Psychiatry & Psychotherapy Podcast - Primitive Defense Mechanisms Explained: Sexualization, Dissociation, Acting Out, Withdrawal, Denial, Splitting, Omnipotent Control, Projective Identification

Episode Date: April 24, 2026

In this episode, Dr. David Puder and his talented Cohort deliver a comprehensive exploration of primitive defense mechanisms, which are the earliest, most fundamental ways the mind protects us from overwhelming anxiety, trauma, and threats to the self. Drawing directly from Nancy McWilliams' Psychoanalytic Diagnosis, they break down key primitive defenses.    You'll hear clear definitions, developmental origins, clinical presentations, countertransference implications, literary examples, and real-world clinical vignettes, plus a rich group discussion on when these defenses are adaptive versus maladaptive.   By listening to this episode, you can earn 2.5 Psychiatry CME Credits. Link to blog Link to YouTube video

All right, welcome to the psychiatry and psychotherapy podcast. I am your host, Dr. David Pudor, and today I'm going to be talking with one of my cohorts on primitive defense mechanisms. One of the great pleasures and joys of my week is leading psychotherapy cohorts. We have been diving into Nancy McWilliam, psychoanalytic diagnosis, and one of the chapters that jumped out to me, and I thought would be very helpful to do a deep dive with this cohort, is on primitive defenses. talking about things like extreme withdrawal, denial, omnipotent control, extreme idealization, devaluation, splitting, somatization, sexualization, projective identification, extreme dissociation,

acting out, projection, and interjection. And we will be going through definitions, developmental origins, countertransference, implications. And this is a great opportunity for me to bring this group of amazing mental health professionals for you guys to meet and see. see that this is going on, this is happening, this is starting up again in September, and I'm excited to continue teaching in this way. So we usually do it twice of, you know, once a week for about two hours. We have some special people come on as well throughout the year and give extra two-hour lectures. And so people who are in this, I'm going to go through their names so you can hear them once and then you'll hear them again or see them if you're on YouTube watching this. Dr. Erica

L. Reynolds is a talented psychiatrist in North San Diego County, who is kind of the mother of the group with 30 years of experience, more experience than me, and comes with a lot of warmth and empathy for the group members. She will be talking about extreme withdrawal and denial. Ariel Shatz Wilderman is an M.A. LSW, who is a psychotherapist founder of the Wilderman Fund for maternal mental health and an expert in reproductive psychiatry. She is someone who has been a great joy of having on the podcast, and I think you'll really enjoy her dive into omnipotent control. Michelle Zittnick is a psychiatric nurse practitioner in Southern Florida with over 17 years of pediatric nursing experience and does a great job of somatization, which is something that she shows. is high in lexothymia, childhood trauma, insecure attachment, personality styles like

histrotic narcissistic or neurotic. And I'm excited for you to hear a little bit of her take on that. Evan Summersup from Canterbury, New Hampshire will deliver a candid, thoughtful presentation on erotization and sexualization, which is a defense in which unconsciously people try to master things like anxiety, self-esteem, shame, and terror with sexuality. Sheila Coles is an integrative psychotherapist from England, who zooms in once a week from England. She's part of the NHS and private practice, and we'll be talking about projective identification with a lens of a master clinician. And I'm really excited for you to hear from her. Dr. Johann Ortizzo is a Sidi MSW who has a special interest in psychodynamic psychotherapy.

He is going to be delivering a very clinically rich, informed, trauma-informed approach of extreme dissociation. Also joined with us is Heidi Lynn, a psychiatric nurse practitioner and co-founder of Halen Mental Health. She has advanced training in EMDR, psychotherapy, integrative psychiatry, and delivers outpatient care for children, adolescent, and adults. She is presenting on splitting, offering warm and reflective clinically grounded exploration in the all-good versus all-bad. It's used in borderline, narcissistic, and OCP presentations, and she presents powerful real-world examples of societal and team splitting.

