Psychiatry & Psychotherapy Podcast - Karen Horney: Neurosis And Human Growth

Episode Date: May 20, 2022

In this episode of the podcast, we discuss the work of Karen Horney, M.D., titled, Neurosis and Human Growth: The Struggle Towards Self Realization. In the book, Horney discusses the concept of neurosis as it stands juxtaposed against what she deems healthy growth and human development. We will be discussing this concept and some of her prevalent theories introduced in the writing, such as the development of neurosis, the contrast to the healthy individual, the components of growth, the tyranny of the "should," the search for glory, and neurotic claims. We hope that you will be inspired to pick up this book by Karen Horney and join us in thinking about her important work. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Before we start the show, Dr. Pudor would like to announce that none of the participants, in this episode have any conflicts of interest. Let's get to it. All right, welcome back to the podcast. I am joined today by a group of residents. We are going to be

talking about a book called Neurosis and Human Growth by Karen Hornay, The Struggle Towards Self-Realization. This is a book which I read as a third-year psychiatry resident, and it was awesome. I felt like it was like my first taste of like really, really, deep deep inner psychic stuff going on and i was i was all about it um i think i read it again somewhere in in my early sort of practice and then i read it again for this so joined with me is serena weber she's been on several episodes hasan canani he's also been on some episodes George Gianna Caccos

Johnaccos All right in ballpark and Sonia de la Cruz who's new to the podcast so yeah I'm sad that some of you

are graduating this is a local Orlando residency and we're going to be missing you guys oh oh we'll zoom in

catch up occasionally that sounds good so so George why did Karen Horneye break from other psychoanalytic schools

So we're just jumping right in. What was the unique? What was the unique about her thoughts? So I think, so Hornay, like obviously a lot of her theories stem from Freudian, like, psychoanalytics. And one of the biggest things that I think she had issue with, at least with, in terms of how Freud in particular defined neurosis, was how he kind of brought everything back to. that psych, what is it, the psychosocial? No. No, like the drives, the early drives, the edible tribes. Right. Like the libidinal drives. Right. Yeah. Yeah. And she was like, eh, I don't know. I think you're just really, you're really kind of narrowing things down to something that is not necessarily

something that she observed in a lot of her work with, with her patients. She felt that Freud kind of failed to address a lot of moral and cultural pressures and how those things affected, how patients responded in their psychological development. She also felt like the whole penis envy thing, all that, like the edible stuff that you were mentioning, really boxed patients in particularly women in areas that I felt like she didn't see as appropriate. Yeah, as we'd all kind of... Right, right, right.

Like, usually the things that we think about Freud are the sort of the caricature things, which have not lasted, everything else we've absorbed, right? So we've absorbed transference. We've absorbed like Freudian slips, you know, early object relations theory. Like a lot of the stuff, the dream, dream analysis, like the unconscious, a lot of the stuff that he put together was absorbed or kind of like odd. And the oddities are usually what you read in textbooks. Right.

So she actually trained with Franz Alexander at his institute. This book was published in 1950s. And actually Dr. Tar. my mentor came out to USC to train under Dr. Franz Alexander as well. And so my mentor, I think, is in his late 90s now. He's still traveling to Europe like three times a year. Yeah. They founded the Chicago psychoanalytic Institute together,

Franz Alexander and. I don't know like if she was a founding member, but I know she went out there for a while. and then she eventually broke off and did her own thing. Yeah, Chicago's good, by the way. That's where you're at, right? Yeah, she was like, yeah. But this was a 90, yes, this book was published in 1950s, right?

And so she was psychoanalytically trained. She would see people pretty intensively. So what were unique thoughts? That was like the second part of the question. Anyone else have any thoughts on what was unique about her? A lot was unique about her. Maybe I should paint just like the big picture so that it's like we can add to the big picture, right? But I'll put it in a way that I feel like it's understandable.

Okay. So you have this kid early on who basically like is not seen for who he is or it's kind of like the true self is stifled. Maybe there's some trauma. Maybe there's some different things where he needs to protect it. And so he, through imagination, identifies kind of like this idealized persona, the hero, the fearless, the conqueror, right? Or it could be the person who is always, you know, winning the person who's always perfect. So imagine this idealized persona is like, there's like a cape behind it, right? So he makes this move from the true self to this idealized self.

and then what happens is, you know, what causes this idealized self is a lot of like environmental influences, right? And so as you're reading this book, if you go back and read it, you're reading it with like there were environmental influences, right, in the 30s, 1930s, 1920s that influenced Karen Hornay and her generation, right? That may be different than what's influenced us, right? we may have different social pressures and environmental influences on what we would then define as the shoulds, right? So the shoulds are like, I should be perfect or I should always be politically correct or I always should have the right thing to say, you know, blah, blah, blah, right? But these shoulds are a little bit different than like good moral, like things that we'd all agree upon, you know, like, I mean, because the shoulds, have like this very, very strong link to the idealized persona. And so this, you have this idealized persona.

Imagine the cape. And there's these things like neurotic ambition, striving for perfection, and vindictive triumph. Okay. And so you have initially, you know, like this real person who's got things that they were built to do. things that desires, emotions, personhood, that then gets shifted into this like false self, right? This idealized self.

And it's the anxiety, it's often the anxiety. Like I feel alone and isolated in a very scary world, right? That's the anxiety that drives this process. And then out of these idealized persona, you have the shoulds, you have the neurotic ambition. So it's ambition, not in a sense like, oh, I want to accomplish something that's close to my heart, close to my goals, close to my person. It's like, I want to win at everything. It's like the person who can't lose at a board game that he's never even played. Or maybe it's like they play a new sport and it's like I should be perfect at this sport.

I should be good at this sport without really, really trying hard for decades and I should be able to beat him. And then if I'm, so it's the striving that's in all domains, not the gifted places in your life where you're like, this is uniquely my talent that I enjoy that gives me a sense of passion and purpose. This is different. This is a competitiveness for the sake of competitiveness. That's the somerotic ambition. Then there's the striving for perfection. So it's like, I need to be perfect.

