Psychiatry & Psychotherapy Podcast - Paul Wachtel's Approach to Integrative Psychotherapy: Exploring Attachment, Anxiety, and the Disavowed Self

Episode Date: September 13, 2024

In this episode, we explore the innovative work of Dr. Paul L. Wachtel, a leading psychologist known for his integrative approach to psychotherapy. Dr. Wachtel challenges single-framework therapy models, advocating for a flexible approach that draws from cognitive-behavioral, psychodynamic, humanistic, and other modalities. We discuss his concept of the "disavowed self"—the parts of oneself that are unconsciously denied—and how therapists can help clients reclaim these aspects to foster growth. We also dive into how attachment theory and integrative methods can be used to treat anxiety, phobias, and interpersonal issues, providing practical insights for both therapists and those interested in understanding human behavior more deeply. Join us for an engaging conversation on advancing therapeutic practices. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Paul Waukettel. He is a therapist, psychoanalyst, did his PhD at Yale. psychoanalytic training at NYU. He has written multiple books, including his most recent Making Room for the Disavowed, per Nancy McWilliams. He is a lovely person, modest and gracious, despite his remarkable accomplishments. He got introduced to me by a listener who did not know him, and so if you are out there and you know people who you think would be a good fit for this

podcast, I always enjoy a good email. This particular person, described your impact in his own sort of intellectual journey. He said, Wachtel's model for psychodynamic therapy is one of the easiest ways for therapists like me, whose foundational training was in behavioral and cognitive therapies to understand how to think and practice psychodynamicly in a way that is still congruent with the cognitive behavior model we offer. That's because he's an integrationalist. And it showed me, this is still quoting, it showed me there is a way to do psychodynamic therapy where the theory is understood in plain language and where the therapist takes seriously and responds effectively in session to the patient's

deep desire for actual behavioral change in important moments in their daily life. So I'm sure CV could go on for another hour if I was to read all your accomplishments, but let's just start it up with a basic question. How does psychotherapy work? Well, I think, first of all, I think one of the most important things and maybe one of the reasons why people from other points of view find my version of psychodynamic work receptive is that I don't think there is,

is a single answer. I don't think it's like making the unconscious conscious. I don't think it's just kind of making your irrational assumptions rational. I don't think it's just deep self-understanding. I think there are many, many factors that all intersect. So that's one of the reasons why thinking integratively is important. I think, you know, as we talk today, hopefully it will become clear that this is not, what I just said, is not just a way of avoiding the question, but really trying to address it in complexity, and the answers will emerge, I think, as we continue to talk. Yeah. So you're someone who, like, has lived the history of the last. decades of change in psychotherapy.

You've studied behavioral therapy. You've studied family therapy. You've studied DBT. You've studied acceptance commitment therapy. We're going to kind of integrate some of those things into this session. Pull out some of the pearls, the things that you've kind of integrated into your approach. Okay. So specifically, when you think about psychotherapy for an anxious person, what would you say are some of the things that would help?

an anxious person. Well, I think two things in particular are important. One is there's enormous evidence that exposure of some sort is very, very relevant, very helpful in reducing anxiety. That being said, that doesn't in itself, in any sense, in any sense, in any, way exclude a psychodynamic approach because I think one of the things that actually many psychodynamic therapists miss about their own approach is that psychodynamic therapy is a very effective way of mobilizing exposure in fact the exposure in that case being to anxiety that is

a result of or generated by one's own thoughts and feelings and desires. And I think one of the really important contributions of psychodynamic work is to highlight that much of what we are actually most anxious about is our own thoughts and feelings. And as we'll see, I think, most likely as we continue to talk. This is partly a result of the dynamics of the attachment relationship and then of life ongoing after that. But it's not just exposure because, you know, when you have, let's say, an elevator phobia or a fear of heights or claustrophobia, by and large, those are phobias and fears where we're afraid of something that isn't that dangerous. The problem with so many of the difficulties that people have is if we start to become

afraid of our own thoughts and feelings, we start to avoid ways of expressing them, and then we kind of lose the opportunities that most people have for practicing how do I express these feelings in my daily life in a way that actually works, in a way that brings me closer to people rather than further, in a way that enables me to get what I want rather than be ineffective. And so paying attention to the way the person actually is living, not just getting rid of the anxiety, but taking the anxiety seriously, that it's almost always not just irrational.

Okay. So, yeah, I think that's one thing that I've picked up in some of your talks and writing. It's like, okay, there's the behavioral approach where you're actually going out, exposing yourself to the feared thing. But then often our fears are deeper. They're deeper thoughts. you know, you described in one audio lecture of a person who had a pigeon phobia in New York. And this person, I think, had been bit by a parakeet or something else when they were young.

And this person had also, but they had some deeper fears that the pigeon phobia actually covered. Do you want to describe this case at all and kind of where there was behavior? where there was behavioral therapy that was helpful and where there was more of a psychodynamic approach. Yeah, that's a very interesting example because the kind of old-fashioned conditioning explanation, which by and large, most cognitive behavioral therapists today don't just follow that old-fashioned way, just the way most psychodynamic therapists today don't follow the, you know, the Freud. of a hundred years ago. But in that old-fashioned way of thinking, the pigeon phobia was simply a generalization of anxiety from being bitten, being nipped by the parakeet. I don't think that

accounts for very much of what happened with this person. As soon as you kind of start to expand the lens, and these are things about her life that began to emerge. as we work together. It turned out that around the time that she got nipped by this parakeet, her father was very, very sick. He had both heart problems and cancer and was in and out of the hospital.

And the family attempting to what they thought would be sparing her, the anxiety, didn't really tell her very much about what was going on. They told her, oh, Daddy has to go on a business trip. That's why he was away for a couple of weeks. Daddy's in bed because he has a bad cold, things like that. And she could see, she was, I think, about nine or ten at the time, she could see clearly that something really bad was going on, that everybody, in the household was very, very anxious. But they weren't talking about it.