Dr. April Staples, a sci-D, is a licensed psychologist and member, of the Ku-Mei Nation and does thoughtfully clinically grounded work and very reflective, highly reflective person. We will be listening to her talk about acting out or enactment, and she'll jump into other people's stuff as well. Grant Limon is a new psychiatric nurse practitioner who is an energetic, enthusiastic learner, and we'll be talking about projection and interjection. Finally, Danny Martino is a physician assistant with a certificate in psychiatry who will bring a sharp focus on extreme idealization and devaluation. And he's been a joy to work with this last year. Sadly, one of our other members, who you may have

remembered from a previous episode, Daniel Smith will not be joining us. He was unable to make these recording sessions. But you can go back and you can listen to our prior episode together on his recent book and his expertise on things like shame and envy and annoyance. So, all right, let's start the episode and I hope that this gives you an increased level of psychological mindedness. Erica Reynolds, you're going to start us off talking about extreme withdrawal. Yes, extreme withdrawal is a defense that I don't recall ever learning about until this month, which starts in infancy as an automatic self-protection retreat from a distressing interpersonal interaction. So as an infant, maybe I'm cold, I'm hungry.

Who knows what an interpersonal interaction at that level is, but this is the definition. This new state of unconsciousness, the extreme withdrawal, exists largely in a world of internal fantasy for the infant. And now, as of 2001, it's even included in the fight, flight, freeze, or withdrawal saying. And I thought that was very interesting that an old thing has now been included in the fight or flight, and then we got freeze included. And now withdrawal is also in part of that descriptor, sort of for the proverbial deer and the headlights situation. It's a flight into fantasy without a distortion or a misunderstanding of reality. It's a rejection. It's a rejection of reality, if you will, and escape from it.

And one can remain perceptive and sensitive to reality while electing or choosing to disengage from it. Some settings in which it commonly appears clinically are an instinctive response to an overwhelming encounter of danger. So as one gets a little older, this could be a helpful escape from something happening to a young adult or an adult past the infant stage. In the short term, it can help a survival. or rebalance after a trauma. And in the worst case, withdrawal can be prolonged, complex,

and a process that really takes over the inner life. So that is a highly undesirable state. And you might find this in someone who's appearing perhaps catatonic that would be on the differential. Somebody very, very ill in the hospital. Some of the more common personalities that extreme withdrawal is seen in are schizoid. So we have a deep voluntary process. preference for isolation and an ambivalence about a desire for relationships. So usually a lack of desire. And then there's emotional detachment. Another personality that uses extreme withdrawal is avoidant. So you can see withdrawal and social inhibition because they're really paralyzed by fear. So they perceive the social situation as fearful and their defense against it is to

really withdraw, again, reject reality, not deny it, but rejected. as schizochipple, I may withdraw due to tremendous perceived social anxiety. So again, we have that fear component and the social construct. And paranoid, which can show a withdrawal as a defense mechanism towards an unjustified suspicion. A literary example of extreme withdrawal is from the 2016 novel called The Vegetarian by Hong Kong, where the protagonist gives up meat and decides to live like a plant. So this is an example of a conscious decision to abandon a malicious act before complete withdrawal from a destructive social environment. So again, this sounds like an extreme example and that befits the name of the defense.

Wonderful. Great job. Yeah. So it's that shutdown phase of the fight and flight. So the shutdown, there's no, maybe no escape. So there's just a withdrawal, withdraw to self and fantasy. withdraw. Like you could see someone curling up in a ball. Sometimes patients will just kind of end up in their room, isolating. Sometimes after fights, like, you know, there's someone who will withdraw into the garage, shut down. It's like you talk to them and there's no emotion. They're kind of flat, very flat, very distant. Yeah. So great. Withdraw. Okay, and moving on to denial, this way may start as a way for infants to refuse to accept an unpleasant experience. And it becomes an unconsciously motivated inability or unwillingness to acknowledge the existence of a painful emotional, interpersonal, or physical reality.

So this is a very broad swath of issues here. The unstated or unrecognized goal of ignoring the realities is to, to reduce the anxiety. And the rejection of reality can lead to distortion. So we have a little bit of a distortion factor which can come into play with denial. Three clinical states where denial is prominent are the mania hypomania. And here the person denies that they are participating in events that could be dangerous or distressing to others. They just don't see it as a risk. Addiction. Also denial. we all know this, the severity of the substance use or that it is or could be harmful, and denial of how bad the substance use is, and grief, a normal early phase of loss that's seen

in the grief process. So those are some interesting clinical sightings of it. And for personality disorders that rely very heavily on denial are your borderline, your narcissistic, antisocial, and dependent. This is an interesting example. So denial, as has been discussed with some of our other defenses, is that there are some qualities, two that are higher order and mature, wrapped into denial. And those can tend towards repression, rationalization, or reaction formation. So denial is not only a very broad swath of things that it could occur with, but it also has hints at higher level defense. So it may not be just all bad, as we could say.

