Psychiatry & Psychotherapy Podcast - Nancy McWilliams on Mental Health, Transference and Dissociation

Episode Date: March 3, 2023

In today's episode of the podcast, I speak with Nancy McWilliams, Ph.D, a renowned psychologist-psychoanalyst. She has authored several books, including, Psychoanalytic Diagnosis (1994; rev. ed. 2011), Psychoanalytic Case Formulation (1999), Psychoanalytic Psychotherapy (2004), and Psychoanalytic Supervision (2021). She was also the Associate Editor of the Psychodynamic Diagnostic Manual (2006; 2nd ed. 2017).   We discuss different aspects of mental health and how it pertains to relationships. We also discuss qualities that make a strong therapist and the ideas of dissociation and transference in therapy.  By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Dr. Pudor and Dr. McWilliams have no conflicts of interest to announce. All right, welcome back to the podcast. I am joined today with Nancy McWilliams. She has a PhD, is a psychoanalyst. She practices therapy and supervision in New Jersey, and she has authored several of my favorite books, probably the books that I've bought the most for young professionals for their education. the books include psychoanalytic diagnosis, psychoanalytic case formulation, psychoanalytic

psychotherapy, and psychoanalytic supervision. And I would say, like, if I was to give you an award, now I read your 18-page CV, which was, it's like, I was reading it and I was like, wow, can I, like, can I like travel as much as you someday? Oh, yeah, that is a wonderful feature of you. my life. Yeah. Yeah. One that was completely unexpected. Oh, so wonderful. And so my award to you would be, if I was to give you another award on top of all your awards you've received, is maintaining the transfer of wisdom from authors past who have decades and decades of experience of real life seeing patients, right? So deep qualitative research that they have done through deep case series, right? So transferring that wisdom to the next generation through your books, that would be my

award. Well, I would happily accept that award because that's what I've been trying to do for my whole career, is pass on clinical wisdom, which often gets devalued by academic people, because it is insufficient. We do need research as well. But there is tremendous wisdom in clinical experience. Yeah. And I would say looking specifically at human personality with curiosity and openness to discover something new with each client. That's the end of, that's the last part of my little award. Oh, okay. I'll take that too. Thank you. That's a really nice description of what I would like to have done in my life. Yeah. So, okay, one thing I was thinking about was we could start with what is a healthy personality?

Like, what is, what does mental health look like? Interesting, because we don't talk about that a lot. Ever since the 1980 edition of the DSM, we talk about what symptoms people have, but we don't talk about the overall aspects of mental health. And I've thought a lot about this. In fact, I had planned to do a book, about it, but my editor told me it was too scholarly for a popular book and too popular for a

scholarly book and it kind of... I'll glad we published that for you. But I imported it to my book on supervision. And in that book, I talk about things like, first of all, some sense of basic safety, especially with other people, attachment security. the sense of basic trust in the world and the capacity to evaluate whether you are in a safe position. Secondly, a sense of agency that, irrespective of what culture you live in, some of which emphasize individuality more than others, you have some sense that you can find your own power or choices in any situation. Third, a sense of continuity, a sense of going on being, a sense of being able to have empathy with who you used to be and imagine who you might be in the future,

to be able also to good and bad aspects of yourself and see it as the same person rather than dissociating from aspects of yourself and sometimes seeing yourself as wonderful and sometimes seeing yourself as wonderful and sometimes seeing your yourself as the world's worst villain, being able to feel continuity with your body so that you understand that that's you, you don't starve it, you don't cut it, you don't burn it. So continuity is a big part of it. So kindness, kindness with your body, right? Kindness with your own body, yeah. Caring for your body, okay. Self-esteem should be reliable and reliable.

realistic. Realistic self-esteem is not unduly perfectionistic and not inflated, that you have reasonable standards for yourself and you give yourself a break when you come close to them. And reliable is you don't get shattered if you're criticized and you don't get all inflated if somebody sucks up to you, but you can count on your own self-evaluation to carry you through. affect tolerance, capacity to tolerate the whole range of human affects is a big part of mental health, the capacity to stand for yourself, but also to sacrifice for your family, community, or village, children, some combination of being able to do both those things is part of mental health, the capacity to accept what can't be changed and grieve and move on rather than getting stuck in an attitude of complaint and victimization to accept the bad things that happen and grieve.

And with that comes forgiveness eventually and gratitude for what is and the capacity to love, work, and play. Those are the things that as a therapist you want to see increase in people over time. Probably left one out, but that gives you the general ballpark are the kinds of things I've tried to conceptualize. What about like what would emotional or mental health look like inside of relationships like with other people? How would you sort of further define that or further describe that what that looks like? The capacity to be fully honest in a relationship emotionally, the capacity to repair whenever you inevitably have wounded the other person or feel wounded yourself. That includes the capacity to apologize, which is a huge part of mental health, to take responsibility for any failings that you bring to a relationship. the capacity to accept the other person as they are, as opposed to as you want to improve them,

to love people as they are, and to be devoted to someone else's well-being, your child's, your partners, as well as your own, all those aspects, being able to be grateful and to remember what you're grateful for with your partner, because we all tend to start relationships idealizing people. That's the normal part of falling in love. And then the question is, once you start seeing their clay feet, can you move that idealization into a more mature kind of love? Or do you decide you haven't found the right person and you want to trade up and you throw that person away rather than being able to deepen the relationship. I've been seeing a lot of that in recent years of people who,

and it's partly, I think, a result of the Internet and the fact that people feel they have endless choices of partners and there might be somebody better at there. It gets in the way of making a commitment to one person and deepening that relationship. It involves forgiveness and gratitude and the capacity to say what you need and to tolerate the other person's imperfections. Okay, yeah, that's good. And then so, like, as we kind of move from healthy to, like, the furthest from health,

you categorize them with words that some people may not know, and I think it may be useful to kind of define how you would define, like, healthy versus neurotic, versus borderline versus psychotic? Yeah. Well, those are just terms that have evolved from clinical experience. You know, some of them have gotten kind of pejorative sounding, but I tend not to like the movements that rename everything to try to make them not sound problematic because eventually those terms sound problematic, too.