My house needs to be perfect. Like I need to be perceived as perfect. And the perfection is defined by the culture. Okay. So the culture creates the shoulds and your subculture, too. So you could be in like a subculture and you could start to notice what the shoulds are, what the things are. I mean, there's probably some in psychiatry, right? They're probably some.

The subculture of medicine is full of shoulds. Oh, yeah. Medicine incultures you. And psychiatry then, like, tries to reincultrate you. and then I'm trying to get you to enjoy and love what you're doing, right, and be passionate. You should be passionate. You should just find your... That's good.

That's good. Yeah, it's hard. It's hard to escape it, right? It's very, very hard to escape it, which is why I try to lead with like, hey, I'm not perfect. Like, I'm in process here. I think we all suffer anxieties and worries and, you know, different things. It's like I talk to a lot of residents and nurse practitioners and PAs. And, you know, it's like the same things.

Everyone's struggling with the same things. Insecurities, like, what do I do with this difficult person? How am I going to be perceived by my colleagues? Interpersonal conflicts. My boss doesn't understand. It just makes me more busy. So, okay. Sorry.

Can we talk a little bit about, like, how neurosis is being defined in this book versus maybe how, like, a layperson might, define like, oh, my mom is a neurotic. And like what, you know, we mean by that versus what, like, the author might mean 50 years ago or 70 years ago. So this process of living out of the idealized persona and not out of your true self is what it means to be neurotic according to Karen Hornay. Now, had my wife started reading this book and she calls me up all worries, she's like, but you've told me that I score high on neuroticism, you know, and like, I mean,

a little bit higher than the average, you know, on like. the big five and I'm like okay the big five neuroticism very different than this okay could be some overlap but like it's a different measure they created the big five out of like all of the adjectives that existed to describe people and they narrowed it down into clusters and looked at factor analysis like that's not a psychoanalytic tradition based measure okay so this but then neurotic according to psychoanalysis, there's three levels like neurotic, borderline, not borderline precise order. Borderline like organizational.

Borderline organization and psychotic organization. And so that's not what this is talking about either. Okay. So she's like recrafting pretty much psychoanalysis from the ground up. So I hope that didn't confuse too many of you. Okay, let me finish this like big picture portrait of what's going on and then we'll dive into the facets of it. Okay, so you have this person, they have their shoulds, they're defending these shoulds now.

Okay, and so now what happens is they live their life and people point out the discrepancy between who they really are, meaning the experience other people are having of you, and this idealized persona that you are so fervently trying to defend that you are. And that discrepancy makes you react in three ways, or makes the person who's neurotic accorded Karen, who are and I reacted through this? One is to attack and to, you know, and we're not talking about like a little attack. We're talking about a big attack. And then the second is to join.

So you join the aggressor, join the person and take on their sheds. Oh, I should be doing this. Oh, I'll change my sheds, right? Which is another, like it may appease your sort of psychological problem. process for a little bit, but it still is suffocating, right? And then the third is to just isolate and run away and just, you know, by the time you're in your late 60s, you're like no friends, living in the middle of nowhere, like very little human contact, right? So it just pushes these people out further and further into the abyss of sorts. So they retreat. So that's what happens

when someone pushes you, pushes against you, and shows the discrepancy between your real self, who you really are, and this persona that you're trying to portray to the world. Okay. That's the basic thing. The one thing I forgot was, so I mentioned they have neurotic ambition,

striving for perfection, but I did not mention vindictive triumph. Okay. And so this is like when they beat you, they just it's like right-sided smile gloating in a really kind of a negative way it leaks out most most high social EQ people hide this probably pretty well but it's there so it's like I'm going to steal your partner and then I'm going to like rub it in in a way maybe that just like defeats you or like I'm going to I'm going to beat you at this like game of settlers of

Catan. And then I'm going to like, you know, basically just gloat and maybe internally, but maybe it comes out externally. But it's like there's a vindictiveness aspect of it, right? Okay. So how's that? Good. That's good. So I'm the outlier here and that I didn't. Serena Weber. I told her to come. She was busy. I told her to come. And so I've asked Serena be the voice of the listener who doesn't really know this. And so she's going to ask questions when she gets confused. Go ahead. What you said, though, reminds me a little bit. And I don't know if this is accurate, but it sounds like a lot of narcissism, potentially, like the idea of like the false

self or idealized self and the true self. And then I guess it reminds me of like Winnicott and like go ahead. Yep. Yep. Yeah. So there's, um. Like injury. Yeah. No, that's like what you described to me sounds like narcissists. And I'm glad you brought that up. So I've never done an episode on narcissism. So this could be considered like my sort of like first episode where we're touching on a lot of things that are narcissistic.

One thing that she brings up is that there's also that when there's this knowledge of the discrepancy, there's self-hatred that comes in, which you'll sometimes see when you get the narcissist in your office for a problem. a long period of time. It's like at first, they're very sort of, like, everything is awesome. It's really hard to connect with them because that you don't feel like they're congruent, congruent meaning you're not, they're not really talking about their real emotions. You know, they're distant. So people who are very neurotic in the way that Karen Hornay defines it. By the way, for the rest of this time, I'm just going to use that word and we're just going to

know Karen Horneye. We're talking about Karen Horan I spoke here. Okay. So in the way that people are neurotic, they are, they're not living up to their shits at times or they're in denial that they're not. But when they catch themselves, then there's that self-hatred. So it's a little bit different maybe than a psychopathic narcissist who just has no affective empathy. I think they can be more of the, the pure Machiavellian, dark triad, you know, narcissist, psychopath, Machavelian. And they can, they might see everyone else as like objects like cockroaches everyone's a cockroach. So they don't, it's, they just they're in their brains. That's how they're wired, right?

That may be a little bit different than what we're talking about here with Karen Horneye. But the narcissist that you could consider that would fall into this category would be someone who gets deeply angry whenever they get challenged and they lash out. and they like call people names, they degrade people, they, you know, they attack. Yeah, sorry, I think at one point I can't remember where in the book, they do talk about like a narcissistic person or personality. Someone has really married that, that idealized self with the actual self so that they truly see themselves as that godlike person. And so then the challenge comes in and they say, well, that's impossible. because my actualized self is my idealized self.