So an example of a strong affection for another, an example of denial may end up as, I don't love you, I hate you, in terms of a reaction formation. Somebody may end up saying that. And a beautiful example in literature, again, of denial is in the Great Gaspi, where Nick Carraway tells Jay Gatsby,

you can't repeat the past. and Jay Gaspi says, why, of course you can. That's my favorite example of denial. Wonderful, yeah. I think the denial is very, the switch from like something distressful to like pushing it down into the unconscious with denial, it's like so rapid that the thing that they're trying to hide from is not even registered in their brain.

So whereas like repression, registered and then it's pushed down denial it's so instant that it's like they don't even see it it's like there it's almost like a delusional there's like a delusional quality to it so with hypomanic defenses for example it's a little bit different than maybe bipolar like how we see it in the dsm but a hypomanic defense which various people can have even if they're not bipolar they deny some bad negative emotion and see something as positive so i've had co-examines who have hypomantic defenses, and it's like anything bad is like they don't even see it. It's like they only see possibility.

They only see that we're moving forward. They only see that, no, we're progressing. Like, everything is good. You know, and in some ways, that's like a, it could be adaptive in that way, right? To deny and to be able to keep moving forward despite, you know, the grimness of a situation. So, thank you, Erica. That was great. Thanks, yeah.

Okay, Ariel Wilderman, tell me about omnipotent control. Maybe give me just a brief definition. Sure. So omnipotent control is a primitive, primary defense process that can be described as an unconscious belief or fantasy of having absolute power over others or one's environment. So in a maladaptive context, the defense allows one to bypass unpleasant emotional states, distorting or disavowing fear of smallness, weakness, or annihilation into a self-image of the all-powerful and supreme. Yeah, so it's this great. So it's an unconscious belief or fantasy of having absolute power over others or one's environment. So tell me how the PDM3 talks about omnipotent control. Sure, yeah.

So in the 26 PDM3, omnipotent control is characterized as treating another as an extension of oneself and insisting that the other person thinks the thoughts assigned to them instead of having their own. Yeah. And it seems that this is linked in a lot of transference-focused psychotherapy with other primitive defenses. It's like they're always listed together throughout articles. What are some of those other primitive defenses that it's listed with? Yeah.

What comes up frequently in TFP is the grouping together with devaluation or extreme idealization and devaluation, as well as projective identification and splitting is really inherent to omnipotent control. Yeah, so it seems like all those three are kind of going together. And I was thinking about Nancy McWilliams' chapter on psychopathy, and how does psychopathy have omnipotic control as part of it? Yeah, yeah. So psychopathic, in the psychopathic realm, essentially there's this controlling of other. around them with a sadism component for power. It's not really to destroy, but rather to control

while they still can control. And I also think about, you know, with reference to Nancy, this element of omnipotent control or omnipotence in the psychopathic position is actually part of a conscious process in the control element as well. So that also is, is interesting among the psychopathic realm. Yeah, I think psychopathy, it's so centered around power and control, whereas like, you know, someone with a more dependent personality, it's centered around like, okay, how do I stay connected to this individual? Someone with schizoid, it's like, I don't want to be consumed.