And then we lose the sense of continuity with our own history. So healthy I've just described. The neurotic range of suffering can be quite severe, but when you call somebody neurotic, you should be meaning that they have a conflict internally, a problem, attention that they see as a problem, that they can collaborate with you to look at in themselves. if they're more in the borderline range, and the DSM uses the term borderline very concretely, very categorically, but the way the term emerged from clinical experience was,

there were some people who seemed to be more troubled than just neurotic, and yet they weren't psychotic. And they would get very regressed in treatment. They would alternate the treatment. clinging and hating you, they would have transference reactions to you where they really couldn't differentiate you from people in their past, you know, at the neurotic level, if you said to a patient, is it possible that you're experiencing me like your critical mother right now? They would get interested in that and look at it and explore it and think, gee, maybe I bring

that assumption to a lot of relationships. If you say that to a person in, of a certain kind who suffers greatly, they will react with, yeah, it's my bad luck to have a therapist exactly like my mother. Right now, you're exactly like her. So that was hard for therapists to work with because it didn't have the usual response. So this whole group includes a lot of trauma victims, a lot of people who can't keep a sense of continuity, who go into states of all good and all bad, who have very intense reactions, who feel abandoned when they're separate and engulfed and controlled when they're close to other people and numerous other things that you can describe in the clinical literature. At the psychotic end of the spectrum,

I use the term the way the psychoanalytic community has used it over decades, which is to say that we all have a potential for being psychotic. Not necessarily schizophrenic, though. That seems to have some particularity. But by psychotic, I mean you start being confused between what's inside and what's outside. If you're angry, you may instead feel that somebody's out to get you and not be conscious at all of your anger. you may understand things self-referentially a lot. This is about me.

They're looking at me funny. When somebody else makes you unhappy, you think they wanted to do that because you can't quite imagine them as having a different subjectivity than that. So in psychotherapy, when the therapist is trying to say something empathic and the patient suddenly feels in terrible danger and bruising. brutally attacked, that's kind of psychotic reaction therapy. And there are some people that really struggle with keeping their sanity, who are quite self-referential, who have terrible annihilation anxiety, not just separation anxiety,

but they live in constant fear that they're going to be totally fragmented, cease to exist, that they'll be destroyed. So there's a whole, I think most therapists, not just psychoanalytic therapists, think dimensionally about numerous aspects of psychology. And down at the struggling to survive end of the spectrum, we think of that as in the psychotic range, even if you don't have a diagnosable psychotic illness, you're fighting for your sanity all the time. Yeah, I think that's that's pretty clear. And I think it's it's helpful. I like what you said especially. It's helpful to think about the historicity of looking at these categories as it's been written in the literature and how we rename the same thing over and over again. And I think there's like there's something a little bit self-beneficial to renaming it and then having your own brand. Yes. Which, which, you know, like, I mean, in the great psychotherapy debate, I don't know if you've seen that book, but they talk about how modality is not really what makes a huge difference in psychotherapy. It's more the therapist and therapist effect.

Absolutely. All the empirical literature suggests that. That's a good book, I think, because they really looked at the empirical data. And psychotherapy progress depends about 85% on the individuals involved in their relationship rather than the technique that's applied to a symptom, although certainly there are valuable techniques to apply to symptoms out there. Yeah. Empathy. I think that's why kind of the more interpersonal things that psychodynamic therapy can teach us are so valuable because so much revolves around empathy, therapy.

Appetate Alliance. Yes. How do we tolerate our countertransference when it does come up? How do we stay in a healthy frame? Yes. How do we understand the uniqueness of the patient, our curiosity about finding what things mean to patients? I think all people who are attracted to being therapists tend to have those qualities.

And whatever your theoretical language, if you are curious, There's an interesting book by William Miller and a colleague who listed eight qualities of effective therapists, and they are the qualities that go across theoretical orientations and started with psychoanalytic people trying to help people and then went humanistic and then behavioral and cognitive behavioral and systems and biological psychiatric and so forth. Yeah, what do you see? I guess that's a kind of an interesting question. Like, what do you see as common personality traits of a good therapist? Or maybe a better way to put that is, like, in the therapist's journey towards becoming a good therapist, like, what are some common pathways that the therapist, like, you see they grow in, and that allows them to be a good therapist?

Well, it helps to have had your own therapy, especially when you're a beginning. therapist for many reasons, but one is that you've internalized a gut-level sense that this process helps. So some kind of confidence and conveying of hope to the patient comes from a deep experience of being helped oneself. That's when people don't have that and many beginning therapists don't have enough therapy behind them to really internalize that. They suffer from a sense of being an imposter, and I can't imagine they can as easily convey a deeply authentic sense, I think I can help you.

So that's something. Temperamental factors like curiosity about what it's like for other people to grow up the way they did whatever is their story, not just diagnostic differences, like what's it like to be a more schizoid person or a more hysterical or a more obsessive-compulsive person? But what's it like to be an amputee? What's it like to have grown up in a Hindu family? What's it like to be a twin or triplet?

What's it like to be someone who was adopted? What does it like to have come from a tribal culture? That kind of curiosity, the willingness to be taught by the patient. that taking the position of, I'm an expert in a process, but I'm not an expert in understanding you. You have to tell me about your experience. That's part of it. Normal kindness, normal compassion and empathy. Some people are high on that. Some aren't. If you're not high on that and you're curious about people, probably should be a researcher and a clinician because you need the empathy to survive all the states of affective activation that happened to you.

Patients will devalue you, they will hate you, they will question your competence. They will bring their worst selves into the treatment and they should because part of psychotherapy is feeling like I showed my worst self to the therapist and they're still there. they're still accepting of me. So I think one of the things that non-therapists don't fully get about being a therapist is how many toxic affects we have to live through in any given day. We have to worry about suicidal people. We have to worry that if we take one misstep, our paranoid patient is going to initiate a lawsuit.

You know, we have to worry about this child and whether they're going to be beaten, whether we should report their parents when it's a borderline case of child abuse. There's so much that we worry about. So we need love to carry us through. Yeah. Yeah, it's a, and we need support. And one of my mentors talks about how you can be a little bit more needy at the end of a long day of seeing clients. You know, you can be a little bit more emotionally need.

to yourself and that's okay. Yeah, and let's hope you can really feel that and allow your partner or friend or community to help you. Because sometimes therapists in their private lives, you have nothing left for the people that they live with. And we can be hard to live with. My daughters used to accuse me of a listening disability at the end of the day. You? I have some listening quotes here I wanted to read.

