermines their efforts at that separation and individuation, brings them back into a place of increased dependency on the family. So one of Hilda Brook and others' observations was that, you know, the father in these families often struggles to step in and help the child with that process of separation and individuation. And so my question was, well, why? What's happening there? And one thing I noticed clinically was that it seemed like these patients were having trouble using their own aggression, their kind of aggressive, assertive energy to move out into the world. Their aggression tended to be self-directed as a kind of self-punishment, self-criticism,

self-evaluation, and less of a kind of umph, you know, energy that takes you out into the world. And so I started to think about, well, what a fathers do with their children that facilitates that kind of expression? And rough and tumble play emerged as a kind of metaphor. If you're looking at the paternal relationship, fathers interact with their children. Let's just stay with the metaphor of rough and tumple play in a way that encourages the child to express their own aggression, not too much, not too little, and the father is also modulating his own expression. You don't want to be too dominant, which kind of overwhelms the child's attempts of expression. You don't want to be too passive, which makes the child feel

too powerful. You're modulating your own expression of your aggression to facilitate the child's expression of aggression. Love it. Yeah. Keep going. Yeah. Yeah. Yeah. I think, yeah. I think rough and tumble play is so, so good for kids. And there's some kids that I see my kids' friends. I can just tell they have not been wrestled very much and they need to be. Right. And my son, if I would wrestle, he would do it every night. You know, I try to get him to do other things like basketball and go rowing and stuff like that too. But he just loves.

And, you know, it's like, okay, I want him to keep fighting, right? So I never want to get him into a place where his body goes limp and dissociates. But it's like for him, the ultimate pleasure is when he, he's on the edge of like he's about to lose, but then he pushes through. Like for him, that's like the ultimate pleasure, right? And then I let him win a little bit.

So I'm just thinking about that myself. Yeah, I think it's a lovely example, right? And I mean, for sure, there's, you know, temperament or constitution at play. And some kids will be more kind of inclined in this direction than others. But I think, you know, it's a reality that's important. It's also a metaphor. but just to read, you know, something I wrote somewhere.

I'm not a person that can just, you know, kind of cite articles without notes. But empirical evidence suggests that paternal dominance in rough and tumble play moderates the relationship between rough and tumble play and physical aggression. So in other words, the father's capacity to provide appropriate levels of opposition is a key component in whether rough and tumble play facilitates or undermines the child's capacity to regulate his aggression. So I think it's exactly what you're saying. It's like titrating, the father titrating his aggression appropriately. And, you know, I mean, this has links when you look at, say, muscle dysmorphia, one of the things that you see, and again, muscle dysmorphia is a kind of newer

diagnosis. And so the research is really just starting to kind of unfold. But one of the things that you do see, and I've, you know, written about as well, is that, that, There is often a history of pre-morbid bullying. And that can be by a coach. It can be by a father. There's some experience that the young person has had of being made to feel small and weak, vulnerable. And you can then see how the development of the musculature

would be like a defense against that. Nobody's going to mess with me again. Yeah. It's funny because, like, I feel like some of that probably is pretty adaptive for that young person, you know, to like gain some mastery over this sense of powerlessness. And I would say is that in my mind, at least that would be better, you know, to some degree having, you know, this kid in martial arts or strength training would be better than just allowing him to go on in that feeling of powerlessness.

But I guess the ideal would be as well to have it not be driven. out of a sense of inferiority or trauma, interpersonal trauma. And so I think that's where your work comes in of like, okay, now what do you do with that? How do you work with that kid or adult? Yeah, I think that's exactly right. I mean, you know, the idea that you could have a child that,

you know, is maybe shy or has been teased or bullied and they're able to get into say martial arts, and that becomes a real source of self-esteem and confidence. You know, that's great, you know, all for that. I think, you know, depending, though, on what came before, you know, does the martial arts or the strength training or whatever take on a kind of frantic driven quality, or is it more of a healthy adaptation?

That would depend a lot on what came before. And then also, you know, are the feelings from what came before? able to show up in other ways, be talked about, and worked through so that the martial arts becomes a healthy adaptation versus a kind of frantic driven defense. Yeah, I read the biography of Mike Tyson, and it seems like, to some degree, you know, he had a lot of bullying early on, some antisocial behavior that he talks about, but his, and a combination of not having a strong father figure. So when he met this amazing coach and his adolescence, he became completely obsessed.