Someone with OCPD, it's more like, I don't want to be, I want to control every little aspect of my environment, like, in an orderly way, but psychopathy is all about power. And so how might some of these elements of this desire for omnipotence come out practically? Yeah, there's a lot of manipulation happening among psychopaths. So again, unconscious defense, conscious process, some ways that omnipotence will show in psychopaths or in a psychopathic kind of realm is when you say, see someone rigging the game. People may cheat. They want to set the rules. People will blackmail others, play kangaroo court. There's a lot of isolating of the victim. People in this range will

often try to turn the family against the other. And even in our position, turn a psychiatrist or a therapist into a controlled substance pill dispenser. So there's a lot of, conscious manipulation that may be motivated by unconscious processes. Right. The quest for power, right, they'll do anything to get the power. They want that omnipatical control. They want to control the thoughts of others. You've seen this in kind of awful dietic relationships between someone who's more of maybe a dependent personality and more of a psychopathic where they're wanting to control all of their thoughts so they really isolate them. Great summary. Okay. And then, interestingly, when we're looking at, like, narcissism, a lot more of the trans transsex therapy articles, they talk about omnipotent control in more of a narcissistic person. What is the goal of control in someone who's more narcissistic?

Yeah, I mean, the essence is to promote this grandi, grandiose, inflated sense of self, but it's really an image. not even a sense of self. So it's this whole fantasy that is about supremacy, control. We see a lot of those other defenses coming in as well here. So there are a couple of just main aspects of that to stress control of others' perception of you, of the narcissist, in more of the depressive personalities or dependent personalities, the masochistic personalities, the masochistic personality types, it really manifests as control, very, very good targets for someone in the narcissistic realm.

Right. Yeah, the narcissistic person is finding that person with the depressive, with the dependent. Yeah, absolutely. It leads off of those traits of the depressive, dependent or masochistic personality types. Yeah. And one thing we have to be careful about as mental professionals is they can turn the psychiatrist into kind of like that ego booster, but then devalue them because maybe they feel some envy of their position or power or authority as a mental health professional.

But really, they really want like this, like someone to co-author their narrative about themselves, the way they see themselves. So as therapists, we might have an omnipotivist. fantasy that we are capable of rescuing a patient. What would you say? I would say that the therapist's omnipotence is an important one to be aware of. It also ties back to Kernberg's views on omnipotence, which she relates to the borderline level of functioning patient. So here there's this self-idealing patient who, in order to sustain their fantasy of

self-generated power, will overreact. idealized self and object representation. So the therapist is essentially an ego booster. But the patient ultimately devalues the therapist to maintain their position of power. So that'll occur when the therapeutic alliance becomes too much. The patient then will project disavowed parts of self, that vulnerability, that openness onto the therapist. So as Kernberg puts it, he states, and to quote, the projection of that magical omnipotence onto the therapist and the patient's feeling magically united with or submissive to that omnipotent therapist are other forms which this defensive operation can take. So what happens through

projective identification with the patient, the therapist can start to embody these disavowed emotions or internal states. So the dysregulation of, of self on the behalf of the therapist can shift gradually or abruptly so that the therapist feels the patient's feelings, frustration, annoyance, rage, hate. And these are manifestations of omnipotence and devaluation, ego defenses. So this is an important one to think about as providers, as therapist, in this role, because it can have severe impacts on the therapist. I mean, even ethical dilemmas. It can even lead to a therapist feeling physically ill and burnt out.

Yeah, it's really good because it kind of gives this pattern of they can initially very idealize the therapist, but then the closeness becomes too much, so then they have to, it's like then they go into the devaluation, but the omnipotent control here is part of that piece, and I like how you weave that all together. By the way, if you're curious about this, Kernberg wrote a article called Omnipotence and Transference and Countertransference. Great article will link that as well on the website with this.

You know, the word that Kernberg, in this paper that we've just referred to, he has some wonderful descriptions of how this plays out. So in the case of the narcissistic personality, and I'll read from the publication, in the case of narcissistic personality, omnipotence and omnipotent control protect the patient from dreaded separation, dependency, and envy, maintaining the idealized concept of the pathologic grandiose self. That's so good. Let me reread that. In the case of narcissistic personalities, omnipotence and omnipotent control protect the patient from, dreaded separation, dependency, and envy, maintaining the idealized concept of the pathological, grandiose self.

When I hear that, I think about how the grandiose self is kind of like this image of themselves that they're trying to portray. The omnipotence helps them maintain that by separating all the bad out. So it's like it all kind of is working together, you know, this like devaluation, idealization, they're idealizing themselves, they're devaluing the other, they're maintaining the grandiose self. And that's where I think this like, this other quote here comes into play. Maybe it's worth reading about how omnipotence and devaluation go together.