Yeah, my younger daughter used to be chattering about her day, and she'd see this glazed look come into my eyes, and I'd say, oh, that's interesting, that's interesting. She'd say, Mom, your listening disability is kicking in. Have a rough day. Oh, that's really funny. So it's like you're parodying the words of a therapist, right? Yeah, I'm phoning it in.

You're phoning it? Instead of being able to be fully there for another period of time. Yeah. I've noticed when I treat professionals, like any words that are just me phoning it in, like are, it's like the meter at which they see through that is a lot higher, right? Yes. So it's like you have to be like present. and it's like you have to abandon some of the techniques

or some of the common phrases that you normally hear therapists say and just kind of be more real. Yeah, if any patient feels you're not being there as a real person, you're out of luck. Yeah. Yeah, okay, so, oh, I think this is a good kind of like segue into some of my favorite quotes about what you say about listening. You said, listening is a professional capacity. Listening in a professional capacity is a disciplined, meditative, and emotionally receptive activity in which the

therapist needs for self-expression and self-acknowledgement are subordinated to the psychological needs of the client. What do you think of that? What do I think of that? I think there was something that spoke to me about that because maybe because that was so foreign to me before I started therapy, my own therapy, you know, there was something like refreshing about receiving that. And then there's something refreshing about being able to give that. And then when you give it, it's like, it's different. You know, it's like how often do you have someone who's listening to you in that way for 50 minutes, even at all ever, right? Like, people are always putting out their own competitive needs, you know, envious needs.

Yeah, let me tell you what I think. Or advice giving, you know, like I, or let me tell you what to do in this situation type of mentality. So I think it's a very different capacity to listen in a way that you kind of are maybe aware when you're listening of your desire for self-expression or self-acknowledgement, but you kind of subordinate that. And I think that's a different way of being. Yes. It is. It's not entirely different from some activities, like meditative activities or

trying to understand what a painting is saying. It's using a right brain. skill taking stuff in. Yeah. Okay, here's another one of my thoughts on that. It's like, I think intent is felt like on a mere neuron level between humans. So like I had this one supervisor who like, I could always feel money and like him moving forward in life was like so, so important, you know? And he actually, he actually left to work at this place to make the most.

money possible within like a couple years of me noticing this, right? That's rather rare for therapists in my experience to be that obsessed with money. That's interesting. Well, I'm going to say it was like a mental health professional. It wasn't necessarily a therapist. I don't want to like give away. I mean, yeah, where this person, where I knew this person or what the context was. But when I would hear him or when I would be with him,

Because my mirror neurons would go off in that way, like, I would find myself, like, talking about that because I knew it was pleasurable for him, you know? Yes. Or, like, behaving differently, right? Yes. And so, or like, I had this one resident I taught for a number of years, and I teach all the psychotherapy at the university I'm at. And then I would, in third year and fourth year, I refer my own clients that have been following for a while in my outpatient clinic for them to do therapy to. And I could hear her or him say the right words to this client, right? Like they were saying all of the empathic things that would sound like empathy, but they didn't care.

Like at the end of the day, they just like did not care. And I think this person ended up not being more of a. a therapist, ended up in a job in psychiatry that was more administrative or more further from patient care, which is probably beneficial for them. Yes. And so I think what I'm talking about is like there's some sort of mirror neuron representation that's perceived by the patient. Yes.

Like, this person is for me or this person has my best interest. It's like that's very interesting that you're mentioning intent. my husband Michael Garrett has spent 40 years doing psychotherapy with patients diagnosed as schizophrenic among the urban poor. He's a psychiatrist and psychoanalyst, and he gets wonderful progress with these patients. You know, most of them are also medicated, but we've really failed with the psychotic portion of our populace there, you know, on the streets and homeless and jails. but he does wonderful work with him and he is starting to he does a combination of CBT for psychosis and psychoanalytic understanding of what it's like to be psychotic and he's

with Jeremy Ridenauer at Austin Riggs they are developing a training program for people who want to work therapeutically with people diagnosed as psychotic emphasizing the intent to understand emphasizing that you can't always understand somebody who's in the delusional state. But if the patient feels that you have the intent to understand, that's all you need. And I think that's profoundly true in every kind of therapy. It's like whenever I tell a patient's story, I try to change a couple variables, right? So I had this very situation like this week, right, where I had this person who flipped out, sent me an email, thought I was going behind their back.

They were going to fire me. And I said, hey, you know, this guy has a certain hobby. And it's, and I actually decided to purchase something to get into this hobby so I could kind of relate to this person. Yeah, yeah. And so I replied to him by email and I said, hey, you know, don't know where this is coming from, but I got in the, you know, and then I jumped to, I got this thing and I'm really excited to share. this hobby with you. And he came in person. And I think he could feel my intent that, like, I really want to help this guy.

And the paranoia completely vanished. But I would love to have you and your husband on to talk about what he's finding. I mean, really, maybe that could be another session. Because it's so, yeah, it's so valuable. Like they know, they know that you care about them. And that's really what leads to them. being willing to take an injection, despite, you know, injections being really scary. And it's like, I don't want to put this like pathogen in me.

Yeah, you would enjoy talking to him. He has written an interesting book on this that's getting a lot of play, psychotherapy for psychosis. Okay, yeah. Integrating cognitive behavioral and psychodynamic treatment. Wow. And he's a good interview, too. He's been teaching people.

for a long time about this approach. Okay, here's another quote from you. Most of the ways the therapist talk during the clinical hour are intended to demonstrate they are listening. Yeah. And so I was thinking about how a lot of the reflection, the empathy demonstrates listening, and how meaningful that is.

Yeah, that chapter spoke to me. Thank you. Any more comments on that or any thoughts or further reflections? I just think we all really need to be listened to. I'm seeing so many people these days who were brought up by well-intentioned parents who didn't understand the importance of listening to their child. They had an agenda for the child. You have to compete.

You have to be the best. You have to be a doctor or a lawyer. You have to go to school and get A's as opposed to how are you experiencing the world? Helping them name their feelings, being curious about who this child is. What kind of temperament does your kid have? What kind of talents? What do they want to do? What gives them joy?

We're such an anxious culture now. Things change so fast. People have to adapt to cultures that they didn't grow up in. We live in a mass culture. It's much harder for people to have the experience that someone took the time to be curious about them. I think it's just profoundly healing to feel like somebody listens to you and hears your story and helps you make sense. of things that have happened to you and how you reacted to them. Yeah.