They thought they were sparing her. So she had all this free-floating anxiety, this sense that something terrible is happening, and I don't know what it is. And in a certain sense, being afraid of both the parakeet initially, but then pigeons, which were much more pervasive, in her life of the New York City. That fear gave her something

to sort of hang the anxiety on and a way to be a little more active by having something she could avoid that would reduce her anxiety. So until we would begin to work on, not just, it wasn't just a matter of recovering her mistrust from her childhood, but the way her entire life from that point on had begun to be one of not trusting people, not being able to be reassured, and also avoiding, again, a host of normal

developmental activities that would have helped her develop the capacities that we need to to live effectively in life. So all of these things were kind of wrapped up together. You talk about disavowed, like, emotions, experiences, and is the family in some way disavowing the knowledge of the narrative? And I think about a nine-year-old, a 10-year-old, I have a 10-year-old daughter. She's a very bright girl. She picks up more than, you know, she picks up a lot of information, right?

And that's one of the things that I've been thinking about a lot is the, the neurodiversity of a very intelligent child, how they just absorb a lot more information, right, than maybe somebody who doesn't have that gifting. And so from a young age here, you have a client who's hearing tidbits, they're feeling the distress in the home, they're feeling the tension, but this narrative is disavowed,

and maybe emotions are disavowed as well. Do you think that played a role with this particular person? Right. Well, in this case, what was particularly difficult to access for her was the anxiety, the wish to find out more the anger at sensing something is going on and she's not privy to it and not being trusted with it and that therefore or in a way that she couldn't articulate, but nonetheless felt not being helped with it. So there was a complex mix of anxiety, mistrust, anger,

and then eventually what also added into the mix was because she then developed this avoidant lifestyle. There were all sorts of other aspects of confers. afflicted wishes for normal living that had to be disavowed. So that, for example, because the pigeon phobia in New York City where pigeons are pervasive, it eventually led to things like her social avoidance because she couldn't go out, she couldn't go to visit friends. She couldn't eventually go to parties and so on.

And it affected her work life. there were all sorts of ways again in which she was avoiding and then again all of that sort of collapses on itself so that she then has to begin secondarily to disavow the wishes for social interaction and and the anger that comes with the deprivation of it and a whole host of things. So in her case, we can, we could trace a lot of it back to that experience when she was nine or ten. But as I'm sure we'll talk about later, just the tracing back is not sufficient. I think one of the kind of wrong directions the psychoanalytic work took for many, many years, was the assumption that we have to just trace things back to their core, and once we find out where it started, that's how it gets cured.

It doesn't because you go on living your life and you keep complicating it and you have to address it in the present. Yeah. I think you described it as like a cyclical, the cyclical nature of you may have an injury, but then you repeat it over and over again. Yeah. Yeah. Like let's say, for example, fairly early in life, you begin to learn that seeking affection and connection isn't working well. It becomes a source of anxiety. Let's say you grow up in a family where either the way you're doing it is not responded to positively or perhaps where the parents are, parents themselves or have their own difficulties with connection. So your wishes for making these affectionate connections kind of start to have negative consequences. Part of what can happen then is that those very wishes, the very desire and need for closeness, begins to be disavowed. You begin to become more like Simon and Garfunkel described. I am a rock. I am an island. You manage to try to be self-sufficient. And then the cyclical process is that doesn't completely

make those wishes disappear because they're so fundamental to us. But when you are pushing them away to such a degree. You don't learn how to do it. You know, learning how to connect with people is a decades-long process. You know, little kids are really good at connecting, but if we tried as an adult to connect the same way, it would be very ineffective. You know, we learn it gradually evolves age-appropriate ways to do it, to connect, and then to interact that way. But if we have been avoiding and we haven't learned it, then it becomes, feels, it continues to feel dangerous and to feel maybe even more dangerous because when you do reach out, because again, those desires don't totally disappear, they're just pushed back.

When we do try it and we haven't learned how to do it well, we're likely again to have a negative experience and again to have the anxiety increased or maintain. And so it keeps itself going. This is like social anxiety maybe. This is like how this patient that you're describing behind the pigeon anxiety was social anxiety. And it sounds like you're saying you can't just read like a manual. like if there was a manual for social anxiety or how to socialize or how to overcome autism through social skill training like you're saying that's not going to work something something else is needed maybe a relationship maybe a conversation maybe practice right all of those yeah yeah all of those repeatedly and in ways that all

also push against the anxiety. One of the things that has attracted me to acceptance and commitment therapy, to act as one more element that I'm now integrating into my work, is the emphasis on not letting anxiety be the sort of the end of the story, you know, that I'm anxious, therefore I can't. One of the central messages of act is you go and you do it even though you're anxious. You keep pushing to do what's really important to you because we can only get to where we want and need to be by continuing to live it. We can't just think it. We can't even just feel it.

We have to live it. Right. It's not enough to just, you know, think that, like, let's say someone has a fear of getting on an elevator. Like, I'll make, this is a close to a patient's story, but this patient got a huge raise. Now they had to go up 20 flights of elevators to get to this new office. And all of a sudden he develops a petrifying elevator anxiety. And for some reason, it really comes out only. when he has to go to his work.

So if he's practicing on the weekend with his wife on the elevator that's not his building, he's able to do it somewhat. But he was developing like three to four days before needing to go up this elevator, this petrified anxiety, fear, panic attacks, you know, inability to sleep. So I'm thinking about this client

as you tell this pigeon story because it was so much deeper than the elevator. right yeah and what's interesting is you know the psychoanalyst in me you know immediately thinks of well you know especially since it started when he got this big raise and so on it's he's moving up in the world you know both symbolically and in the elevator as it were and one represents the other So that's a part where the psychoanalyst in me feels there's something further illuminating about it. But I also feel that just interpreting that, that somehow being the clever psychoanalyst pointing that out is not going to be all that helpful. Very helpful to understand it.

but then I would, at least provisionally, I wouldn't assume it, but I would explore the possibility that part of what we need to work on is, what does it feel like to outachieve somebody? What does it feel like to go further than your father, if that was the case in this instance? What does it feel like to move up? what does it feel like to be in a position where you are now a boss of somebody else? All these kinds of things I would be exploring, even while I also was pursuing exposure to being in the elevator. And I remember a patient of mine who had an elevator phobia, and my office was on the seventh floor. He would come into my office at the beginning, huffing and puffing because he had walked up seven flights.