Yes, so Kernberg on omnipotence and devaluation states that these two intimately linked defensive operations of omnipotence and devaluation refer to the patient. identification with an over-idealized self and object representation, with a primitive form of ego-ideal, as a protection against threatening needs and involvement with others. Such self-idealization usually implies magical fantasies of omnipotence, the conviction that he, the patient, will eventually receive all the gratification that he is entitled to, and that he cannot be touched by frustrations, illness, death, or the passage of time. A corollary of this fantasy is the devaluation of other people, the patient's conviction of his superiority over them,

including the therapist. The projection of that magical omnipotence onto the therapist and the patient's feeling magically united with or submissive to that omnipotent therapist are other forms which this defensive operation can take. And I think that's a beautiful, beautiful way of phrasing that relationship, the omnipotence and the devaluation together. Yeah, that's great. I was also thinking about OCPD and how, like, someone who's like at the borderline level of functioning with OCP, obsessive-compulsive personality, might have like, it might take a different flavor than the narcissist. How might it take a different flavor? Essentially, controlling others enables order. Others essentially become an extension of the order

that people in this position will want to take. Yeah. Yeah. And how about with schizzoid? Sure. In schizoid, a lot of control comes out in fantasies. Yeah. So think about like how different personality types, right, manifest defenses in different ways. Really interesting to think about that because it's all like omnipotence is a portion of like a multiple of these different types of personalities. But with a psychopath, the power is, for like their own, the power is for power's sake. Whereas like the schizoid, the power is to not be consumed, the OCPD is for order, for narcissists to protect their image. How about someone with paranoid personality? How might they use omnipotence to protect themselves or, you know,

help their own sense of like equilibrium? Yeah, so, so by projecting negative emotions, in often cases anger, the anger that's projected onto the, the other is interpreted as the other projecting putting anger on me, the other being angry at me. That puts me in a threatening position. Therefore, I don't feel safe. So the natural tendency in this position would be the defensive tendency would be to control them. Right. Because if you can control the person that's angry at you, then you're safe.

even though you're the one that's projecting the anger on the other person. You know, there can be some positive ways that we could think about omnipotent control, but maybe not. Like, let's talk about that. Is there anything that you can imagine, like, a good use of omnipotent control? I mean, I can, and, like, if you take a utopia view, So, like, I think of leaders who may use omnipotent control. In a sense, they're demanding, but they're also creating conditions where when one has all the power, you could have a utopia.

Everything could be stable, but it could also be hell. So depending on the context, outcomes of omnipotent control can at least look like. a fully like functional well-oiled machine. But again, it's the motivation of the individual, the omnipotent control defense that's playing out that can make it more like hell. Right. So it's like a leader like Mousie Dung used a lot of control

to basically control every facet of a whole country. Lots of deaths happened. But in his mind, this was going to lead to a utopia of sorts. So was it successful to have that much desire to control every little facet? It was successful for himself, right? It wasn't necessarily successful for the most possible people, which is where I think, like, you know, leadership research on, like,

high psychological safety leaders probably don't have a need for omnipotent control, whereas they aspire to give other people power and control and empower other people, you know. Right. So what folks like a well-oiled machine or stability in a society, again, what is the leader's drive? What is that coming from? Is it really utopia or is it hell? So it's an interesting position to think about. Yeah.

Before we move on, let's talk about an. actual clinical example? Sure, a clinical example of omnipotence. One patient that I worked with initially presented as highly educated, a natural born leader, had this strong moral compass, was respected and well-liked by all according to how he described himself. At the time, I learned he was approaching his 10th year of working as a department store clerk and claimed that he loved his job.