Yeah, I think even like how you, when we first got on and we were recording yet, and you're like, tell me about how you got into podcasting. And I was able to tell you that felt, it feels good to feel known. Yeah. It feels good to have someone who's excited when you're excited or, you know, resuming. And it has to be authentic. If you try to do it manipulatively, people figure it out sooner or, later. I mean, a lot of people do it manipulatively. We're all pretty sick of hearing.

Your call is very important to us while you're put on hold for an hour, right? I actually think that this next generation, you know, adolescence that I'm seeing to maybe like early 20s are so skeptical of anything that's false. Like they're just done. And yeah, you know, like people are critical of TikTok and I actually see. TikTok as an expression of people's yearning for authentic voices. I agree. And the news is like changing because it's like you have these people who really believe in a certain thing sharing like, oh, there was a train that, you know, lit on fire in Ohio.

And the news seems to not be reporting how scary this is. And here's why I think it's scary. And it's like these people are coming from a very authentic place. Yes. And I think this next generation. has just a complete intolerance of anything that's not truly authentic. And even like reality show, like the way, like if you think like 15 years ago, like the way reality shows were done, those weren't really reality shows.

And people watch it now and they're like, yeah, that's not real. Like, you know, they're evoking certain scenarios or they're creating storylines, you know. And yeah, it's so I'm with you. on. Like, it has to be real. And therefore, you have to do your own work, because if you don't do your own work, it's like any empathy or the right words are just going to be felt as, you know, facade. As being used. Being used, being played. Yes. I mean, that's a normal young adult preoccupation. In my own era, we, in the 60s, we railed against hypocrisy.

We resonated to Holden Callfield in Catcher in the Rye calling things phony, but we didn't have nearly as much of a culture of phony manipulativeness on a grand scale as young people today are dealing with. Yeah. Yeah, that's good. You know, I think that the, yeah, the people are yearning to be heard. They're yearning to be understood. They're yearning for mirroring. I think that there's also, in this next generation, you know, with the rise of social media, there's, and the rise of social media that's influenced their parents as well.

Yes. I think it's creating some unique dynamics where people feel that stillface. I don't remember. Edronix stillface. Yes, absolutely. Right. I think a lot of kids are getting more of a still face. Observation.

We've got a whole generation that is used to the still face. What do you think about Beatrice Beebe and her work on early infants and showing the link between like attunement within the first four months to attachment styles? Was that influential in your analytic thinking at all? Yeah, I love her work. I think she's one of the most creative and, devoted researchers we have out there. And one of the things I love about her findings is you don't have to be devoted 100% of the time to be effective. You know, if you are, I think I can't remember

her data exactly, but something like if the best mothers of infants were tuned in about 40% of the time. And that's amazing actually, right? Yeah, it is. It is. Even 40% These aren't easy. Yeah. Yeah, I think that her work was really influential for me understanding, like, this disorganized attachment. Oh, yes, yes. And putting that on my radar as, like, something that leads to later life dissociation in adolescence and different issues. Yeah, I really like how you talk about.

how dissociation is common with more people dissociate than they realize, right? Can you talk a little bit about that? Well, we're all in somewhat different self-states, and we all have the capacity to dissociate to some extent. If you've ever driven down the highway and you're thinking about something, you can go 20 miles and not remember that. experience of driving because you're in your head somewhere else. If you are a trauma victim, it's an extraordinary capacity that the human mind has. If you're a little girl being raped,

for example, the human mind can say, I'm not that little girl. I'm up on the ceiling watching that happen to that little girl. And if you are subject to enough childhood, trauma, you develop as a coping mechanism, shifting self-states in which you may have amnesia for who you are. And in the most extreme case, you have dissociative identity disorder where you look in your closet and you find a whole bunch of shoes that you don't remember buying. But there's, you know, there's an alter personality who has done that. And people, I think, very often misunderstand and patients with dissociative identity disorder, they get so preoccupied with the exoticness of it

that they don't see that this is only an extreme version of what all of us do. I mean, most of us can think of times when we kind of zoned out when we went into a state of derealization or depersonalization and life felt kind of like we were watching a movie. There's a lot of contemporary literature in the relational psychoanalytic movement, mostly inspired by the work of Philip Bromberg,

about how we all have different self-states, and part of mental health is being able to stand in the spaces between those states. So that if I feel like I'm a completely different person when I'm in a different role, like now I'm being the Nancy who teaches. Now I'm being the Nancy with grandchildren. And I can't feel like I'm Nancy in all those roles. Then I'm slightly dissociated. Sometimes people use this adaptively.

I had a patient who had a kind of alter personality who went to the dentist because she couldn't bear the dentist. She'd been traumatized by a dentist. So this dissociated part of herself that she felt no attachment to went to the dentist. So these things can be adaptive, but mostly when people come to therapists for them, it's because it's maladaptive. You're making love to your beloved partner, and suddenly you're out in inner space somewhere and you're not there and you can't come back and your partner feels it. And you don't know what to do about it.

Yeah. A couple of directions I could go there, but one of the things that I heard you say elsewhere, that was really helpful as you talked about, you know, some of the transference that comes from that trauma where there could be the dissociation. You know, we often think of transference as like they make the therapist, the rescuer, the persecutor. But one thing you talk about is that non-responsive bystandard transference. Yes. Yes.

And you talk about how that's actually where the patient is often most angry. And when you said that, I was like, that's exactly what I've seen. It's like when they went to their, it's like, you know, maybe their father or their stepfather was abusing them. And then there's that, the mother who's just turning a blind eye passively. Yes. Siding with just going, dissociating herself probably. Probably, no. To seeing what's really going on.

and the abuse and the tragedy. So that was helpful to kind of think through that. I have a patient whose mother was the abusive one and her father was the uninvolved bystander, and she's more angry at her father than her mother. But the scenario you're depicting is a little more clinically common where a child was abused by a male relative parent, grandparent, and they tell their mother and the mother either blames them or zones out or she's just non-responsive.

They have more rage toward the non-responsiveness than toward the abuse. The abuser at least is treating them like an important object. The abuser has a relationship with them. When somebody refuses to have a relationship with you, it's worse than being hurt. Being ignored, being endangered by somebody not caring. I think it goes back to our primitive need for attachment for survival, because we're all born, unable to survive by ourselves.