And it was that level of obsession that opened up opportunities for him that led to a success. That's probably not the person you're seeing in your clinic, though, is that you're seeing someone who gets stuck somewhere. And I think Mike Tyson, you know, in his biography as well. autobiography, he talks about how he got stuck later in life, really, using cocaine, lots of sexual partners as a way of, you know, regulating his affect, hundreds, if not thousands. And then he eventually found this therapist who was that sort of maternal force and a wife who he's currently still married to,

who was extremely warm and consistent. And he was kind of in this frantic, chaotic place until those two people came into his life. So I'm guessing we're kind of talking about that, and that could be an interesting case study to look at. It's like both the, you could see how with different athletes, you know, the energy that they may devote to it is obsessional in nature, but it makes them great.

And I think about my own kids, they're probably not going to have that obsessional nature for any sport. Yeah, yeah, or at least, you know, hopefully not to that degree. But yeah, I think that must be a part of his greatness. It's a really interesting, you know, kind of vignette. I mean, one thing that stood out to me is this idea of father hunger, right, which has been written about both in analytic theory and eating disorders literature. It starts out with a guy named James Herzog and Margot Mayne has brought it into the eating disorders thinking. But it's this kind of longing for a psychological father. It sounds like, you know, Mike Tyson very much had that, drove him into that, you know, first coach that was such a big part of his development.

Yeah, tell me more about this, father hunger. I know this is something you've thought about. How does that show up? How does that get helped? Are you, as the therapist, kind of providing a good representation of that to someone over time? Does a hunger lessen? Do you get internalized into the patient over time, a sense of you? of, you know, so the father hunger

lessons, what's your sense on that? Yeah, so father hunger, just to define the term, is a kind of longing for a psychological father who can provide certain functions that, you know, a real father sort of ought to provide,

at least in our culture, often does provide. It doesn't necessarily have to be a man that's providing those functions. Maybe it is, maybe it isn't. But, you know, functions like, you know, a certain guidance, a certain showing how to do things, helping a child navigate the expression of aggression. You know, for a young man, it can involve, you know, other things as well, like how to, you know, navigate the world of dating and sexuality and, you know,

kind of relating to, you know, women outside the family and this kind of thing. It is a very kind of culturally bound idea, and so may apply more or less to a given person. And I think, you know, it's a question of the transference countertransference. Some patients, as a therapy proceeds, this father hunger is something that can very much show up in the transference. There may also be patients that it shows up in their life, like say Mike Tyson, but it's hard to bring it into the transference for whatever reason. So it's not something that you can force or script. but it may show up in the transference. You may sense it from a given patient.

And then it becomes something that can be, you know, talked about and thought about. And I certainly do think it's true that, you know, a therapist, at least with some people, some of the time, you know, can provide some. You know, we have this phrase, corrective emotional experience, which is a complicated phrase with its own complicated history. But it is certainly true that a therapist can provide a kind of corrective emotional experience, to some degree for people that have that kind of longing. How does the father hunger come out specifically with eating disorders and does it? Is it unique? Do you see it more with people with eating disorders?

Yeah, yeah. I think, you know, it would depend on the particular diagnosis, but say with anorexia, you know, clinically I often see it. It has to do with this process of separation and individuation. there can be, especially as a person starts to get better, especially as they start to recover more and more, a kind of longing for somebody who can show them how to be apart from their family. How do you kind of separate and individuate,

become distinct from yet connected to your family of origin, and move into the outside world? How do you do that? How do you set your own agenda? How do you exercise your own agency? Show me how to do that. There can be very much that, feeling. But, you know, it can be very different, let's say a different patient with muscle dysmorphia

who was very abused and humiliated by their father. You know, they're looking more for a father that can be attuned and kind while also being a father. Is that kind of experience possible in the world? That might be the most alive question for them in a given moment. Okay. Coming back to this idea of um, elxathemia you cite and alexothymia appears to decrease significantly post-treatment with all eating disorders. Tell me about that. Yeah, I think that's an empirical, you know, an empirical citation. So it's just something that you see that as people get better, they become less, less elixothymic. And so then, you know, the question we'd want to ask analytically is what kind

of developmental process between therapist and patient facilitated? that. Now, part of it may be, you know, weight restoration decreases alexathemia, but it's not just that. And, you know, there is an analytic literature on this beginning, I guess, in the 60s or 70s. There's an increasing recognition that there's certain classes of problems or disorders that are associated with elixothymia. So, you know, addictions, drug dependence, PTSD, and, you know, eating disorders would be another. Probably there are others. and analysts would think of this as a deficit in what they'd call symbolic function.