And then all of the fallout that you just kind of described. Right. So it's like, so the more of the grandiose type of neurotic, she also describes a self-effacing neurotic, which is like very sort of internally punitive. And that may sort of come in more like a depressed person. Yeah, when I think of self-effacing, I'm thinking about somebody who, like, will lose at a game but make you feel guilty to the point where they regret losing and they, like, get, you know, that vindictive triumph by sucking you in and making regret that you won.

And then I know when we're talking about the narcissism, we have the self-effacing type, and then we also have the expansive type where they're trying to get that mastery. And that's where they're getting that sense of pride. And that kind of has that flavor of narcissism. And I know she talks about these three different types of personalities and one of them where she's talking about narcissism, but she makes sure to make that distinction between the narcissism that we know and what she's describing. That they mentioned in the book. Okay, define what you remember of that type. So what I remember is they kind of shun like the idealized self and then they kind of have a sense of shame with it.

But then they're not living a vital life. Like they're not going after their ideals or living out their true self. They've just kind of retreated kind of a shell. Yeah. I had a couple of patients in, like, psychodynamic therapy, who, for cultural reasons and family reasons, like, you know, they were, like, homosexual men, and couldn't, they felt like they could not live that way openly. and so they kind of made themselves or you know like we're basically doing this this false self and maybe maybe it's not maybe it's not the same thing because because I wouldn't necessarily call it

narcissism and that's in that case but when you talk about you were talking about how like there was moral pressures that that created ideal self well an ideal self maybe as they see it includes being heterosexual and then they live like a really false self in a different way. I don't know if she touches on anything like that. Yeah. I mean, I think that totally, I think it still fits into her framework because the idealized self, I think can be anything like you were describing with those patients that you had. And so just because they're not exhibiting how we would define narcissism today, I mean, I think to a certain extent it is what you were describing. I think it does still fit.

That gap between, right? The idealized self and the actual self, whatever that may be. But it just sounds, I guess, I guess what sounds different is because we ended up talking about narcissism a lot, and that sounds different, right? Because I don't know if. This isn't always narcissism. And honestly, I think if you're listening to this and you're like, I probably have some of that too.

It's like, yeah, yeah, we probably, maybe not. full-blown in the way that if you read the book, you'll be like, oh, okay, it's a little bit different. But we all have a persona that we present to the world, which is probably different than our real self. And especially if you went through medical school, like, you learn how to, like, be a certain way to get less pain, right? Because, like, if you, it's like, you can't show signs of weakness a lot of times. You can't say you're hungry. So there's lots of, you can't have emotion. like I don't want to stay till 12 o'clock and keep operating, you know, it's like too bad. Like you're, you know, you have to just kind of like play the role and roll with whatever

is happening and then all the chaos of like, like you don't, you may not have a lot of choices, right? So I feel like that, so we, that's a little bit different than the neurosis that she's talking about. But it could be kind of like, as you're listening to this, I'm imagining that you could be thinking like, oh, I have a list of shoulds that. I believe where I have this persona that I'm aspiring to be good. No, I'm just thinking about how, like, how we've basically like introduced the topic and

kind of given an overview. And initially, it definitely seems a little bit more confusing. And there's like so many other concepts that, that we already know and comparing that to this can actually seem difficult, not difficult, but confusing to when you're trying to understand it. And that's why when, like, when she wrote the book, most of the book is actually talking about the whole pathology or the whole concept of neurosis. And that last chapter is then talking about like the therapy aspect of it. And she talks about why she spends all of that and why she goes like piece by piece or element by element starting from the root of how neurosis

is developed and then working her way to introducing us to each of these these, these parts of the idealized self. And so for me, most of the time spent while reading the book was maybe those first five, six chapters just because it was so dense. And each concept is new, foreign, and you're mixing it compared to like what you know. And so you have to like build this new schema in order to build on that. And so it's okay with you. I know. I know. we've already talked about neurosis or like briefly talked about it but i really liked how she started off the book with like the acorn example about how like an acorn doesn't become a tree itself but the acorn actually has to be um you just have to provide a safe environment a supportive environment

it needs the good soil it needs the sun needs the water and and when the when the acorn feels safe then it grows up into a tree and and and so really that's how it is in an ideal a situation where a person or a child, if they have that safe environment and they feel that love, unconditional love, then they're able to identify with the real self and have that healthy growth. But the whole problem happens that parents or the people that they're around or the environment that they're around, they're struggling with their own neurotic, the neurosis. And so they're not able to provide that safe environment, the environment of warmth and compassion that the child needs. And the child eventually learns that they're not safe. And so since they're not in safe,

they go into like a warrior mode. Or this is how I like see it in my mind, that they see it in a warrior mode. And so they're not worried about getting that love as much. And they're more worried about protecting their self in order to be able to grow. And so that's, where this destructive energy of neurosis comes in. So I would just put some nuance to the last thing you said. The energy that would lead them to grow into their true self gets diverted to then the neurotic goals. And so what you're doing in therapy

is you're helping them move from spending all of this energy towards their neurotic goals back towards their true self, if that makes sense. Absolutely, yeah. And I mean, how do you do this, right? It's like you are looking for glimpses of their real personhood. This is where I think, like, logo therapy is so helpful. It's like, like, what, you know, or microexpression.

It's like microexpression cuts to the core of, like, that emotion is your emotion. Like, that anger that you flashed is a real emotion that you just had. Okay, I know that. Now what do I do with that as a therapist? well, let's say the person is denying that they're ever angry, right? Like, I should always be happy. I should never be angry. It's like, okay, then how do we help them get less shame around being angry?

How do we help them being safer, right, with being angry? And so a lot of what we, what I would do then is I would empathize with the distress of being angry or empathize with the shame that's contained in the anger or, you know, try to allow for the person to have transferential anger towards me, which will come out in a way that they would be safe enough to then start to get in touch with their real personhood. So, yeah, so it's like the energy. One thing that Karen Horanai says that I like is that everyone has an energy to move forward, right?