And in this very superficial but humble manner, he shared that he was the best employee because his managers never felt the need to promote him. Wait, wait, that's confusing to me. Like, they never felt the need to promote him? What does that mean? Was that confusing to you? Well, when I realized, you know,

what I was working with, than we were, this was omnipotent control at play, you know, to, after 10 years to be the best employee, but again, still not a manager. His managers never felt the need to promote me because I was so great. I was so good in my position. I was the best of the best in this position. It would be foolish to promote me. Oh, yeah, okay, because like, like, I'm so, like if you're car salesman, like, I'm the best car salesman. I don't need to be the manager of car salesman. If I was stopping to be a car salesman, like this, this would be awful. Okay. But, but I'm also thinking like he's trying to control your view of him to really buy into this

narrative that he's this great employee. He's great at what he does. Okay, keep going. Yeah, absolutely. And so this controlling holier than now, I'm just this wonderful, you know, this narrative. I realize I'm listening to a fantasy story. I'm listening to this narrative. I'm listening to this narrative in his, you know, essentially effort to control the therapeutic alliance, to distort the narrative, to build up his facade of power. It also showed in how he would talk about his disappointment in others, other people at work. Again, he really would highlight his qualities in the context of work. he would be disappointed in others who just did their basic jobs, never felt the need to rise,

never felt the need to go the extra mile in their work. And he would, in conversation, brush them off. It was like he felt burdened by them. And interestingly, he would say that he never would want to be like them. Right. Strong devaluation, strong like, but it's also kind of boistering up this narrative that he has about how great he is. Like, everyone else is so poor, I'm this great.

Yeah. Yeah, so again, this defense process allowed this ideal self-image to remain impermeable. I mean, it was really, there's such a contradiction because the use of omnipotent control in this clinical example, another way that this came out when talking about work and about how wonderful he was. You know, when talking about his employees, his coworkers,

he would tell me that he would never want to be like them, right? But he felt really proud of himself when he took it upon himself to finish their jobs for them. So he's actually, you know, doing their jobs just like them. So again, there's this contradiction, but nonetheless remained this narrative, this false image, you know, impermeable to weakness or any trait that he devalued and disavowed onto the other. So in his case, it was weakness, smallness, dependency, or inferiority of any kind. That was a really...

Totally intolerable. Those would be like... Totally. Those would be completely intolerable feelings. And so to escape from that, he put those on other people to keep himself idealized. Yeah. And this happens in therapy. And if you're not, it's, yeah, it's subtle, right? Yeah, it's subtle.

And, you know, in his case, multiple marriages, multiple therapists, what was also subtle but telling is his initial therapy goal was to have a sounding board to bounce his ideas off of and figure out his own thoughts. I mean, breaking it down, the therapeutic alliance is a relationship between people, not an object, you know. You become, you feel very objectified in this position. You feel like you're being used. You feel like you're being, like, just this pawn in this person's like, novel of greatness.

Yeah. the projective identification like we talked about earlier. So we have to really watch out for that and realize what we're working with. And it's intense. It can be intense. Very intense. Thank you so much for sharing and let's keep going with the defenses. Let's go on to Danny, break down extreme idealization and devaluation.

Yeah, sure. So because these two defenses are intertwined, I think I'll just going to touch on what they have in common first and then discuss them separately because they do, in fact, have their own functions and origins and are used individually. But extreme idealization and extreme devaluation are commonly considered complementary defenses. and they're more classically observed in a dyad in the defense of splitting, which Heidi is going to cover in this episode. But like Erica said, as defenses, they can be a component of other immature defenses that will cover. So extreme idealization and extreme devaluation pop up to some degree of omnipotion control, which we just learned and can be part of a project of identification, denial.

So their similarities will start there. So a common feature of both extreme idealization and extreme devaluation is that they're also distorting defenses like denial, which Erica has talked about. In this case, the distortion is of the perception of oneself or the perception of others. Another commonality between them is that they're both reflected, in some way of a deficit in object constancy, which for me I'm coming to understand

is like the capacity to maintain a stable or a whole or complex mental representation of someone. But here these defenses lend themselves more to like a all-perfect versus all-rotten kind of perspective. And then they're also similar in that they both stemmed from disruptions in probably like core attachments in the first three years of life. those disruptions being like some degree of neglect or inconsistent or invalidating caregiving. So we'll start with extreme idealization. Simply, it's the primitive act of exaggerating the value

of one's positive qualities to the point of perfection while kind of simultaneously overlooking flaws or negative attributes that exist. Colloquially, I think this is the placing someone on a pedestal kind of mechanism, you know, the best, the greatest, the only one, these kind of hyperbolic but kind of absolute assessments of others. Nancy McWilliams summarizes it really nicely by just saying extreme idealization is a primitive need to idealize that is unmodified from infancy. So if we kind of look at that developmentally, idealization emerges in this period when infants are operating with the fantasy that their caregivers are omnipotent, which is just like one advancement beyond the fantasy that Ariel just presented of omnipotent control.