So we all have this ability to take kind of raw experience, which is body sensation, right? I mean, emotions, they start out as sensation in the body. So we've got this kind of somatic level of affective experience. In health, we have this capacity to represent that. semantic level of experience in images and in words. We have this ability to symbolize the kind of raw data of emotional experience. That's symbolic function. People with eating disorders struggle with their ability to do that. They can be very in touch with their body, but it may be more like, you know, I feel hungry, I feel cold, I feel tense, I feel anxious.

That's getting more towards a feeling. But, you know, they can't generally at the beginning, a treatment, talk in depth or with complexity about their inner life, you know, their affective inner life. Their experience has kind of collapsed more towards this concrete level. And so something needs to happen between therapist and patient to develop that symbolic function over time. Yeah, good. And then you also talk about this word of abjection, A, B, J, E, C, T, T-I-O-N, which is commonly described as loathing that these types of patients will experience towards their bodies. Tell me about this.

Yeah, sure. That's a tough one. So abjection is an idea that is developed by an analyst named Julia Kristava. And, you know, her writing is difficult. And so it's a complicated idea. but just to try to lay it out, you know, briefly. So the abject is that which is taboo or horrific or monstrous or disgusting. It's the parts of oneself that have been kind of rejected and cast out.

So I think what Christava is trying to do, you know, for people that are true kind of Christava scholars, they may not kind of go with me here. But I think what Christava is trying to do is get at a certain layer of experience. that for many of us is not so conscious. So, you know, examples of the abject would be like vomit or a corpse, or, you know, she uses the example of the skin that can form on the top of a glass of milk if you leave it out for too long. These are things that are disgusting.

They're revolting. They threaten us with contagion. Words like purity and impurity come to mind. So this is the kind of layer of experience that I think is actually present for all of us. for sure, it's present for all of us. But it's not something that we think about that much. But for people with eating disorders, it may be more present. It may be more prominent. So if you talk to people, especially when they're in the depths of something like anorexia, they're very much often in touch with the affect of disgust. The fat on their thighs is disgusting.

The fat on a steak is disgusting. You know, sugar is impure. It's not a clean food. There's very much a sense, you know, I think I give an example in one of my papers that I found in the media, the news media, of a young woman who was in an inpatient facility and would, you know, I think it was rolled up towels and, you know, cover the gap at the bottom of her door because she didn't want to be kind of infected with flying calories. And that's a much more kind of psychotic expression of the sphere. But it's at this level. Wow. Flying calories. Like a fly? flying calories like you know like pieces of dust well so i don't i don't think it was i don't think it was as coherent as that i think i mean i don't know it was in an article i found but i think it was that it was at the level of you know i don't i don't want to be infected by this thing that makes you fat that i.e disgusting yeah i've never had or you know think think think about um a person who's bulimic, right? They purge, they eat all this food, they're awash in shame, their body feels disgusting, and then they vomit and they feel clean, they feel pure. These are the kinds of words

people will often use. So they're evoking a kind of level of experience, and this is important because we want to be able to kind of empathize with what they're going through, not in a kind of, you know, simplistic way. We want to be able to immerse ourselves in the experience of what they're going through. Yeah, no, I'm glad you're, I'm glad you're giving us this, this way of looking at it because some of us, this is the farthest thing from our experience. We love ice cream. We love a good state. Right, right. You know, none of that inspires disgust. Right, right, right. So it's, it's, but you could see how the moral centers, disgust centers, kind of intertwine, how they get revved up, focused on things that would be nourishing?