But the problem is that often this energy is diverted into the goals of the neurotic ambition. and people don't know how to get it back on track. What do you thinking? Yeah, absolutely. Yeah, absolutely. I follow that. And that's why, like, when she starts off talking about it, she calls it a waste of energy.

It's a lot of the neurotic ambition can be a waste of energy. You know, there are things that we uniquely enjoy that gives us a sense of pleasure and purpose for me. like, you know, connecting with other human beings. It's like, that's like, I really enjoy that. So it's like, I feel very privileged to be in a job where I could do that. Or just even with you guys, you know, or like, look at each other. Like, you know, I enjoy teaching, right?

And so it's like, how do you find what is your true passion? Well, honestly, it's probably been years of therapy, you know? Like, I mean, I don't know how you do without doing your own, you know, having someone who's trained and helping you sort of uncover, you know, what might be under it deeper. And she mentions that one part, like, dreams give her, like, a glimpse into this world as well. And I really do think that, like, looking at dreams and, like, it can uncover unconscious fears. had this one patient that would have dreams of water crashing over her. And it was like in the world that she felt,

she felt like overwhelmed, like and suffocated. And then eventually I appeared in the dreams as like a guard against the water. Like I created a bubble of like air around her. And in my mind that was the bubble for her to allow herself to find her true self. And then, you know, it's progressed to this. Safe holding environment. You know, and it's, I've, with this particular person,

and I imagine this person might listen to this, so it's like, you know, change a couple details, right? But this person has found their creative outlet, and the world has noticed, you know? And it's like, it's like as this person has become like someone who is doing this creative outlet, it's like, it's like there are people that are flocking to it, you know? Like, it's that close to this person's like persona,

but it's taken time to like protect that part, right? That would have otherwise been like suffocated by the waves. You know what I'm thinking about? I'm thinking about how like she starts off talking about search for glory and how like the complete opposite is that the search for meaning. And, you know, how we talked about, their search for meaning with Logotherapy and with Victor Frankel. But, yeah, yeah, that's exactly right.

We talked about search of glory and all of this the entire time, and I'm like, oh, what is it on the opposite? And it's right there. Search for meaning. And it will be very idiosyncratic to yourself probably, right? And it may take a while to find it. Right, yeah. This is where, like, I think in therapy,

it's like we don't just empathize with the sadness and the anger and the negative emotions, you empathize with the good stuff too. Like the positive emotions, like when someone lights up, when someone accomplishes something, an achievement, like graduating from residency, you get excited with them, you know?

You like share in that. And sometimes I'll see this with like, when I watch videos of residents, the only attuned to the negative. And it's like, that's what I should do as a resident. I should empathize. You should empathize with everything. You should, or at least, like, it's hard to get away from the should, but it's just as important

to connect with the positive. It is. I, like, relate to this so much. Well, and I don't know if maybe everyone can relate to this a little bit, but I do feel like in medical school, I was driven by the shoulds, like, a lot. And then I think more recently, I feel like life is easier and more enjoyable and less stressful just because I'm thinking more in the, just what I choose to do. Right. Yeah. And, and Hassan knows, because we share an office sometimes, sometimes he'll catch me saying, like,

oh, I should have done this or I need to do this. I should do this. And he'll be like, you say too many shoulds. And I know that's, you know, that's. It takes one to no one. And I think we talk about this, too, in medical training or, you know, we hear a lot of like imposter syndrome. But, like, who's the imposter? Like, what are you supposed to, how are you supposed to be, right? And so the imposter is like the actual self filling the role of this, you know, omniscient, omnipotent doctor. And you're like, well, I'm an imposter because I'm not that person.

When in reality, like, you know, who is that person? Dr. Cummings, otherwise it doesn't exist, right? I'm not that person. You know, but like it's, you know, and this is like another thing is a lot of patients come wanting this answer. Like if only I got this answer, I would be cured. And it's like, for me, it's like, it's not an answer. It's like it's going to come out of relationship and it's going to take a, it's going to take a while to uncover it. Sometimes it comes quickly, but usually it takes a while, right?

And it's like a good, like meaningful thing to dedicate yourself to. Sonia, what year are you? I'm a second year. Second year. How's your journey going? Honestly, my journey in residency has been wonderful. That's good. Genuinely.

I kind of, you know, relate to kind of what you guys were saying where I feel like in medical school, you're just so drowned and swamp by, like, needing to meet these grades and, like, having to impress these. people and kind of molding yourself into the perfect applicant for that residency track. And it's compounded by your environment too. You talk to us on about like the environment on which you're in. And when you see kind of everyone around you in that atmosphere and like, you know, that's also reinforced, becomes a really difficult current to go against. So I think it's also important to have an environment where you are given the freedom

to be you and to have that support and putting in necessary ingredients to let that person flourish and be genuine. And it's hard because there are so many hoops to jump through. When I meet with medical students, I say to them, sometimes you're going to do a project you don't want to do if you're working with me because we need to get it done. Sometimes you're going to do a project because we've sat down

and we've talked about what your passion is and your passion. I can imagine some topic that's close enough to your passion that we can we can kind of like get you to do something closer to what you're really interested in. But sometimes, yeah, you just got to be a part of a team. And the other thing is like sometimes when you're learning the craft of like how do I review papers or how do I do research, it's like there may be a topic in your mind that you eventually want to get to. But when you're learning the craft, you're learning the craft. You can't just jump in and do research if you've never done research. It's easier to be mentored. In an upcoming episode, I'm going to go through a paper I published,

and I had a great mentor and a series of great mentors. But it's like I couldn't have done that without great mentorship. It's like, so you have to be a part of a team and sometimes do something that's like a little bit less interesting to you per se. But maybe you can eventually more closely approximate what your passion or you need. curiosity is if that makes sense yeah she she says a growth with with others it comes in love and in friction so there's there's love there's a safe environment but there's also friction or or you know like would you know that you liked psychiatry if you hadn't gone through internal medicine and

surgery and er and obi-gyn and then you're like oh what i really enjoy is this so sometimes you have to like try out a hundred different things You know, to know that you don't want to do those things. But there's something about this that really, like, gets you excited. Yeah, or you're out there coming out of the womb wanting to be a psychiatrist. That's okay, too. Yeah. And I think she talks about it in the book, too, where we are able to kind of have delayed gratification

because we have these values that we hold so dear that it's okay to kind of forego, like, immediate desires in pursuit of that thing that you value that gives you meaning and vitality in life. I have questions, but I don't know if we should like dive back into them or this is a good line of thinking as well. Any thoughts? Was there things, maybe let's go. I do want to, I know we talked about the shoulds and I want to talk about the consequence of the should. Not not like in the long term or just in the moment when you're in the sheds. Okay. They're exhausting. They're exhausting.