And he wasn't yet, he couldn't do the exposure therapy on his own. So I went down to the lobby to read him. I rode up with him to the first floor. And then I said, can you walk up? one flight, I'll meet you on the second floor. We kept alternating that. We did various things like that. So I walked up one flight and he took the elevator in the second floor.

That's what I really meant. Okay. I set myself up. So there was a mix of his being alone in the elevator, his being with me in the elevator. So there was a relationship element and the reassurance of being with me. there was an exposure element. We talked about what it meant.

And very, very interestingly, he also was a guy who, when he was a kid, his mother was very problematically laissez-faire. She would, you know, in the name of being a... you know, kind of helping him to feel confident and not feel pushed around. She kind of let him do anything. And he actually almost burned the house down more than once on two occasions where he was playing with fire. He was doing something. He wasn't a fire setter trying to do that.

But he got himself into trouble. And he began to feel them that there's nobody taking care of me. There's nobody kind of watching over me. And so that was another element of there's danger in the world. And, you know, moving up for him also was taking on more responsibility. And there was a part of him that felt I already am dangerous when I'm in charge. I need somebody to hold on to me. And so, you know, our talking about these kinds of things, not only in the office, but in the elevator, you know, where the elevator could be a place where these anxieties could be thought about and discussed even while he was letting himself be in the elevator.

So we need to get past all of these either oars and you either do it this way or, or you do it. or you do it that way. We really need to bring to bear all the different things that all the different traditions in our field have alerted us to and given us the power to use. So like this particular scenario, let's say they had a dream. And in the dream, he's unable to get up the elevator.

And so he's fired. And because he's fired, he loses his house. and because he loses his house and his job, his wife doesn't want anything to do with him. And so leaves and takes the kids. And they're separate from him. And now he's all alone. And, you know, so it's kind of,

I don't know if you've seen this with people who gain success. It's like when they've initially gained success, there's something about, like all of a sudden they have a lot to lose. And they start having these fantasies of losing a lot. losing everything, you know? Kind of this like, I'm going to then be thrown in jail because, you know, this lawsuit that's going on at work and so I'm going to be in jail separated from my family without a job. And that's where they're at, you know. Any, yeah, where do you, where do you go with that? What would you say or what would you do? Well, it's interesting.

You know, coming back to the expression of this in the dream, that you are just describing. As you know, the traditional Freudian view of dreams is that they are disguises of deep underlying wishes and that there's a latent content and a manifest content and one has to get through the manifest content to get to the latent content. I don't view dreams that way.

I don't think there's this real sort of secret kernel that this is what it is. A dream is both the thinking and kind of going through things that we do at night, and it's a communication. There's certainly the telling of the dream is a communication. And so any given dream, I think, doesn't have a single latent content. It has many different potential meanings. And what I would be saying to the patient would depend on my assessment at that moment in the therapy of what he needs a focus on. So I might, for example, with the patient you were describing, say at that point, you know, it sounds like the dream is expressing a deep wisdom that you have about where this phobia could take you, you know, about the real necessity.

necessity of getting past it. Saying stuck in it is going to lead in bad directions. And I think you're right in thinking that we have to figure out how to help you get past it. So in doing that, instead of interpreting the meaning that the benighted patient hasn't seen, you know, I'm the all-knowing interpreter and he doesn't know until I tell him. Here, I'm actually empowering the patient, you know, that perspective of your right. I think there's a wisdom in what you're trying to say, I think is often a much better way for us to get across to the patient.

And I don't mean it in an insincere, kind of made up. manipulative way. I mean that there are these multiple meanings and the more we are able to use them to respect the patient, respect the potential that has been pushed aside and help stand behind the patient in his effort to move forward. That kind of tone is. really important. Okay, I like that. Yeah. So it's like you're honoring their internal wisdom that's coming through the dream.

Okay, so next week he comes back and same dream except there's a lion having a chess game with him in the jail cell. So he's lost everything. And now he seems more peaceful having chess, playing chess with a lion. And I have to give you some context for those of you who are here on YouTube watching us. In my office, there's a lion painting right where he looks at me, right? So I'm like, oh, there's a lion right behind me, right? So yeah, any thoughts on what you would do with that at this point?

Well, again, I think I would be thinking like a psychoanalyst, but talking like a person. And what I mean by that is, you know, any psychoanalyst is likely hearing about a lion to, I mean, think about aggression as at least one element. Not that, again, not that it's the element. And even for a psychoanalyst, you could make up 10 stories that have what the symbolism of the lion is. You know, the king of beasts. And is that about the father or usurping the father or so on? And chess is itself a game where there's a king. So there are all sorts of ways, but I might wonder out loud, you know, so you.

And who and the lion are playing, who's going to win? Who's going to be more aggressive? Who's going to be the one who destroys and defeats the other? What does that feel like? And I might ask, what would it feel like to beat the king of beasts to come out on top? Let's, I don't know, if you're okay, let's jump into a roleplay here. I'll be the guy, you be the therapist. Okay.

So I've just told you this dream. And so maybe I would, maybe let's start out with the role play. And let me get into character here. Okay. Well, you know, it's interesting as I think about chess in particular. I think about playing chess with my dad growing up. And there was, it wasn't about winning and losing. Because if I was losing, he would flip the board around.

And he would give me, you know, an opportunity to win from a place of higher. pieces. And it's interesting in this, in the second phase of this dream, I was calm and I wasn't necessarily, like I'm in jail. I've lost everything, but I'm calm. And so I'm not sure what that means. Well, sit inside that calmness and see what the calmness is saying to you. Let's say, let's say it's saying, I think it's saying, um, maybe it's over. okay if I end up in jail, I'll be okay. You know, one thing that just occurred to me is, you know, you've been talking about this whole downward trajectory in your, in how what you imagine your life would go.