Yeah, yeah, I think that's right. I mean, you know, we don't live, for the most part, in a culture that's oriented around purity and impurity anymore, but, you know, there's still our cultures like that in the world, and Western culture used to be more oriented in that way. And there's a whole history here that's fascinating. I can't really talk about it at length, but, you know, some of the kind of earliest documentation

of anorexia is associated with, you know, religious practice. So, you know, you've got anorexic saints and nuns, you know, hundreds of years ago. You know, you've got histories, traditions of asceticism that have a lot to do with purity and starvation. You know, there are, I think, important links there. There's this quote that you put here. I'll read it. Like many, I spent my childhood feeling disgusting, however, at however any evidence of that time is scant the series of photographs that document my childhood there is an absence that occurs about the time that I was severely anorexic the reason for the lack of previous documentation is simple why or how could such a site be documented

Even now my eyes turn in aversion from memories tinged with a mixture of shame, disgust, and guilt. At the same time, I do remember the splinters of pride that accompanied the disgust. Pride at the beautiful, prominent set of ribs, the pelvic bones that stood in stark relief, causing shadows to fall on a perfectly concave stomach. Looking back at my experience, I wonder at the forces of pride and shame doing battle in a body that knows itself to be disgusting. Yeah, that's a quote from a woman who wrote about her recovery from anorexia,

and I think it really does get at the level that we're speaking about, you know, disgust, pride, shame. you know, certainly discussed is very much a kind of at this level of the abject. Robin 2004, this was a quote that you gave me. So, yeah, so this object, how do you help someone who has this? Like, how does someone work through this when they feel this revulsion towards their body, you know, this disgust towards their body? Yeah, yeah, yeah.

Well, I think there's, you know, no simple answer to that. But in general, I think of, we've talked about this idea of Alexis thymia. So, you know, you're helping somebody through your developmental relationship with them, develop their capacity for symbolic function. So first of all, you know, they're developing the ability to identify these as emotional experiences that they're having and to give voice to those emotional experiences in the therapy. be relationship. And then, you know, as the treatment proceeds, hopefully you're also, you know, helping them develop what's called mentalization or reflective function, right? I mean, I think in one of the articles, I didn't get a chance to read it in depth, but in one of the articles you sent me, and I've seen this in other articles as well, right? Low reflective function has an association with eating disorders. If you don't have the electsifymia to some degree worked through, then the reflective function can't get much traction because you need to be able to have, you know, mental states to reflect on in the first place. But, you know, as a person develops

their reflective function, I think that applies to these experiences of abjection. Can you think about? Can you reflect on them? If you can reflect on them, then you can take, hopefully, meaningful action in relation to them. Seek out experiences that, you know, promote a satisfaction with the body, that promote a feeling of enjoyable embodiment. I mean, this is very far into recovery that we're talking now, but I think that's the general trajectory that you hope to see unfold. Yeah, so this was Reflective Function by the time this, our episode will air.

I will have an episode air with Steele on Reflective Function. And in one of the articles that we discuss, reflective function there was a group of impatient psychiatric patients so these are in patients with eating disorders and the average reflective function score was

2.8 which for people with borderline personality disorder in the same study it was 2.7 so it's very very similar to people with borderline per size disorder and the reason why I think that's significant

is this is low and this is something that can be improved with psychotherapy. And specifically, so just to back up to define reflective function, for those of you who have not heard that lecture yet, reflective function is defined as very similar to mentalization, but it's very specific. So mentalization is the ability to know. your own states, other people's states, read accurately into your own experience, other people's experience. So to some degree, there's some overlap with the lexathymia. What am I feeling emotion? To another degree, it's overlapping with empathy. What is someone else feeling? But specifically, reflective function is scored on the adult attachment interview. And so it is looking at your

ability to look at your own mental states and other people's mental states, motivations, the complexity of what was going on from age zero to 12. And I think why that's important is because you're looking at your nuanced understanding of your developmental relationships, what you could or could not know in yourself and other people. And it's a scale that's gradable from negative one to nine. And so a score of three, which is these patients with eating disorders and people with borderline per size disorder, it's a low score, which shows room for improvement. Now, there was another study on transfer's focus therapy that showed that reflective function increased from 2.8 to 4.1, which is significant because you're going from questionable or low reflective function

to almost average reflective function. So you're getting a huge jump just with that one unit increase. And so I think understanding that is so potent to understand the importance of what Wildridge is really capitalizing here is that the depth therapy experience, with some psychoanalytic sensibilities

of understanding counter-transference, transfers, is pertinent to making this shift of increase in reflective function. And this is why I get excited about it. If you're listening to this and you're like, wait, psychoanalytic psychotherapy for eating disorders, like how does that make sense?