So here the fantasy is that the perfect and omnipotent caregivers allow the infant to entrust them against all kinds of realities or dangers that are outside of our control. Now, in adulthood, extreme idealization is often used to compensate for defects in the sense of self or to defend one self-esteem or protect them self-esteem. It can also build self-esteem kind of by association with an idealized other person. And this pops up in, say, narcissistic personality. So the idealization of another or making another perfect, a narcissistic character can achieve like their own feeling of superiority through association or through like affirmations. Ranking seen in narcissistic people is another way of idealizing, assessing others based on wealth or beauty or status is a process of idealization.

And to get into devaluation, we'll see like this quality, this maladaptive quality of the defense is ultimately revealed because no human is perfect. We're all flawed. And so this idealized person fails to prove themselves perfect. And that's often where extreme devaluation comes in. An extreme devaluation is what it sounds like. It's assigning exaggeratedly negative. the qualities to others. Again, to preserve self-esteem or self-image. And maybe a good way of thinking

that is like by making others feel small, a devaluer temporarily feels superior. It's often deployed after extreme idealization, but not necessarily. And this too is a defense that develops in some predictable order in development. Here, it's in the separation and individuation process. When a child no longer relies solely on their caregiver for a sense of self. So there's this process of learning to de-idealize or kind of devalue the childhood attachment in this process of seeking autonomy. So that's where it comes from. But in adulthood, the primitive use of devaluation, again, is a protection of self-esteem,

avoiding feelings of vulnerability or feeling inferior. You can avoid that by lowering the value of others. temporarily relieving that feeling and feeling more superior or safe or in control. It's also used extreme devaluation as to manage intense affects. So a way of detracting from like acute, overwhelming or uncomfortable emotions, you can kind of rapidly shift from, say, admiration to contempt. And in that way, kind of protect against those feelings of disappointment or hurt or being threatened. So those are the explanations of what the defenses are.

I think in personalities, they come up kind of just classically in narcissistic characters and in kind of borderline organization. I talked to a little bit about narcissistic already, but for borderline folks, this is often seen in relationships. So this kind of intense infatuation or kind of love bombing. of a new romantic relationship and these cycles of extreme idealization and devaluation that come up for borderline folks. Interestingly, it's also present paranoid personality, antisocial personality,

schizzoid personalities, which I thought was quite interesting in the sense that in this case, the extreme idealization facilitates the sense of connection, but where the object is like remains at a distance, where there isn't a risk of interaction, and the extreme devaluation in schizoids comes up in times of retreat. So if there's a sense of engulfment, it can be avoided by then suddenly devaluing

the connection or that retoucher. And I have other examples, but I think maybe I'll stop there for the sake of the time. Excellent. That's very good. We've talked about, idealization, devaluation. I mean, Diana Diamond come talk about devaluation particular. And I'm curious, as you learned about this, Danny, has it been helpful as you see patients in med management assessments. Yeah, yeah. I took some time to just kind of think through like a

typical day at work. And yeah, I think it's been helpful. And mostly in in identifying just the dynamic and what's occurring in the visit, in a med management visit. So there's a lot of a certain kind of cohort of patient that I see culturally. I get a lot of like, I trust you're going to give me the right medicine. I'll say, you know, I'll do whatever you say. You know, a lot of thank you doctor. Again, I'm not even, I'm a PA, but still like the thank you doctor.

you're the only person that's able to understand what I'm going through and will help me. And often these are comments I hear on the first time meeting somewhere, right? Where so there is this exaggerated and elevation of my value or worth or ability to help that is not, you know, based on any kind of real connection that we have established yet or, or, you know, information that. they have about me. And the contrast I also see is, I mean, I think there's other things going on here, but like the only medicine that works for me comments. This is the medicine that saved my life. I can't function without it, this extreme of utilization of a singular treatment with the elimination of all of the other realities that come into play with taking that sort of treatment. So those are helpful, I think, to help frame kind of the relationship early on and anticipate.