And if somebody isn't paying attention to us, it's more dangerous than if somebody is paying attention in a bad way. Yeah. Yeah, I think there's something about that like still face that they're getting from the non-abuse, non-abusive partner who's, well, it's a different form of abuse, right? Yes, it's neglect. It's a neglectful abuse or, you know, being complicit. I think the trauma researchers, people like Bessel Banderthoke and Richard Chaffetz, are finding that neglect is more profoundly pathogenic than explicit abuse. I have this one article that I've looked at that talks about the long-term effects of the enduring effects of trauma.

and there's this picture of a brain, and it's just half the size of a normal brain. Yeah. And it's because the brain requires relationship for growth. Yes. And, yeah, so neglect is some awful long-term consequences of neglect. Yeah. Yeah. And I think it goes back to kind of like, well, what is the primary drive of the kid?

you know, it's for attachment, for connection. Yes. And I don't know, like, if you kind of side with that or more of drive theory and your thoughts. Well, I like Yalk-Pank-Sips work. I think there is a place for the idea of drive, but I don't think that the drives that we respond to are the Freudian dichotomy of libido and the death drive. or I'd like to oversimplify things and overgeneralize things. But Panksept talks about there being seven motivational systems in the brain.

The seeking system, that's kind of dopamine mediated mostly, and that's like what we've called affectance in some of the early psychological literature or, you know, enthusiasm, curiosity. I have a need. I'm going into the world to find it. There are two anxiety systems in the brain. One is what Yacht Panksa has called the fear system, which is the terror of predation. I'm going to be destroyed by a predator. And that's mediated by one set of neurochemicals. And then there's the attachment system, which is the panic grief system that is mediated. by other chemicals, including serotonin. That's why for more paranoid patients, the SSRIs don't tend to reduce their anxiety because they're reacting to the fear system. I'm going to be destroyed. So that's a different brain system. So there are those three systems. There's the anger system.

You irritate any animal. A certain part of the brain lights up and handles that with anger. there's the care system, the parental system, there's the lust system, and there's the play system, all mammals need to play. And if you don't have rough and tumble play, whatever your gender growing up, you'll have more troubles with concentration and focus later. Thanks up has suggested that maybe one of the reasons we're seeing more ADD and ADHD is that our kids aren't getting enough organic, spontaneous, rough and tumble play. Instead, they're being stationed in front of computers or giving monitored play dates or sending off to lessons of various kinds.

So those systems are drive systems, and they all involve feelings. They all have their affective component. You can't quite separate out affect and drive. But one of those primary systems is the attachment. That's the panic grief system. And yeah, I think that's absolutely primary because if we don't have that, we don't survive. You know, you can't leave a kid on a hillside and have it survive. Yeah, I really like how you, yeah, enjoy Pinksep as well. It's the name's always hard for me. And I think play, there's something about, I was even thinking about like this study I read about the benefit of martial arts for ADHD and the effect size was phenomenal. Really? That's interesting. And I'm like, I often see these ADHDers and I'm like, this kid needs more sports. Whatever you do, I tell the parents, do not discipline them by taking away their sports. Yes. Because I've seen that as well. It's like, well, they aren't doing their homework. They're not allowed to play their, you know, sport. It's like, no, don't do that. You know, like, let them play. They need the body contact. They need the energetic experience. I get my son out and I'll have them do sprints in the morning.

We make it play and fun, so daddy races him. And that gets him ready for school and gets his brain kind of like, okay, so we can focus. That's a time-honored method of dealing with ADHD long before we had the medications that are so popular now. Yeah. Yeah, so, okay, so dissociation. Let's see, we talked about,

we talked about some of that sort of transference and kind of how that can be placed on you as the therapist, potentially you can become that non-responsive bystander. When that happens to you or when you, you know, what do you say to the client, like when they imagine you to be that non-responsive bystander? Well, interestingly, that doesn't come into the treatment nearly as obviously as other transferences like their fear that you're the abuser or their expectation that you're the savior. But you do notice it in a couple of ways. One is just thinking about your patient's material on how, where was their father or where was

their mother? So you notice it in what they're talking about as an absence. you can also notice it through the counter transference, which is if you start feeling oddly bored, distracted, vaguely irritated, not fully there, tuned out, zoned out, that probably means you're being placed in the position of the person who was zoned out when they were little. Interesting.

Or maybe your experience of part of them, that zones out and you're both sort of in a trance. But when that happens to the therapist, I think the proper way to deal with it is to say, I feel like there's this odd trancy thing going on between you and me. Are you feeling fully there? I realize I'm struggling to stay attuned. And I wonder what's being recreated between you and me.

So that you have to address it like anything else that gets in the way of continued authentic connection. Or you can ask about it too. Are you experiencing me as fully here? You know, whether you are or not, you can ask the patient if you pick up that they are talking to you as if your wallpaper. And sometimes that goes somewhere. Sometimes there's some kinds of patients that are irritated by that kind of question, and you learn that. There's some patients that say, this is not about you, this is about me. I just won't, you know, stay in your role. Maybe that's one step of them getting out of their own dissociation, you know, if they're.

It could be. They're getting angry at you, kind of moves them out of that dissociation into a emotion, not probably the emotion that's more pleasurable. useful emotion in psychotherapy. We have to make sure patients know that the fact that we invite them to be fully angry at us doesn't mean that they should go around, you know, doing that with everybody. But this therapy should be a safe place where anger comes in and all of its intensity. Because there's no growth without anger. You don't give a child a limit like don't run into the street. without the kid getting angry. It's a part of normal development.

You don't say to an adolescent, I don't want you to go out later than midnight. Oh, my friends are going out later. There's a normal adaptation to any painful aspect of limitation, where people have to go through anger or else they're just being compliant in a way that doesn't fully get integrated. So therapists have to be objects of anger. and the anger is better than

than people just going through the motions. Right. So that's often the first step to authenticity. And if a patient's never been angry at you, it's important to start asking, you know, you never complain. Where's your normal feeling that you wish this therapy would go faster

or you think I didn't understand something? You know, this is costing you a lot of money. what are the, all the normal things that I would expect you to be irritated by, you never bring up. What's that about? And then you work through whatever defenses they have against feeling what are normal feelings. You know, not necessarily feelings that you want to act out, but normal feelings. Yeah. Do you think, do you think therapists in general have a harder time experiencing anger? Like, is that, is that a common thread that you see?