And now that you're sitting in jail, it's sort of like you have nothing more to lose. And losing seems like, you know, having something for news. is one of the things that seems really scary. And it occurs me, I wonder if kind of in the family, there was a feeling that losing was a terrible thing. Because, like, your father couldn't bear to let you lose to him. I mean, in some way he was being very kind and supportive. But in another way, he was protecting you from that experience of losing

to him. So let's see. What does it feel like to lose? Just sort of go into that and see what that feeling is. You know, I think I would push back

on the family of origin dynamic that I experienced growing up because my parents could care less about sports. They could care less about any of that. They would show up. You know, and I was very much to sports, but they would show up and watch the band and comment on the band. So I'm not sure,

like, winning. You know, I know a lot of kids have that kind of dynamic where the parents are overly focused on winning. I just don't know if that was the dynamic. But I think what the dynamic was, was, I think there was a lot of disconnection going on with my parents, but I have a lot of good connections now with, you know, my family and my wife. And so it's like losing now something that I didn't have maybe even. You know, that seems like a true loss. Well, you do have now a lot that would be lost, which is, in fact, it's a wonderful thing.

You know, we all kind of want to have lives in a way where there's a lot to lose. You don't want a life like you're describing in the jail. where there's nothing left to lose because there's nothing there. Your life is rich, and that's wonderful. And that's what we're working on, sort of not only preserving but enhancing, but clearly there's something that scares the hell out of you, you know, and shows up when you're in the elevator.

But it doesn't show up, at least in the dream, when you're vying with a lion when the opponent is really strong you're calm and so in a way

it sounds almost like you're looking to engage a strong opponent and that you grew up in some way and clearly there was a lot in your family I agree that there was a lot that was benign. And, you know, from everything you've described,

your parents didn't just push winning in that kind of way. But it does sound like really vying, really going head to head was hard. You know, and even going to a sports event and paying attention to the band is sort of like, I'm not even going to look at what's most aggressive and competitive there. I'm going to go look at what's harmonious. And that's great. But that's only a part of life. And you're trying to figure out how do I include in myself the part of me that wants to knock heads and

clash and engage in rough and tumble competition? What does it feel like when you picture yourself really engaging competitive. Yeah, I can see where, and I know in other sessions we've talked about how hard it's been to feel the anger that maybe I disavowed and how sports kind of gave me that position, that place. And I think there's something about the playing a line, which would be normally pretty scary, but it's peaceful here because there's nothing to lose in a prison. And there's something glorious about maybe coming face to face with like that aggressive part and not being afraid of it. And I think that's part of the work that we've done, which you've helped me with.

And I'm also seeing that there's a lion behind your desk here. And so I'm thinking like there's something about our conversations, which is, it's kind of like playing chess with maybe parts of these things that were disavowed. Yeah. Don't seem so scary anymore. Yeah. If I can have a lion in my office, maybe it's okay for you to be a lion. Yeah, or face the lion.

Both. Right. I think you're right. I think it's not one or the other. the lion is you and the lion is a worthy opponent who is strong enough for you to be strong and it's probably a bit of both yeah you know i think there is kind of like when when i think about worthy opponents i think about on the 20th floor of this office that i work out it's like like in this higher state the stakes are so much higher you know and people's lives are

at risk large amounts of people's lives. And I think that there is something about needing that aggression, and it's so hard to feel like I could disappoint someone. But then, I don't know, how did, I guess I get confused there. It's like, why do I fear so much disappointing these people that believed in me that gave me this higher position in this company, you know? So the disappointing them is I think that might be central. Yeah.

Yeah. What does that feel like? Suffocating. It's hard to breathe. It's hard to get a full piece of air. Yeah. So, you know, we obviously we're not going to have a whole session here. I think that's good.

Some of the flavor where I... Okay. So comments on things I'm noticing you doing, you're allowing the emotion, you're allowing the emotion, you're allowing the, there's an experiential component, right? Like, so as you sit in this, you know, type of thing,

you're still trying to pull on themes. You're setting out like little, this is a hypothesis I have, you know, is this it? And then when the patient's like, no, it's not. It's like, okay, you're not like doubling down on that hypothesis. You're kind of shifting gears a little bit. I notice you're looking for the disavowed, the disavowed emotions. And so I kind of imagined what it would be like to be a couple sessions in where we kind of have, I don't know, avowed, allowed the emotions.

Yeah. So any of your thoughts, kind of debriefing? Well, when I sort of step back and think about what I observed between us, as it were, one of the things that occurs to me is that, you know, I'll say you as if you were, so to speak, that I never told you anything that I knew and you didn't. And yet, of course, I did. In other words, the tone was not, here's what you're missing. Here's what you don't see about yourself.

It was acknowledging the kernel of what the person does. see about it. I think in part one of the places where psychoanalysis went on is that it took the word unconscious too much

as a noun and not enough as an adjective. And what I mean by that is the unconscious, like it's a thing that's in there. Whereas what's really illuminating in a

psychoanical psychodynamic viewpoint, is that so much of our experience is unconscious or is actually more accurately less conscious or minimally conscious. I think, again, the formulation of here's conscious, here's unconscious and there's this impermeable barrier is very problematic. And then we have to, you know, deconstruct that barrier and that's the patient's resistances. And it becomes then an adversarial way of approaching the therapy. Whereas the very same insights where psychoanalysts do see things that often other therapists don't see as much because they haven't been as trained in it and that the patient doesn't see because yes there are defenses there is

avoidance but instead of it being i see something you just don't see it's more i see something that you kind of see but wish you didn't or kind of why not to and I'm paying attention to your seeing it rather than to you're not seeing it. I'm

sort of saying let's you sense that you know like let's say playing chess with the lion you know there's something about being able to really battle with

a strong, worthy adversary that feels good. I'm not telling him that, though in some sense I am. I'm amplifying an experience he has and sort of building on the insight from within rather than an enlightenment from without. Okay. Yeah. It's kind of like empath. their own subtle discovery while in kind of like the subtle times that I did notice things, right?