Read about reflective function. Read about elixothymia. This does make sense. sense, right? That's my way of understanding it. And of course, I would also agree with this idea that there needs to be a team approach. Like sometimes when someone is way under BMI, their brain may not be ready for depth work. When you see patients in outpatient setting, have you had cases where you're like, I think this person at this state, with this degree of low body weight, is not ready for the type of work that I would like to do with them. Like, how often does that happen?

Yeah, can you speak to that at all? Yeah, I think it happens all the time. I mean, people walk in, you know, to the office in all sorts of different, you know, places in their process. And so, you know, there needs to be a very kind of thorough evaluation at the beginning, including a medical evaluation of what level of care is appropriate for them. You know, do they need a higher level of care, number one. And if outpatient care is appropriate, what forms of intervention need to happen in what order? Or, you know, what's the priority in a given moment? And so, you know, often people, you know, push back. They often come in and they want to do psychotherapy, you know, even though they're severely underweight and they're not, you know, kind of wanting to gain weight yet. And

That in itself is a very complicated process that needs a lot of reflective function applied to it. You really need to be kind of very thoughtful about how you go forward. So, you know, in an ideal world, right, everybody would come in and they'd say, okay, I'm ready to, you know, get my body weight up. And then I'm going to start, you know, a psychotherapeutic process to work through the underlying components here. And then, you know, I'll try to sustain this gain in body weight over time. But that's just not the way it works. Some people are in that place, but other people come in and they've been in an inpatient treatment two or three times. They're not willing to do that again right now.

And so something has to happen to get them to a place where they are willing to do that again. So a lot of thoughtfulness, care, consultation, you know, is often really appropriate for a clinician to think through a given situation. It's complex. And then any, I know any thoughts on this reflective function stuff that I brought in and kind of of my interest in it or how it speaks to the overarching interest that you have. Yeah, yeah, yeah. I'm completely with you. I mean, you know, I'll be interested to hear that episode.

I'm definitely waiting for it personally. I think, you know, this idea of reflective function was a big component of my own kind of postdoctoral training at Children's Hospital in Oakland where I worked with, you know, children that were zero to three. and their families. And, you know, it's such an important component of the direction a child's development takes, the reflective function of the clinician and the mother and the father, you know, before birth and in those initial years. So it was really, really driven home to me in that postdoc. What a central factor this is in parents that facilitates or derails a child's development.

I think, you know, the link to eating disorders is a really important one. And I think, you know, psychoanalysis, psychoanalytic theory, it has all these complicated ideas, developmental theories, you know, this idea of objection, the ideas about separation and individuation. Those theories are, you know, important for a number of different reasons. But I think one reason they can be important is that they provide scaffolding that we can use to refaverage. on what's going on in a patient, right? They give us a kind of vocabulary for thinking with complexity about a person. That is, I think, part of their use. And so, you know, I think a therapist having that reflective function in hand, I mean, I think you mentioned this when we had an earlier conversation, something Steele had found about that being a really important common factor in therapeutic effectiveness. That's totally believable to me.

this was actually uh that study was post steel um and it's something that i stumbled upon that got me really excited about this because i've been studying common factors for years trying to understand it trying to you know think about how like what is the active ingredient in good psychotherapy and yeah in this specific study which i've cited a lot at this point in this podcast but i'll cite it again when they looked at what made the best therapists the best the best 70.5% of it related to their reflective function score. The therapist's reflective function score, meaning when you ran the adult attachment interview on the therapist, how the therapist spoke about their childhood related to their outcomes with their clients. Which if you look at all of the

different aspects of how they score reflective function, it makes sense. It didn't have as much to do with actually their attachment style, the therapist's attachment style, it had much more to do with their reflective function. And I think about this as well when we think about countertransference. Like when you have a countertransference response to a patient, if it's unconsciously registered and then reacted towards, that's a low reflective function stand. towards that client. And I think that learning from you about, okay, these are the common things that occur in the countertransference, this actually increases our reflectiveness about what might

be going on with us in this specific client. It can actually increase our curiosity about what's going on in ourself. And then that increases the reflectiveness, that decreases the reactiveness with clients, that increases our compassion and our empathy. So when someone experiences is something that may be that you otherwise would react towards, and instead you have compassion, I think that allows the treatment to be powerful and effective for the client. That may be the ideal perfection that I strive towards, which I need to have some compassion towards myself when it's not perfect, but, you know. I think that's exactly right. Yeah, I agree with everything that you said.

and adding in the recognition that, of course, will always fall short because there is, you know, however you want to think about it, there is the unconscious or there is dissociation and enactment. There's processes between therapists and patients that always foreclose our reflective function to some degree, but we're always working to open it up again. Yeah, and I would say this is where if you're a clinician and you're with a patient and you're in an enactment, which is like something maybe even from the from the patient's past is getting relived in the present moment with you and the patient. Or you can also be an enactment where you are pulling the patient into a sort of type of relationship that's very common to yourself.