So exhausting. It takes such a toll. And, you know, we were talking about it. And, you know, I can probably think about my own exhaustions, but I know she talked about hers, like how I remember, what was it? I think she was like on a journey from Mexico back to the States or something. And she had a flight, but then she was taking off the flight because I guess some priorities. and she had to take a bus from, from, somewhere in Texas, Corpus Christi all the way up to New York, and it was a three-day bus ride.

And she was so frustrated. She was like, because it's like a resistance that you're feeling, right? And so she was so frustrated that, you know, this happened to her. Like, of course, it makes sense logically for you to get booted off a flight and this to happen to anybody else, but why did it happen to me? It's like that sense of entitlement that comes, that brings about the frustration. And, you know, the insightful that she is, she was able to recognize in the moment that she's getting frustrated.

And, you know, she shares how she recognized it and that frustration, that exhaustion, the fatigue that happened, and just went away. And not just that. She enjoyed the trip, the three-day trip, all the way back to New York. And so I definitely relate with that in my own life, like should come all the time. And in relationships and stuff, it's like, no, I should do this or like that perfectionist mentality comes in. And sometimes I don't, you know, that should bring that resistance, the energy of resistance. And so sometimes instead of saying should, it could be I want.

And so changing that mentality takes away that resistance and really makes life easier. Okay, yeah. Because I think there are sheds that are like good sheds, and then there are sheds that are the neurotic sheds. And she defines the neurotic sheds is like they always come with this weight and this punitiveness when they're not met, right? There's general things like, I should do these things. They're good things to do.

I don't necessarily feel like the, this sort of like self-hatred that quickly comes when I don't do them. You know what I mean? Yeah. The should's associated with the ideal lifestyle in that whole system. I should work out. Like if I miss a workout, okay, you know, like, I'm going to be okay, right? Whereas like someone who maybe is more neurotically focused around working out, it's like,

now the rest of my day is completely destroyed. I'm like, you know, and then they beat themselves up. Like, I'm a coward. I'm lazy. I'm a procrastinator. and then that self-hatred then turns into like, well, you know, maybe I should drink or maybe I should do something, you know, to hurt myself now because, like, I've been bad. So it's like, now I'm going to, now I'm going to do something that hurts me.

And so you could kind of see how there's a difference between like, in general, like, you know, we can benefit from eating a certain way or exercise in a certain way, but then like it could become a neurotic drive in a way that's unhealthy as well. Yeah. I mean, I still think there's value. Like in your example, I still think there's value in exploring why should you exercise, right? Like I think, you know, and then it may go down a path where it's like, well, because I want to obtain the certain physique because that is the cultural expectation of what it, of what manhood is or what manly, you know, masculinity is. And I want to, to, you know, achieve that standard.

Right. So it could be, I mean, superficially what you described, right? And he might not spiral down into that that death spiral that you described. But I think it's still, you know, as therapists, you know, our job to kind of explore. You said you should work out why. And then see what they say. Right. And this is exactly why it's such a loaded thing to prescribe it for depression or anxiety. Because like people are coming in with all sorts of ideas about why they were exercised in the past or what it meant to them. when someone recommended exercise, you know, are they recommending it because of they're not pleased with my aesthetics or it's like, it's like in my mind, it's a potential dynamite feel that I kind of have to like tiptoe around like, okay, hey, there's this thing that's like almost like a medication that you could do. Better than a medication. No side effects except for some soreness. Right?

Yeah, good, good. I've converted you fully, no. And I've started to run a little bit, too. You'd be proud. Good, good. People in our program actually ran a 5K this morning. And I like to think that I started that. Good for you.

Good for you. Not positive culture as well, do. Shouldn't you have run that? I chose not to. Oh, good. You had the freedom not to. That's excellent. We can embrace that freedom.

I'll take my kids running. And it's like I'll let the slower of the two lead. The faster one goes in the middle, I go in the caboose, right? And so we try to run one house, walk one house. And slowly, you know, like over weeks, they're making me hustle. Like, I'm running faster than I would if I wasn't running with them. So it's been fun. But it's trying to create it in a fun way where it's like, you know, at that age,

It's like, how do you make it into like a Pokemon game or something like that where it's like, you know, there. Anyways. Okay. So we got, Sonia, tell me, how do you think Karen Hornay would describe someone who was healthy? So I think Karen Horan I would describe someone as healthy if they develop like the unique alive forces of their real self. So that means like tapping into their goals, their desires, their gifts, their values. So in other words, you can say that the patient is moving towards self-realization or self-actualization. Yeah.

Okay. Hassan, what is the false self and how does it grow? So the false self, I know we've already talked about that, but just kind of to bring that into focus, it's the idealized self, the one that neurosis is feeding, which is. which has been molded through neurosis and the efforts of the pride system that I guess we'll get into a little bit more including the neurotic pride, the tyranny of shoulds,

the self-hate and self-contempt, all of these together feed. And it's a positive feedback loop, really, which continues to feed and grow the idealized self and continues to degrade and devalue our real self. Okay. That last part was neurosis. Neurosis is the positive feedback loop.

Neurosis is the positive feedback loop. Right, yeah. Okay. Yeah, basically, how does it grow? It grows by, you know, it's kind of like sometimes when you argue with the delusion, the delusion gets stronger, right? And so it's like if someone has a delusion that there's like worms moving around their skin, in an ER and you say there's no worms moving around your skin.