Yeah, yeah. And I am kind of leading the dialogue, sort of leading from behind, so to speak. You know, I am noticing what are the elements that the patient. kind of shies away from and trying to call them into play. And as you said earlier, I'm trying to do it not just in a cognitive pointing out, interpreting way, but in an experiential way. I'm inviting the feeling. And I'm asking the patient to experience the feeling, to sit in the feeling, to be in that situation.

And that's where also the illumination that comes with psychoanalytic work also is exposure. Because in asking him to experience it, to live in it, to be what's it like to be able to be strong and know that the other side is strong also and that you're not going to just destroy them. what's it like to really bear the feeling that you're disappointing them? You know, whatever it is, the what's it like? I'm both amplifying something that was implicit, but I'm doing it as an invitation to feel what had been disavowed or pushed away. yeah i've seen that a lot in like eFT work where instead of just moving past an emotion they kind of sit in it for a while

what other words come to you as you're sitting in it what yeah what's it like to sit in just going to say just before you said it we're on the same wavelength here that what I was saying exactly points to a way that the intersection of the way I'm working with EFT and other experiential therapies.

That's another element of it. The way our field has developed, it's developed with these separate silos, each with their own acronym. And what we miss, This is the really important ways in which they overlap, but they're not the same. They overlap, but each comes from a different angle, so it enriches it to pay attention to each of them,

but not to see them as separate and bounded by an acronym and a manual and, you know, this is what we do, this is what they do, this is what this other approach does. Yeah. Okay. So in that line of attachment, I know you have some thoughts on attachment therapy, how to integrate attachment principles into therapy. How would you describe it and then how might it play out in this kind of scenario that we've built? Yeah. So increasingly in recent years, I have thought more and more about attachment. It's become more and more a central element than the way I think. And I realized that part of what delayed that is that for many years, I was thinking of attachment the way much of the field does as a way of kind of, in a sense,

categorizing people. You know, there are people who are securely attached and people who are are insecurely attached. And among the insecurely attached, there are people who are avoidantly attached and people who are anxiously ambivalently attached and people, disorganized attachment, and so on. And those are very rich, very well validated and clinical useful concepts. One of the ways I've most seen it really valuably used is in David Wallen's book, Attachment in Psychotherapy, which I think is a wonderful example of how you can use these attachment categories clinically and in an enriching way. But at a certain point, I began to

really step back and think more about attachment as an interpersonal process, most of all. that attachment occurs between the parent and the infant and then the child and then other figures in the person's life. And that attachment, of course, centrally is concerned with how to provide both protection and an accepting structure so that when there's a anxiety, you can come back to the secure base and then go out and explore and so on. But there's another element of attachment, I think, that's central to what it's like for all of us growing up and then throughout life in a way, which is that we, as we, as our, as the very hard of our security depends especially early in life on our connection to the attachment figure, getting the right kinds of signals from our attachment figures becomes crucial, that we all,

in a sense, learn to be what our attachment figures need us to be. And that doesn't always mean, being a good boy or girl. It doesn't always mean conforming. Sometimes, for example, our attachment figures without necessarily being aware of it very much themselves, need us to be rebellious, need us to express what they haven't expressed. So it's not a simple, we do what they tell us to do. but in subtle and complex ways we become what either what they need us to be or what they can bear to see in us so that the most difficult thing is to not be seen or related to at all. You know, one of the classic research studies in the realm of early development and attachment is that the still face study.

Love it. You know, the mother is relating to the baby. And then she doesn't do anything hostile or negative overtly, but she just suddenly just doesn't say anything. Doesn't say anything. Non-reactive. And the baby is terrified. You know, there's something about not getting that responsiveness that is deeply,

deeply disturbing. And what happens as, even as, in the very best of developments, even as we evolve and elaborate on all the things that delight our parents, and we do more of it, and we get better at it, and are enlivened by it, every single parent on the face. of the earth, I think I will say confidently, loves certain aspects of their child more than others. That there are some parents who love their infants and then their child's and their adolescence, feistyness and are really troubled by their anxiety. There are others who love their child's gentleness and are really bothered by the child's aggression and so on. And there's always going to be some kind of figure and ground in this.

And the things that don't meet with parental responsiveness kind of are among the things that go underground. And again, it doesn't have to be things that the parent disapproves of. There are all sorts of ways in which the parent may just, almost not noted, doesn't disapprove because they don't even notice it. You know, the child. Attention, attention. Yeah. Yeah. So, yeah, I see this all the time.

It's like what parents give attention to get more happens, right? So like I saw this the other day. I was at a friend's house. Daughter comes up to him three times she asks him for something. He doesn't hear it at all. And she asks him nicely. You know, she's holding his hand. Daddy, blah, blah, blah, blah.

Third time, she's crying now. She says it. He reacts to her in an angry way, but he's responsive. At least he gives her attention. And she goes away and she's like, man, I just have no idea why she cries like that. And I'm like, do you want me to describe to you in the most blunt? And so I say to him, this is what happened. And he was like, wow, okay.

And I'm like, yeah, if you only give attention to her when she's crying, you're going to get her to cry more. That's kind of what you're describing, but I think you're describing it on multiple levels. Like, even with more nuance than that, like this subtle, it's like you have no idea the thousands of ways you're impacting a child, making them disavow certain aspects of their personhood,

either anger, aggression, it could be the comforting aspect of them. and you're subtly behaviorally conditioning the child towards a certain pathway and then they get to be 20, 30 years old and they have these disavowed parts of them that somehow need to get integrated.

Yeah, and I think it is often very subtle as you say. One example that I discuss in the book, making room for the disavet, was a woman in her 30s, a married woman with a couple of kids who, by almost any criterion that one might employ, seemed really securely attached. It would be very hard to describe her as insecurely attached.