Well, my friend Judy Hyde in Australia did a doctoral dissertation on personality types among therapists, and the most common personality type was depressive personality, which makes sense. You know, people who feel pain, and I don't mean that they had clinical depressions. I mean that they tend to be self-critical. When they're criticized, they immediately feel it must be their fault. And when they're, if you're a therapist, if your patient does well, you credit the patient's capacity. If your patient's not doing well, it's your fault. You like to move toward people to solve problems.

So a lot of therapists have a somewhat depressive psychology. They're hard on themselves. They use interjection if you want to get psychoanalytic about it rather than projection. And they're always worried that they did the wrong thing. So they tend not to find their anger very easily. And they have trouble. It's not usually a proper thing for a therapist to express one's anger at a patient. But it is a proper thing for a therapist to have really clear rules about the frame.

This is my fee. This is when you can call me. This is what you should do if you're upset and I won't be available. This is going to be my vacation. during the pandemic. I'm sorry if you don't believe in masks, but when you come to my office, I want to insist that you wear a mask.

Whatever are your conditions of labor, those are really hard for therapists to stand by. They have to learn those. You have to learn how to say my fee is such and such. Or I've seen you at the same fee for five years now. It's got a little out of line. I have to raise it. I'm sorry.

I understand you don't like it. but this is going to be my fee. Those kinds of comments, I think, are much harder for early therapists than natural empathy. Empathy, you don't have to drill into them. They're naturally empathic people. But standing for the conditions under which they can help people, which involves a certain degree of their own aggression, is really, really hard for them. So I don't know if that's where you were thinking with your question, but that's what I've observed

over years of teaching people how to be therapist. No, I think that's, I mean, boundaries are a form of, I see often when, you know, a micro-expression of anger when people go to form like a boundary, right? So I think boundaries are a form of anger or, you know, exerting yourself, here's what I stand for, here's what my frame is. Yeah. So, yeah, I agree. I think that those two are very related, so it makes sense why you discuss.

what you discussed. You know what I was thinking. I was thinking about how we're talking about dissociation. We were talking about how some people like live in a facade, right? Because maybe they have to perform or they have to like, you know, maybe they have a lot of that, that parent with a lot of shoulds. They should be this. They should be that.

They should be this. And then they kind of like live to those shoulds. And I was thinking, what do you think about Karen Hornay and neurosis in human growth? And that kind of like her version. of seeing the neurotic structure. And what do you appreciate about that, or what do you kind of differentiate about that? It's been a long time since I read Karen Horn,

I whose work I did like a lot back in the 60s and 70s. I remember her talking about the tyranny of the shoulds. And back in those days, it was very common to locate neurotic problems as in the domain of the so-called harsh super ego, that people were always saying, I should do this, I should do that. You know, I would say that I see those patients

who are suffering from the tyranny of the shoulds, but I also see patients who feel a kind of entitlement not to feel a moral compass. It's more like you should adapt to me, you should compensate me for my suffering. I'm entitled to, I've been victimized, so I'm entitled to the world taking care of me. And that's kind of the opposite,

instead of being too full of a critical voice inside, it's kind of an empty psychology of who's going to just fix this? Is that more of like the not full DSM? narcissistic personality disorder, but kind of a, you know, on the spectrum of narcissism. Is that what you're seeing? It's a narcissistic element, I think. Any kind of sense of entitlement does, because, you know, what entitles me to the life I think I should have?

You know, I always come from the position of, I'm very lucky. I could be a Syrian or Turkish person buried under Maloney. of earthquake debris in the bitter cold. And what is it that some people can't sort of contextualize? All right, I have many things to complain about, but I also have things I can build on positively. I think we live in a culture that feeds our narcissism. I've been interested that commercials

have been doing this. Commercials, early on in ad culture tried to appeal to our sexuality a lot. Now they're appealing to our entitlement.

You deserve this. Give yourself a break. You're entitled. It's appealing to this primitive wish we all have to be able to make the world over

into whatever we think it should be for us. Yeah. I like how you say the historical and also the time context of like how we forget how comfortable and how little dangers that used to be here don't exist anymore. It's like we have an amnesia to the human experience of, you know, 10,000 years ago was brutal. Like I think Pinker talked about the homicide rate for men was like 50%, you know, like 50% of some of the ancient,

bones that they found have like gashes in them and you know it's like yeah now it's like we're talking about six per hundred thousand you know it's like the homicide rate or you know in developed countries and so we're just yeah it's like i definitely resonate with that like coming from it coming to life from a place of gratitude but then the question is like how do we get other people into that space you know yeah you can't get there just by trying to talk them into it. There's a slow process, I think, you have to go through. There are some patients who approach therapy as if their job is to complain until you finally get it, and then something magic is going to happen, as if they still have some image of an all-powerful parent who, if they can only

make their sons understood, we'll fix things. And I remember saying with a patient once who threw a fit at me because she felt like it had taken me forever to understand how disorganized she was. I said, well, let's do a thought experiment. What if I could say something that made you feel I really, really get it. I get what it's like to be you. Then what? And there was this pregnant silence. And then she said, I'd still have to solve my own problems, wouldn't I? And that was the beginning of her, beginning to feel some sense of agency in her life and feeling less passively like the victim of circumstances. At the end of that therapy, it was very interesting. I did what I always do with patients who are terminating, saying, well, how do you evaluate our

work looking back? What was helpful? What wasn't? Do you feel it was overall good for you? And she said, oh, yeah, it was great for me. I don't have many complaints at all. I said, well, what you think was most helpful? She said, well, you just fixed things. I said, what do you mean? Because I was thinking the whole therapy was about my not fixing it and her learning how to fix things herself. She said, well, when the light bulb went out, you just changed it. When the air conditioner was too cold for me, you just turned it off. In my family, we would have sat around for hours talking about the bad quality of light bulbs these days or how air conditioners don't work anymore. And she said, you modeled that you can do something. So you never know what patients are

taking from your presence. But what she took was, oh, you can do something about that. Maybe I can do something about that. So that was an interesting feature of her therapy. I think I'm a little bit off the topic that you posed there. No, I think I think you're, well, do you, do you, sometimes when I hear like patients continually wanting to talk about the hardships that they're in, obviously that's why they're coming to therapy a lot of the time. I think to myself, as they're talking about this, are they experiencing that emotion congruently, right? So it's like, are they as sad as their stories tell? Or sometimes I feel like sometimes patients will think that that's how therapy is supposed to go and that's how we connect maybe based on previous

therapies or sometimes when I do attune to them usually they feel pleasure or some sort of some sort of connection and so it's it's like or gratitude in the best cases and it's like feeling that in the midst of what they're talking about feels really good so we talk about how that's being experienced but I don't know, maybe you're talking about, I do have some clients that are really stuck, you know, and just... Yeah, I'm talking about the people for whom empathic resonance is not quite enough. Okay. That certainly everybody needs that.