I think good supervision where you have a supervisor who can help you reflect with curiosity into what might be going on, especially in a way that decreases shame because the shame will not allow you to explore it maybe in a reflective way. I think that can be important, realizing that a lot of the greats of psychotherapy had very imperfect lives.

And so, yeah, to not think that we are above it ever, right? right okay so kind of as we as we kind of start to wrap up our our own sort of work here together are there any other categories that you wanted to speak to that we have not hit big categories on eating disorders on working with eating disorders and i know i mean i'm scratching the surface here yeah i mean i would echo that i think you know we're scratching the surface we're focusing on something very particular which is what kind of a psychoanalytic sensitivity and theory contribute to eating disorders that certainly has overlaps with empirical research and other forms of intervention. I think we've alluded to this treatment team idea a number of times,

which I think is, you know, again, so important because I don't at all want to come across to saying I'm advocating for taking somebody who's in the depths of anorexia and putting them just in, you know, an analytic treatment. Many different things need to happen for people in that place and I think that you know the sensibility we've tried to kind of unfold today can be a really important piece of that work yeah I would I would say I mean my sense is that if you if you had a client that came in who needed a higher level of care you know could it be that your connection with them was somehow maintained during that higher level of care I don't know do you have any thoughts on that? Like when you send someone off to like a higher level of care, do you continue to

correspond with them, talk with them, or how do you normally navigate that scenario? Sometimes, yeah, or, you know, correspond with their families that can take different shapes. I think, you know, and this would be a whole other topic, and so I'll just speak to it very briefly, but how they're sent off to a higher level of care or a different form of care is really important, Right? Because if you are a person who is, say, anorexic and you're going into FBT or inpatient treatment where there's going to be a strong interpersonal press towards re-nourishment, that in itself can be a very emotionally overwhelming experience. Your whole defensive structure is oriented around not eating. And now you're going to be pushed, sometimes pushed very, very hard to eat. And that, you know, in itself can be, you know, a traumatic experience, really, even. as it may save your life. And so the way in which that transition, that handoff happens,

requires a lot of thought and care because it's a pivotal moment in a person's life. That's good. Yeah. Any last tips for providers on how to be patient with the process of helping someone

with the difficulty in electathymia? Yeah. Yeah. Yeah, I mean, I guess I just point to consultation as key, right? Because when you're with a person and the space in which to reflect and feel is very collapsed, a third relationship with a consultant or a supervisor can really help to open it up inside the therapist so that they can remain alive in a relationship that feels constricted or deadened.

You know, consultation has certainly been key for me, many different kinds of consultation. over the years, if you're working with people that have this degree of difficulty. Excellent. And any advice you would give to any patients who might be listening to this, who might be like, yeah, maybe that's what I'm missing. Maybe I need to find someone to help me in this regard. What would you say? It would be a good way of finding a good provider, finding someone with expertise. It's a tough one, you know, because you're speaking to, you know, the patient, which is who's the particular person that needs the advice and the guidance and advice and guidance needs to be so tailored to the individual. But just in general, I think, you know, you want somebody that has training with eating disorders that can balance the pragmatic aspects of recovery and with whom you feel listened to.

and understood, not just kind of instrumentalized and treated. And I think that balance is really what we're going for. Can they hold the practical and can they hold the emotional depth of what's gotten you to where you are? Very good. Well, wonderful. Tom, Woldridge, thank you so much for coming on. Appreciate it.

If people are interested in learning more, I will have links to your books, website, and my show notes and in my the article that we will work on

that will go with this episode and try to cite some of the sources of things and yeah, any final closing thoughts?

No, it's been a pleasure. Thanks for the conversation. All right. We'll leave it there for today. Thank you guys for listening and have a great day.