She had a really close, full-bodied, three-dimensional relationship with both her. parents, with her brother, with her husband, with her children, and with friends. She was, in many ways, she was living an admirable life. The reason she was in therapy was the one thing that really was troubling to her was that she was sexually unresponsive to her husband. She loved him. It was very clear, and he felt loved by her. But when they had sex, it just, nothing happened for her.

There was something that felt sort of deadened. They had sex and they had kids. And they could be very affectionate with each other. And they could kiss and she could start to get aroused even. And she found him attractive. But once they were actually starting to move to. toward intercourse, it was the way she described it was, I can do it. But that says it in itself. If she describes it that way, I can do it. Can I ask two questions. One is, so the psychiatrist in me

says, you know, when did this start? Like how many years into the marriage or, you know, before the marriage? And any, so any changes in medications around the time that this started? if it did start a couple years ago. Yeah, good. Right. And obviously really important questions. And in the course of our work, I had her go for full medical checkout because clearly, you know, both a gynaecological checkout and a general medical checkout to see if there's any. medical or physiological explanation or anatomical explanation.

And she tried sex therapy. And that too didn't really help. And then one of the things that happened sort of by just a kind of wonderful stroke of luck to some degree, she was talking with her brother. and her brother was considerably older than her. He was about 15 or 16 years older than her. And now as adults, they were very close. As children, she was like his pet.

You know, she wasn't yet a peer when she was little. But they were talking, and he was, something brought up a memory on his part. of her mother teaching my patient, this woman, to talk, you know, beginning, beginning, you know, the way when a child is about a year old and just beginning to talk, and so he remembered seeing her mother. And parents teach them things like the names of the parts of the body, you know. And so he remembered seeing her mother going through what starts out as a very familiar sequence, but becomes very interesting. You know, he watched her with the mother, and these your eyes, this is your nose, this is your mouth, this is your neck. you know, we parents do that all the time when kids are first learning to speak and learning parts of the body.

This is your neck. This is your chest. This is your belly. These are your knees. This is your foot, etc. And he noticed her both like anxious pause and the clear omission of a part of the body. And he saw this happen a number of times. when he told his sister this, a whole bunch of things started to kind of become clearer that the mother who was in all other ways that we could see genuinely responsive to her daughter, attuned to her daughter in the way that we were talking about just before. but the one place where a piece of the doctor kind of disappeared was the genitals, that region of the body. And as they began to think about this together, they began to also talk about, in my patient, in our work, began to talk about to remember, to get clear things like, you know, when they were older. and the family would sit around together watching a movie or a TV program.

When something sexy or seductive was going on, and this would now have four adults, the mother would sort of get up and let me make you a snack. You know, I have to do this, have to do that. Yep, yep. She would just, would never be announced, but there. Very uncomfortable. Very high levels of discomfort.

Yeah. And that in some way, in my patience securing her attachment with her mother, who in so many other ways was a wonderful mother and somebody she really wanted to stay close to, it was like she left out a part of herself. and that kind of remained when she was growing up. And that part of herself, interestingly, was left out of a loving relationship because her relationship with her mother wasn't a tense, unloving one. It was a loving one.

And so, you know, with her husband, it got left out even as there was a tremendous amount of love and attachment. And we started to kind of talk about this, and she began to talk about it with her husband. And one of the interesting breakthroughs that kind of both preceded and then eventually just became a kind of fun part of their sex life was her husband, who then heard about this story, when they were engaged in foreplay, would start to say to her, this is your nose, this is your mouth, this is your chin, etc. So he would be playing with it in a way this anxiety, what had been in kind of an anxious and avoidant situation, and it kind of made it, it integrated it, you know, it made it light, and, you know, over time things really did improve.

So that to me is a kind of, way of thinking about attachment. Remember we're coming back to this as under the label, the rubric of attachment, you know, that the attachment is both the reassurances and the connections, but also the omissions. And often we need to sort of look at the omissions. Right. And not just that what was.

So let me ask you about this. case like when you're in this case and you were talking with this patient the first how did it even come to her talk or when she started talking about her body her body parts sexuality what was her level of discomfort initially talking about it and did that change over time well i i mean she the description, I mean, initially when she came in, there was distress about it, but also very much puzzlement. She kept saying, I don't understand it. I love him. I find him attractive. I even get aroused when we're kissing. And then something just stops and I don't understand it.

And maybe because it wasn't so much forbidden by her mother as kind of like avoided, it didn't become it wasn't something that

she went through with a lot of anxiety but and I think as she began exploring this, a lot of a lot of what came up was sort of anxiety mixed into it, but there was like nervous humor. She would laugh a lot as she would do thinking about it.

But it wasn't just a, you know, a kind of simple, open laugh. It was a nervous laugh, but also a laugh of release as well, of, you know, something's coming forth that. had been in a way kept in, you know, in bubble tape, so I'm saying. Bubble wrap. Okay, so yeah, this is a helpful example of kind of how things are disavowed by how parents don't give attention or what kind of, instead of attention and just describing it, there's kind of like this anxiety avoidance, not direct shaming, like I've seen in a lot of patients like this is bad or this is dirty or this is and of course that's, I'm certainly not saying that that doesn't happen. It happens a lot and that's an

important part of our work also, but that it often can be more subtle and it can be something where a certain aspect of either interacting with the parent or just the child's being and feeling in a certain way, as the parent notices it and detects it, that makes the parent anxious. You know, so that there's a subset of kids, for example, when they look sad, that's when the parent has a heart. time relating because there's something about the child's sadness that touches off something that's so uncomfortable for the parent that they just have to ignore it, push it away, try to distract the child, et cetera, but aren't able to be relating to the child or helping the child. and you know again you know it can vary all the way from a very hostile don't be such a wimp

to a very subtle just changing the subject not being there etc it's not one or the other it's a whole continuum a whole range of ways yeah that's good but in all of them i think the one of the important things is how often we become the version of ourselves. And it can be a genuine version, but we become the version of our genuine but limited version of ourselves that works in our parental situation. Okay, so let's say the therapist. I know you talk about therapists making mistakes, how we need to become more at ease with this idea that we are going to make mistakes, but we do make mistakes.