Everybody who's suffering needs to feel as if you're trying to understand their suffering. But they also need help imagining that it's possible to move from a position of victimization or helpless suffering, to a position of having some say in your life and solving some problems. And there are patients for whom it's problematic to be too consistently sympathetic because it reinforces the only kind of attachment

they have had in their life. That was true of the woman who got so impressed with my changing the light bulb. The only warm attachment she'd had to her mother was when the two of them condoled together about how unfair the world was or how bad men were, how unfair the family was. And that was her prototype for attachment. So you don't want to just reinforce a pathological attachment configuration. You want people to learn they can be angry at you.

they can, they can, often, again, you have to go through a period of some anger. I think people can't forgive people for crimes against them until they really get what the crimes were. And psychotherapy is not about blaming parents, but it is about understanding things that went wrong and limitations of other people. And once you get through your feelings about that, the natural progress moves toward, you know, I think my parents did the best they could and given their histories. They did pretty well, and I forgive them for their failings, and I'm grateful for what I did get from them. So the gratitude comes at the end of a process like that. It doesn't come from homilies about how you should be grateful because you're not suffering as much as some other people.

Yeah, absolutely. That's not going to help at all. If anything, it'll make them more angry. you know like that this is just obvious that you don't understand me if if you were to start with some homily yeah it's there's a lot there's a lot to unpack there i think that the connections that people make or the patterns of connection you know whether it's connecting like you said over talking negatively about something they almost become reinforced if that's what they they they don't they'll find something similar in the world, right, often. But then it doesn't really, if it's not congruent, if it's not authentic, coming back to kind of like that Geiger meter of authenticity

that people have nowadays, it doesn't feel true, right? And so I often will think about the creative work of my patients as a way of getting to what is congruent and true, whether it's like poetry or dreams or art or music, music. Yes. And I'm curious maybe like how do you use those congruent spaces to get to the real person and then connect with the real person? It's hard to answer that in general because I think people differ so much in where their vitality exists. There are some patients that have a terrible time opening up to a therapist, not because they don't want to, but because it's just so

painful for them. But they may be able to talk about authentic feelings at one remove. They may be able to talk about it in literature, or they may be able to find it in music or video games, you know, not necessarily high art. Their vitality may come out when they're talking about that kind of thing. And there are some patients that are very passive and you feel like something went wrong with their seeking system. They don't find any enthusiasm. They're not exactly depressed, but they don't have vitality. Winnikot said a person can be normal without being alive. And it's our job to help people find where they're alive. But I've had patients that have communicated better via artwork.

I had one extremely schizzoid patient who had such trouble talking to me that she would sit and rock and wring her hands and mutter to herself for the first 20 minutes of every session saying, I knew I couldn't do this. I know I just can't talk about this. I was crazy to try to do this. This was a person who had a very adaptive false self. adaptation to her work, but she was intimate with nobody. She'd never been close to anybody.

And she got a terminal illness during our therapy and was devastated by it and thought she better stop because the therapy was so difficult on top of, you know, her oncologist had said, avoid anything that's stressful for you. And she said to me, this therapy is the most stressful thing I've ever done. And I said, well, I feel in a bind because you're going to be going through a lot. And we know that you've reacted before with terrible depression when you've lost some attachments that you did have. So it would be stressful to stop, I think. So let's both think about what to do under these circumstances. And I thought a lot about it. And I thought, What's hard for her is to generate her own material, to talk from her heart to initiate that with me.

I have a dying patient here. I could at least let her know I think I understand some features of her psychology. And I asked her, what would she think of if I just read to her from the better literature about the kind of psychology I thought she had rather than her having to generate? anything. And I found an article on schizoid psychology by Norman Doidge that was very non-jorgony that talked about the fear of closeness and the high level of sensitivity and numerous other common internal schizzoid themes. And I read the article to her and she kind of came to life as I read it. It felt like reading a bedtime story to a child who gets, you know, all involved in it. And at the end, I said to her, I think you felt like you were the only person with this kind of psychology.

And she nodded. And we said goodbye. And when she had her hand on the doorknob, she said to me, you're pretty proud of yourself, aren't you? Because she had radar for authenticity. I said, yes. Yeah, right? And that turned out to be our last session. She went into the hospital, had a crisis.

died a couple weeks later. But I would never read the professional literature to most patients. But in that unique situation with a dying patient who was so schizoid, she couldn't generate her own feelings in the session, that was my way of authentically trying to tell her how I experienced her. And I think she was touched by it. And at least before she died, had a sense of having. a human connection.

I wrote her up in an article called The Woman Who Hurt Too Much to Talk. What a great story. And I love how you speak to that. It's so unique. And as a clinician, you know, we can be creative with what that might look like for each person. And that kind of there's an intuitive, an intuitive place I think we have, you know. where we could kind of imagine what that might look like. Yes.

That's good. I was trained in a very intuitive version of psychoanalysis. I was never trained in this classical idea that you don't say anything and you try to be a total blank screen. That was typical of some of the medical institutes in mid-century when they were trying to claim that psychoanalysis was a medical procedure that could be defined the same way surgery can be defined. But I was trained in the tradition of Theodore Reich, the first psychologist analyst, who emphasized intuition, allowing yourself to be surprised, expecting to get it wrong, learning from your countertransference what's going on.

Beautiful. I think that formed you well to be a part of that community. I understand there were, it was like, yes, it was one of those early centers that allowed, non-MDs, which probably gave it a better culture. It did. It did. It was much more diverse. My husband's psychoanalytic institute, which was one of the medical institutes, had a party line about proper technique. And he had one class in four years of training called Deviant Schools, where they covered

Ferencee, Klein, Cohood, Beyond Winnicott. Oh, wow. Anything other than the eco-psychology tradition. One class on that. I had whole courses in the thinking of different psychoanalytic traditions. Yeah, I think that there's, like, the type of tradition that I was brought up in through Dr. Tar, one of my main mentors, who actually, was taught by Franz Alexander.