It's like they're going to throw stuff at you. They're going to get angry. How many doctors are not listening to me? No one cares. And then I pick up their pants and I look at their leg and I touch it and it's warm and it's cellulitis. And they're a person who's maybe used a little bit of methamphetamines. and so they have this like

or maybe they're schizophrenia and so this person in particular just needed antibiotics right but when she came in telling the ER doctor with a history of schizophrenia or psychosis or meth you know I have worms crawling in my skin that ER doctor said call psych right so there's this combination of like

we need to listen with empathy we need to investigate medical stuff we need to be curious. And we need to maybe not initially just push up against the delusion, right? We're curious about it. And then how does the delusion serve them? Right. Where's the motivation to keep it that way?

And then when you find glimpses of the congruent self, it's like, how do you get excited with that person? How do you decrease the shame that they can actually be congruent? Right? Because one of the things that I think drives people towards this false self is shame. Like, I want to be perceived by you as this person. Sonia, what do you remember? You interviewed with me at a different residency than you ended up, which is kind of fun. Cool.

What do you remember of that interview? What do I remember? I just remember, like in terms of, of connecting with you or in terms of like how I was feeling or uh I don't know if you could say anything here I guess. Were you starstruck? I guess. That was the truth.

I was, you know, just thinking about living in a different state at that time where, you know, I had family at, um, I was thinking about how can I, you know, convey, um, I guess in a, in a way, like my worth and like what I can bring to the table in this short, minute amount of time. Right. And how can I, you know, just give a genuine portrayal of my capabilities and who I am as a person to this interview in front of me? And I kind of have to figure out who you are too and kind of how will you react to what I'm saying. That is so applicable about like. Well, just like, because when we interview, we often rather than, I mean, sometimes people might totally be themselves and be kind of.

all that. But I feel like a lot of people are like, okay, this is how I should act. And this is how I need them to think of me as I, you know, as I interview. Like, I need to act this way. I need to convey this so that I look like this. And yeah, I don't know. It doesn't have to be. But I think it's an environment that very much encourages that. Yeah. And I think linking it to to the book, right, are you, are more of that expansive type where you have no problem really talking about yourself and your strengths and, right, your actual self and your idealized self are, you know, they're pretty, you know, they're close together and, and, you know, it's not an issue. Or you more of that self-effacing type, right, where you're like, all right, really need to, you know,

you look at yourself in the mirror before the interview. You're like, you are smart. Like, you deserve this, right? When in reality, you know. Right. Yeah. Because you have to convince even yourself, right, that you're worth what you're, what you're saying in that interview. And so I think, I don't know. Is it something that, Dr. Peter, that you like pick up on when you do these interviews? You know, interviews are always like... He's got all the micro expressions down. It's like, okay, so the interviewer comes in with this, like, idea of this is the stuff that I'm

going to talk about or... And maybe it's like the 10th interview. And so they've like, they have this kind of like narrative that they're going to tell you or like things that they're, you know, going to tell you. And so what I like to do is I like to just kind of like get at like, what is the real person here across from me? And how do I cut through all of this stuff? Because honestly, if it's something that you've told, like, 10 people,

like, your interviewer's probably going to start to yawn. You're almost yawning and Hassan. It's a script at that point. No, no, no, no, not at all. The script is like, and that's why I think. He has a young child. Right. And you're always sleep deprived. So it's like, how do you get to, like, the passion, like what really brought them in?

And sometimes they don't even know. And so if I can, I'm trying to get to something that they've never told anyone. And sometimes, like, the stories are like, okay, you know, you're on an interview. You know, and some things like I wouldn't even tell the group. Like, I wouldn't tell them. Like, if they shared something that was like, like, I knew, like, might hurt their chances at this program, but I connected with them. I liked them. You know, I would rate them high.

I would hide those little secrets, you know? But that's who I am, right? I'm not a forensic psychiatrist. Like, I can't, like, play that game. So, like, it's hard for me not to like people. But once in a while, you know, you get someone who comes in and they just don't, they just don't care. They're there. They're out there.

You know, and you can tell that they don't care. They have no energy for the interview. They don't want to play the game. They don't really want to connect with you. They're just going through the motions. What are you thinking? He seems surprised. Yeah, that's, that's.

that's surprising. I mean, but then again, also like, I was not surprising for me. I was going to say, but also not, maybe not surprising. I don't know. I guess I've interviewed enough people. Like, wasting everyone's time.

Right. And then especially when you had to fly for interview, like now that's like virtual. But I remember like I would do like the tours and like or meet residents or not residents, but applicants at like lunch. And there was always like one or two people that I, it's very clear. They don't want to be there.

And I'm wondering why are they there maybe just to have like a backup. but you're obviously. You're not going to have a backup. Yeah, you're not going to have a backup. If you're not appearing, like, maybe you have some, a place you'd rather be. But like, if this is not, you have to. And that's bringing up the problem of like,

you're real, the real self may be showing through. Like, not interested, right? Which is, which is like, like, what do you do with that, right? What do you do? I mean, that's really where they're like, they're thinking that maybe they're better than us, like the mastery point where, you know, the expansive side is coming out where we're beneath them. And then you also have other people who are very timid, not talking at all, very, very anxious, not able to connect, not able to think through an answer.

And so you have people on the other side as well. And so, but the best people that are the that you connect with are the ones that you feel that there's an actual connection. And sometimes you feel there's like maybe barriers in between or curtains in between. I think to interview well, you have to know yourself to some, you have to know yourself well. You have to be like your story has to be close enough to reality. It can't be a script. It can't be a script.

And people will feel if it's like close. Yeah. That being said, like I would read some personal statements and I would be like, okay, this person needs like therapy. Oh boy. and this is this is so close but i don't see signs that they've actually like done the work so then it's like you know sometimes as if they were a local person you know we'd give i'd give them that feedback or one guy i remember didn't make it his first round like he didn't get in

anywhere and then he got some treatment and now he's like in the field you know so you know there There is a securitus route for some people, and that's not a problem. Okay, I think we should kind of wrap it up, though, because I feel like, I feel like I want, oh, yeah, you want more? Yeah, I know. I like, feels like it's going well. I like, we're having a good time. Absolutely, it's been fun.