So let's say you're a therapist, you're listening to this and you're saying to yourself, you know, I think I may be disavowing some emotion or some experience of my patients. Like I may be subtly ignoring this one aspect of them or kind of like maybe I've been pulled into this kind of enactment of something similar to what it was like for this person in their childhood to have. a disavowed or not listening to this one aspect of this person's experience. How might a therapist, if they're kind of becoming aware of that as they listen to this, one, have some kindness and patience for themselves in this process. And two, how do you kind of like change maybe that

dynamic or how do you start to correct this bias that we can introduce maybe? Yeah, and that, as you well know, is not an easy question, because you're talking about most often things we're not noticing we're avoiding or not noticing we're not responding to or not as exploring as deeply. So sometimes can be hard to alert ourselves to it. Obviously, that's one of the roles of supervision. And importantly, of peer supervision as well. Because it's not just about being taught by somebody more senior who knows better, because after all, they're going to have their blonde spots too. But in a peer supervision context, just each of us has blind spots inevitably.

But, you know, we have different blind spots. So one person noticing something that's not getting picked up on can be helpful to us, you know, just because, and just as we can notice something they're not picking up on. So that's one way. another just in our own day-to-day work, you know, and it follows from what you were saying, that one of the questions we, you know, need to be asking ourselves a lot

is just, it's not just what's going on with the patient and what can I do to help, but just periodically kind of asking ourselves, what am I not picking up on? And to the degree that one can do it on our own, and there's at least some range in which we can, or our work would be almost impossible, that's an important question to keep asking ourselves. Because, you know, as is implicit in what you were asking, it's virtually inevitable that there are going to, just the way, you know, no person. parent is equally loving of every facet of their child, because in the very loving of their child, they're loving certain things and others going to the background. Similarly, no therapist is

able to be attentive and responsive to everything in their patients equally well. One of the other things that your question stirs from me. And it's something I've been thinking about a lot, and I don't fully know, especially logistically the answer to, but I think is important, is that I think one of the limits of psychotherapy as intends to be practiced today is that we think of ourselves as almost like, I'm the universal donor. You know, like I can work with anybody. We may have specializations for a kind of problem.

You know, one person may say, I'm really good with eating disorders. I'm very good with, you know, OCD, et cetera. We do specialize that way. But we don't tend to think of ourselves as specializing just in, here's a kind of personality. I work well. But just the way we don't become friends with everybody we meet, we don't become lovers with everybody we meet,

we connect selectively. That inevitably happens with patients too. So I think the sort of the next increment, the next step in the evolution of psychotherapy, in the place where I think a lot more research and theoretical inquiry needs to be focused, is in how to refer patients, how to really determine, is this someone I should be, I should be working with, or is the connection not right?

and what makes it hard is we often don't know that until we have begun working because that's when we really start to get immersed in those subtleties and what hasn't been on the surface initially. And I think one of the one of the things we most need to pay attention to you is when there's a feeling that continues over a period of time of sort of stasis or deadness, a lack of something happening that I think often is a product of the part of the patient that needs to be brought out being. something that's hard for us to let ourselves, or immerse ourselves in. And that's really hard.

I don't have an answer yet to this for myself. But I think we really need to be thinking about, for example, how do, and maybe we need to educate the public about it so that patients come in with different expectations, that it's very likely, or at least it's common or should be, for a therapist to kind of become aware of therapist and patient pair if they are communicating well in other ways, become aware of maybe we even have done useful things together, but it's really there are things that I somehow not, I'm not sufficiently picking up on and helping you to stay in contact you and we need

to think about not as a failure but as the next step how do we find somebody else to take you the next lap but that of course is really difficult because it can so much feel like a rejection

on the part of the patient so I think we really need to think about that problem a lot harder and more people with more wisdom to join into that question. Yeah, there's a couple things I could pull on there. One of the things is kind of this process of the therapist growing in the midst of your patient's growth and how vital that is.

Sometimes I feel like I need to grow for this person to continue to grow. There's a quote by Nancy McWilliams. like she said, my analysis expanded my empathic capacities in other ways. I became slowly, painfully familiar with my blind spots and with my vanity, greed, envy, sadism, which were only possible to admit and explore because my analysts, matter-of-fact, acceptance. Is there a process in this disavow work

where you as the therapist need to, you know, see some of the aspects of your clients and yourself with more compassion or with more acceptance. Is that been part of your journey or part of what you've seen from the people you've supervised? Well, certainly, I mean, to begin with, I very much resonate with what Nancy had to say. she's one of the wisest smartest people I know in our field

and I think most good therapists recognize the kind of process that she's described and I think our own both experience as patients

and experience you know in in the vulnerable situation of being supervised are really important learning experiences. At the same time, none of us sort of reached the point where, okay, now I'm fully analyzed, now I can just see things clearly. You know, we... They call it going clear in the Church of Scientology. Right, right. None of us go clear. We each remain human beings.

And in that sense, we're not different from our patients. There are parts of ourselves. It's hard to be, especially in a prolonged contact with. And, you know, hopefully we try to keep learning, keep paying attention, maybe even keep trying as we notice any of these avoidances, trying to make more room for what we haven't made room for in the therapy relationship. And that can, you know, in a certain, in that sense, we can also, you know, we can get our own freedom and mental health can gain from courageously engaging the therapeutic

relationship, you know, but we never get to clear, to use that metaphor. but hopefully we get better and better at it and we expand at least somewhat. But at the same time, I think we really need to have the continually honest with ourselves about the inevitable limitations that we're just the way we want to have our patients accept that they're only human. and enabling that by accepting that they're only human, they can come closer to also feeling fully human, the other side of that metaphor, as it were.

I think that's true for ourselves too. Yep, yep. And I think as a psychiatrist, you know, who practices psychotherapy, not every client that comes to me ends up as a therapy client. Actually, most of them don't. A lot of them I'm playing quarterback for and finding the right therapist.