He's in his late 90s now. Oh, there's another psychoanalytic pioneer who emphasized reality and intimacy. The corrective emotional relationship. Experience, yes. Yeah. So I think I'm blessed and grateful to have not, you know, to not have been sort of the kind of like

what seems more like a, a rigid religious doctrine, you know. Yeah, you didn't have to drink the Kool-Aid that went into the medical institutes trying to prove their orthodoxy. Yeah. It's Franz Alexander, like Theodore Reich, was another protege of Freud, who differed with him some but was never, you know, at odds with him the way young or Runk or Reich were. and who represented the humanistic tradition in psychoanalysis, much more the way Freud actually practiced than these medical rules that got instantiated later and came to be defined as classical psychoanalysis. Yeah, I read that he would have dinner with clients or go on walks with clients. Yeah.

I think the clients that he was very warm with that he liked. are the ones that did well. I'm sure that's true. It's true for all of us, I think. Theater Wright tells a story about running into Freud on the street and wanting to have a cup of coffee with him, and Freud said, no, I can't. I have to buy a present for a patient who's been away for two months.

So, you know, Freud was a, he was a warm enough guy. And if you read his actual writings about technique, they're very flexible. They talk about how everybody has to integrate technique with their own personality. Yeah. Yeah, I think when I read him, like the interpretation of dreams, for example, I get the sense that he was pulling from everyone that he had read anything about dreams. And he was kind of like a Shakespeare with psychology,

like taking the ancient stuff and then repackaging it. in a way that made sense to himself. Yeah, what a mind he had. What a mind. I mean, he was wrong about a lot of stuff, but what a mind. Well, most of the stuff he was right about, we just kind of have internalized in our culture without attributed it to him, right? Like things like transference or...

Yeah, Mike Carpenter said one of his colleagues was anal the other day. He had no idea he was using a psychoanalytic term that came from derived theory, you know? or people talk about having an identity crisis, and that term was invented by Eric Erickson in the psychoanalytic tradition. Yeah, I think that there's a, there's in therapy, like one of the things I really try to emphasize is that, you know, there's an addiction of,

because of therapists being slightly insecure, as you talked about it, that's more depressive personality, right? But there's there's an inclination to look towards someone who's very charismatic and want to kind of like absorb some of their confidence. And therefore, you know, there's these kind of new genres of therapy that pop up. Yes. That are seductive and seem to have all the answers. And I think that my perspective is that it's more therapist dependent and that there's things that we can, you know, what we can glean from the traditions of the past that allow us to be more empathic, more

develop, you know, maintain a therapeutic alliance or stay in that place of, you know, positive regard towards a client will inevitably or inevitably allow us to do the good work that's going to help someone. Yes, I agree. One of the things I liked from your, the chapter on manic personality, which I wish we had time to get to, was you talked about how you'll have this kind of conversation with the client because of their high ejection velocity

from therapy that like if at some point, you know, in a similar way that you might have with some of these people in your life that just like the relationship suddenly end and you suddenly want to end our relationship, let's have six more sessions. Will you agree to that at the beginning? Yeah, that doesn't always work.

because sometimes they make that agreement and they flee anyway. But sometimes they stay and at least understand why they might be wanting to flee. Sometimes they actually stay and stay beyond the six sessions. But yeah, that's a kind of personality that it's kind of hard to figure out how much is personality and how much is a subclinical bipolar mood disorder. But, you know, we probably don't have time to go into that in depth now. But some people are stably hypomanic. They're just always busy.

They're a bit hypersexual. They're funny. They're always on. They don't need much sleep. You know, and occasionally they'll crash and go into a depression. But usually they're just on. and it's a type of personality that's organized around a certain kind of denial of pain and attachment yeah that you know when i think about hyperthymia or people have people have labeled this differently

yeah you know but when i think about this type of person um i wasn't expecting what i read from from your from your thing that denial would have such a you know didn't it did the defense of denial would be so important in this type of personality. Yeah, that's what Klein called the manic defense. It's like, this is not happening. This is not serious. This is not a problem. I'll make light of this. Yeah. I mean, if you think about mania as a, you know, psychiatric condition, it's hard to ignore the fact that it's absolutely the polar opposite of depression. In depression, the mood goes down and mania goes up. In depression, you're always tired.

In mania, you're not tired. In depression, you lose your sexuality or your sex drive. In mania, you're hypersexual. In depression, you slow down. In mania, you speed up. So there is certainly a clear connection between those. And so the denial of depressing aspects or just sadness, normal sadness will create a manic defense.

I'm not going to think about this. I'm going to think about good things, and I'm going to distract myself from my pain. And it's when they start feeling the pain that hypomanic people are at risk of leaving treatment because they're afraid they're going to fall into a depressed abyss. Yeah. Yeah. It's very, very interesting.

Yeah, and I think maybe we can leave this as like a potential future topic that we'll explore in more depth and look at how it's different than narcissism and how it's different than other personalities as well. I'd love to do that. Yeah, I would be, I feel bad about my screen, my camera or whatever is doing being off. So if you want to have another meeting where, you know. Well, I would love to have another meeting. So actually I was telling my wife this morning I was like I hope that we could have a good connection So she'll be willing to come back again No I'd love to have you back But let's not worry about the camera being off

I'm sure the people who are listening don't care And the people on YouTube are like happy to have At least the first half with the video So any sort of final thoughts that are sort of lingering in your mind That you still wanted to say or any advice for young clinicians that's still kind of in there that you wanted to say as we're talking. To young clinicians, I would say that you already have the conditions for being a good therapist. And fortunately, in our field, if you make mistakes, most of them are repairable.

It's not like surgery. So, in fact, sometimes when you make a mistake and you repair it with a patient, that's what they remember most, that you were non-defensive, that you admitted to misunderstanding something, or that you hurt their feelings or were insensitive. And so just being a human being that wants to understand another human being is a good enough basis for being a therapist. And the more you learn, of course, the better you're going to feel about what you do. But sometimes you're just as good a therapist at the beginning of your career as you are at the end, partly because whatever you don't know is compensated for by the zeal to help that is typical of beginning people. So don't worry so much that you're not good enough or you haven't been trained at all the modalities you wish you were trained in because the basics are there.

Excellent. Well, thank you so much. Thank you so much for coming on. I really appreciate it. We will leave it there for today. David, it's been a pleasure, really. And we'll be in touch and we'll do it again. Excellent.