We could banter more. Second look. Right. Okay. Okay, but someone who is healthy, I think, is responsible for their own emotions. their own needs. The real self is the original force towards individual growth and fulfillment.

So there's this force that they've connected with. It's the original force that's moving them forward towards their growth, towards the fulfillment. They have responsibility that matters. This is from Karen Ornay. So they have a recognition about their responsibility, a willingness to bear the consequences of their desires and actions

without trying to get by, or putting blame on others, a realization that it will be up to him or her to do something about their difficulties without insisting it upon others, fate or time, right? And they may need to ask for help as well, right? So they're willing to ask for help. And so those are some of the things that I got from the book about like, what is health, what is healthy. And responsibility being one of them, right? It's like receiving feedback, accurate feedback. trying to look at the consequences, how do I actually move forward, being realistic, not blame shifting. So like, you know, you give feedback to someone, it's like how quickly are they going to blame shift, right?

Well, I think that's a good point that you brought up about accurate feedback, right? Because I think with that, with the difference between the idealized and the actual self, we try to bring them closer, right, to their actual self. recognizing that their needs, their strengths, their desires. But we want to make sure that whoever's telling them that is accurately kind of interpreting all of that for them. Because otherwise, you know, they're getting feedback like, oh, no, you're great. You're on a, I don't know, a rotation, medical rotation, right? And oh, great, nothing, you know, no issues.

There's no problems. And you're like, well, I guess I am, you know, I am my idealized self in that case, right? If they're not getting any true feedback to bring them back towards their actualized self and help them grow. Yep. Yeah, really good point. Feedback is hard too, though. I want to say that.

It is really, really hard. And, you know, it's hard not to look at it and kind of go all bad on things as well. Like, you have to apply some of the cognitive distortions, you know, am I having a negative mental filter? Am I filtering out all of the positive things? I'm not paying it. attention to and there's this one little piece of negative

thing. That's why you have to do the sandwich model. Yeah. Tide and true. Except if you're a skilled person

like me, like once you start hearing the sandwich model happening, you're like, oh shoot, they're giving me some negative feedback here.

He needs a Panini model, a hoagie model, something more advanced. I need, yeah, I need like something more advanced. The ice cream sandwich

model. Yeah, okay. Well, there's so much here. I actually like, I think I'll probably, I don't know, I might come back to this book again at some point in the future. So please pick up this old book, but good book. Any final thoughts? I think I need to read this book now.

There we go. Good. Yeah, that's awesome. I think you do because you're interested in psychotherapy. You're interested in the deeper stuff. You know, it's just one small piece of like good things that you should read and sort of absorb. There's a lot, right? So if you want to do psychotherapy, it's like, this is like, I think it's a fun book.

It's a very colorful book because she's so intelligent. And one of my thoughts when I was reading this is like, I wonder how much her intelligence is like seeing things in people that isn't really there sometimes, you know? Like, good. I don't know what that means. It's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, it's a, of, um, attributing your personality onto someone else's personality. Oh. Right. So just like, um, someone who's more paranoid personality, they may think that everyone's paranoid, right?

Yes. Someone who's highly intelligent may think that everyone else thinks at their level. And reading Karen Hornay, like, I'm like, okay, she's definitely up there. Like we're talking about like three standard evasions above the main up there. A lot of layers. A lot of layers. Yeah. Yeah.

You can just like think about like some passages and she has so many quotes that are just so well written. It's just a wealth of knowledge truly. But then she also talks about, I know, how knowledge isn't enough and you got to put in the work. And I know that's something that you were talking about with traits of healthy people or or people that are putting in the work. And that was really one of my takeaways. You had talked, asked about, you know, any final thoughts. And for me, really, it was like, hey, Hassan, you really got to put in the work.

Like, you know, reading all the books or reading all that really won't get you anywhere. And then she also brought up, like, a tapework example, tapeworm example, unless, you know, like, completely annihilate it. It'll keep on coming back. And so, you know, the one thing I was thinking was that if I don't continue to put in the work and you know, continue to build that awareness. And what does put in the work mean? So the awareness. So first of all, like identifying when all these things are happening, like catching my

should, catching. I should catch my should. I was about to say. You should catch your sheds. I should work harder. There's so many. And if I don't, I'm going to just hate myself. Like I'm failing at catching all my sheds.

There's no pressure there. I'm happy when I catch it. Okay, okay. But I think you need more people in your life that are like, Hassan, like you're awesome the way you are, dude. Yeah. I don't hear those people. I ignore that.

We need to amplify those. It's very self-effacing of you. I should only listen to the negative feedback so I can keep growing. But I definitely think that there's work needs to be put in. You're never a complete version of yourself, you know, till there's Brett. You've got to put it. in the work. I think the work also is like therapy, supervision, like relationship, right?

Like when you get out, you're almost graduating, like, put apart some of your budget for continued work. Like, realize that that's part of, like, I still have a supervisor. I still have a therapist. Like, I chose my first job, which was a huge pay cut from some of the other jobs I was being offered because I got to hang out with Dr. Tar four hours a day or one day a week, right? Like, that was so much value that I chose that job. So sometimes the work is that, and not that I've arrived, I'm still paying money for, you know, top-notch, L.A. prices, therapy and supervision, right? But, you know, like, you can track down people that you respect and that are in your area that you, like, know have a very good reputation, and you can set up part of your budget for that. So that's,

that's what I think of the work as. Like, part of its reading, but reading is probably like 10%, right? knowledge is 10%. The real work of the work that we're in is either connecting with colleagues to go over cases, but it's also like receiving the kindness and the decreasing of the shame and the looking at your own emotions, your own dreams, what's deeper in there, you know?

That's what... I can't imagine like doing therapy without being in therapy for years, honestly. And so like, you know, I had, anyways, I could go on preaching, preach to the size example, right? How do you preach exercise without doing exercise? Yeah. Oh, man.