I'm thinking about who the better match would be. Sometimes there's a better match than I imagine myself would be. It's often the case. As I get to know people in the community, people who are truly excellent at what they do and the different niches that their personality fit into compared to mine. So I like that you're bringing this to the attention of like, okay, how do we give a good referral?

thoughtful referral, not a referral necessarily just because we don't want to treat someone, but because they would be better treated by someone else. And, you know, sometimes it's a painful process, I think, of having that conversation. And I imagine rejection is sometimes felt quite a bit in the midst of that. Do you have any kind of inputs on how to, have that conversation? Well, again, I think to begin with, it remains

a dilemma. It is something I am still learning to do. Are you the type of person who has a hard time saying no to taking on clients? Like... I don't think I have

a harder time than... Okay. A lot of us have a But we all have a hard time to some degree, you know, and we all kind of, in a way, overestimate ourselves, but not so much in terms of whether we're good at what we do, you know, whether we're smart, well-trained, et cetera. But rather, because the problem that we're talking about here is not so much, you know, like it's easy when you feel you don't have the right skill set. Like, for example, I, as much as I have embraced a range of cognitive behavioral perspectives

into what was originally a psychoanalytic, psychodynamic point of view. I'm not a CBT person. There are skills, practices, et cetera, that they have, that I can approximate, for some patients, I bring in those principles right into the very heart of my psychoanalytic work, as I was describing earlier. But I don't do, for example, you know, there are protocols for treating OCD or eating disorders or a variety of things that are just not my expertise. And when that's what's called for,

that's relatively easy. That's an easier one. Yeah. When the issue really is this patient, what this patient needs to get more in touch with are the very things that I also need to get more in touch with. that's much harder because it's hard to acknowledge it and it's hard to see it. So those are the harder referrals.

Those are the ones where we say yes when we should say no, so we speak. Yeah. Okay, kind of as we're wrapping up our time together today, any final thoughts that you have that you want to put out there, kind of like speaking to the psychiatrist therapists around the world here? Well, first of all, I want to thank you for a really stimulating and just fun interaction. I really enjoyed this. I think what I would want to highlight is kind of wherever we come from, whether it's

cognitive behavioral or psychodynamic or humanistic experiential or systemic to try to not get caught in our silence to try to be aware that so often

these nominal theoretical orientations become identities as well. It becomes kind of who I am what I am and that can be limiting.

So really trying to make really a maximum use of what we've been trained in, but have real interest in other ways. That's one. The other is that as therapists, who really ought to be therapeutic, that we ought to notice when what we're saying to the, person isn't therapeutic is a kind of an indulgent expression of our theoretical premises. And in one of my earlier books, therapeutic communication, I talk in a lot of detail about the ways that our communications to patients often are unwittingly

rebukes, unwittingly ways that we're telling the person what's wrong with them. And both in the book we were talking about today, Making Room from the Disavowed, and in that book, the center of my concern is how it is about making room. It is about how do we bring forth what the person has been. afraid to think and feel. And maybe one last thing I can say for the more hardcore psychoanalytic people in the audience,

but also as a way for cognitive behavioral people to connect with them. Freud actually, almost 100 years ago, sort of had the answer to what he had been doing wrong, the first quarter century or so of his word, he really articulated it beautifully,

and then he forgot it. And psychoanalysts ever since forgot it. And that was he talked about how he had thought that repression was the most fundamental thing. That's what you had to get at. And anxiety was one consequence of repression, Like if we've repressed something and it starts to come up, then it makes us anxious. But the most important thing is undoing repression.

And that means knowing oneself. And I'm obviously a very strong advocate of knowing oneself and knowing oneself deeply. But the most fundamental change comes from being less afraid of ourselves, less ashamed, less guilty, finding what's been pushed away. And so I think I would say maybe as a kind of little shorthand rubric that captures a lot of what I'm saying. Maybe I would say something like that what we need to find out in the course of therapy, whatever vantage point we're working from is not what we've been hiding from ourselves,

but what we are, have become afraid of in ourselves. Most two are correlated, but they lead to a very different tone in the interaction thing. Beautiful. Yeah, I love, I feel like just what I've read and this conversation

and other recordings I've heard of you, have kind of given me a picture of your perspective here. And I think it's very much an alignment with mine, but also I think you put new words to describe things that I've thought, you know, and I imagine people are listening to they're like, yeah, that makes a lot of sense. And it gives a good emphasis to things that just like, it's like, yeah, that does make a lot of sense.

That could be a focus. That could be something that we think about. Like, what has been disavowed? what are we afraid of thinking about and how do we distract ourselves from these things that we're afraid of thinking about and how can we just sit more and with more comfort maybe with an attachment figure like a good therapist and kind of explore these things that and then how would our life be different if we were to do that maybe we would have less somatic symptoms maybe we would have less anxious symptoms and so I think that's that's wonderful so thank you for

for bringing this to our attention. I was, you know, another thought I had, which is so random, but I think it illustrates this well. It's like sometimes when I talk with people, I know what they're going to say after every sentence, you know, because I've read their book. But with you, it's not like that. Like, I couldn't predict what you were going to say.

And so you're not a non-player character in this interaction. I really appreciate your, the unique thoughts that you brought to this and the unique things that you have to, to bring to the community of mental. with professionals around the world. And so thank you, and I imagine other people are thankful. If you have any desire to send Paul a message, you could always send me a message, or I'll link your website, I'll link your books in the article that will go with this and the show notes as well. And yeah, are you, you're not on social media. I imagine email is probably the best way to reach out

to you, or what would you say? Yeah, email would probably be best. Yeah, and you can, okay. It's pole. Dotwachtel at gmail.com. Pretty simple. And your name is on the YouTube video here and on the episode, so it shouldn't be that hard to figure out.

Okay, great. Well, thanks again, and we'll leave it there for today. Okay, thank you, David. We enjoyed it.