It's like, get me started. And, you know, it's not always, it's not always easy, right? It's a sacrifice at times. Like, it's expensive. Like, good people are probably going to be able to charge more. And they're probably going to be able to be busier so that, they're just going to be charging what they can, right? So there's like market price for like different people at different levels.

Not that I don't think you need like the world famous like inventor of this particular brand of therapy. You don't need that person. Like ask around who are to people who are in the know like, hey, who have you referred clients to in the past like 10 years that you've had a good experience with over and over again? Write down those names and then go to the next psychiatrist you work with and say, hey, who are the therapist that you've referred clients to that you've had a good experience with? Who in the community would you refer your mother or your father if they had issues?

You don't need to tell them you're referring yourself. You could just say I'm trying to get to know some of the names of the people in the community. That's one way of finding a good therapist, you know? In valuing that, like I think, I think at least when I think of myself and how much therapy can cost, even if it's on the lower end, it's like, so you know what might be like, oh my God, that's so expensive, how do I pay that all time? But then I think about it, like, if I went to dinner, you know, like, this is so much more valuable, you're investing in yourself. I don't know, I guess I think about, because a good therapist needed training, they needed supervision.

Like, it makes sense that they're charging, you know, a decent amount of money, and the benefit can be huge if you're invested in the therapy as well. So it's worth that, you know. It's worth, maybe you have to go out to eat a few less times. Right. Like last, last, last. night I saw a client at like 9 p.m. because it was a crisis, which I never do that, right? And why do I never do that? Because my whole night was like, like, I had a hard time sleeping, right? It was... Boundaries. I normally have good boundaries. I normally have really good boundaries. But once in a while, I break the boundaries, right? Once in a while I do. I would say like,

that's like a once every quarter type of like, okay, I'm going to, I'm going to do this. and so like okay yeah it costs that person quite a bit of money for that hour right well but i lost like like psychologically holding that burden like took away about two hours in my sleep like you know took away my time with my family the next day because i needed to sleep and catch up maybe took away from this podcast being like fully alive and awake you know i don't know so like i think like when like as a therapist I understand, like, there's only so many hours a week I can do therapy and do it well, too. You know, like, for me, when I go beyond, like, 30 hours, it's like, it's probably, like, I should probably take some time not to do therapy.

So I think there's a balance, too, where it's like, you know, some therapists are like, I can, you know, especially if they're more neurotically as in Big Five, neurotically wired, they may be able to do 20 hours a week. They may be awesome therapists, but, like, that's, like, what capacity they have there. So when I talk, when I do supervision, I talk to different people. Sometimes it's like finding that like how many hours is your, is like where your limit is and then what is under your margin.

You know, you want to live under margin. You don't want to live like right at the edge or above beyond the edge of your stress level. Like you're forced to do in residency. You don't have a choice, right? You have to live beyond your capacity a lot of the time. but when you're graduated and you have freedom, freedom, choices. And this is interesting because like a lot of new grads don't want to do the 40 hours a week job. Like I hear that over and over again.

Yeah, I almost see like grimaces on your face. You're like, no, we don't. Because you want margin, you know, you want some freedom in your schedule, you own margin. You want to be able to have capacity to rest and not be depleted, right? And so, yeah. Okay. Don't think that you need, I should work 60 hours a week for the first 30 years of my life. It's like, I should drive the newest sports car. So I, you know, I need to work 60 hours a week to drive that newest sports car. It's like, okay, spend the money on therapy, drive the Honda Civic for a couple more years and work on your shoulds rather than, you know. But you should read this book. Yeah. Yeah.

Yeah. For me, I really liked the depths of the book, and it really made me think about deeper themes in life. So for me, my takeaway is to kind of be mindful about, you know, am I getting caught up in the search for glory, like this need for perfection, for like neurotic ambition and the tyranny of the shoulds? Or am I living a life that, you know, like really uplifts my values and kind of is true, is connected to. my true self. And it's really interesting because, like, I'm actually reading another book about, like, don't waste your life. And it kind of, it's interesting because Karen Horne is not at all, like, related to my faith, which is Christianity. But a lot of the themes that I saw kind of are things that I've been reflecting on, which is, like, what is the meaning of your life?

You know, what are you, what are you, at the end of your life, what are you hoping to achieve that people will say about you? And, like, the key, theme of that book as well that I'm reading is like don't live a wasted life how do you live in a way that you know honors your values and makes you really feel connected to your true self on your daily in your in your day so I feel like you know there's moments in our lives where like you really kind of find your true purpose because of at least for me like a feeling like when I went to psychiatry seeing people at their worst and, like, connecting with them in a way that they have not with others

because they're just so real, and they're, all that curtain is, like, lifted. Like, that for me is electrifying, you know, because it's, I have this privilege of doing this, you know, of being in this space with you. And then that's kind of how I knew I wanted to be in this field, because that made me feel connected to my true purpose. It made me feel alive. And what a way to kind of live the rest of my days. with that, you know? So I think

that book was kind of just a reminder for me to keep myself in check and to think about my purpose and my direction. That's awesome. Yeah. Yeah, it's like the search for meaning, search for purpose, which is uniquely you, right?

So it's like even in a religious organization, you could have someone telling you you should be doing this as in like you should live your life or like, you know, you should in a way that's maybe, it's not core to who you are as a person, right? So it feels separate. It feels different. Like every group of people, every clan has a group of like shoulds that you, like, to participate. Some of them are good. Some of them may not be

good, right? Some of them may lead to your thriving. Some of them may not be. So it's like hard to sort of parse that out or find what that is. Yeah. Any other wrap-up? up thoughts. Yeah. Okay. This was awesome. Yeah. I'm glad you guys came.

I'm really glad you guys came. I'm glad we happened. We, I don't know what book is next, but this was an awesome one to go through with you guys. And I hope this was helpful. If you have any thoughts, questions, concerns, feel free to jump on psychiatrypodcast.com.

We'll probably write up a little summary. I found a medical student to help us with it. Thank you. And so, Hopefully it's not a shit for them. Hopefully it's not just a check-off for their CV, but their passion. All right, we'll leave it there for today.