Kind of managed. Yeah, I think early on, a lot of the classic, like, the classic, like how we think about the DSM borderline per seizing disorder, they will have often idealization initially of the provider in the relationship, whereas more of the narcissistic per seizing disorder will have. devaluation early on. Erica, what were you thinking? I wanted to just add that, Danny, the idealization on the first visit that you notice sometimes and these sort of, you, only you know the right medicine for me. In a small dose, that can actually be really helpful in terms of placebo response and the patient believing that they will get better in your hands or with this particular prescription.

So if it's just in a teeny tincture of that, it can actually be clinically pretty pretty helpful. Right. We have to have belief in the treatment where I think it can become more tricky is if the treatment is also long-term psychotherapy and they overvalue medications, but they're really needing the psychotherapy to get to that next level of not being ill. So you could be a provider that inevitably needs to change meds almost every. time because that's what's needed to continue that kind of idealization. Whereas like, pointing them towards, like, actually the process here is, is, on what's going to help you, is different. Not all patients want to hear that. Some people, some patients, like, hear that from

me and they kind of want to, they devalue me in making that recommendation that, like, hey, long-term treatment is going to need this, right? going to need something from you. All right, guys, before we move on to the next defenses, how about we kind of open it up to hear from the rest of you guys, what your thoughts are on these different things discussed so far. Extreme withdrawal, denial, omnipotent control, idealization, devaluation.

What are some of the things that are coming up for you? April, I saw you kind of make some sort of excited expression that you had something to say. So you want to say something? Yeah, I think I always have something. to say. I was just I was just thinking about it came up when Erica was talking about withdrawal and just how it can be adaptive. And so all of these defenses, you know, are adaptive in a healthy range and how they become maladaptive when they're inflexible. And so when we're engaging in these

defenses in an inflexible way where now we have prolonged withdrawal or we have prolonged idealization or we have this prolonged way of using these defenses, that's when we start to see it move into from an adaptive defense to a maladaptive defense. And so I think it's really helpful, I think, just as clinicians to not necessarily see these things as evidence of a maladaptive defense. You know, every time we see it, imagining this is maladaptive, but giving time to the patient and for us to establish relationship with them and to really be able to sense, is this an inflexible, you know, defense that they don't appear to have a lot of tools in their toolkit to be able to navigate some of the difficulties of living? Or is this kind of a one-off and

And it's kind of where they are today because, you know, they, they haven't eaten or they maybe didn't get sleep well or maybe there have some, you know, environmental things going on. So I think just keeping in mind that there is an adaptive presentation with all of these defenses that all of us engage in in healthy ways. Excellent. Yeah. And you can think about how, you know, having a little bit of idealism. would actually allow you to connect with new people quickly, right? And having a little bit of devaluation abilities might be able to protect you from people that you should be protected from, right? You know, you have hints that this person

is not going to be a good person, a healthy person to be around, maybe this person has some psychopathic or sadistic qualities, but you haven't completely seen it, but you can devalue them maybe, and then that helps protect you, right? So you could see how that could be helpful in different situations.

questions. Grant, I think you were going to get to. Yeah, I was going to piggyback off of what you said. When April was talking, that's kind of the same thought I had, was particularly with the idealization and devaluation, how it can be very helpful in a normal bonding of relationship between either child and parent, where you want that child to idealize you and be able to interject some of the positive things that you're trying to teach them. And then later on, as they progress into adolescence, it's okay to have some kind of devaluation there, because if you don't, then you have failure to thrive. So it's not, as clinicians, these defense mechanisms have kind of this maybe bad connotation that we hear in culture, but really, like April said,

they're really helpful. They really have a place in a mental health, you know, frame. Our job really is to assess and kind of play with and kind of either bring up or bring down these, almost like how those of us who are providers kind of treat medicine to a degree with playing with chemicals to try to balance things out. The defense mechanisms are very similar to that in a therapeutic way. I appreciate that point that both of y'all made so well. And the thing I would say is absolutely. And I would say also we have increased reflectiveness if we notice when they're happening, right, consciously.

So if we feel so shameful that they're happening, then we're going to find ways to repress them or deny them happening, right? So if we could be curious about them, playful, we can actually have a higher reflectiveness about our, own experience. I was going to throw in. I think I remember reading. I think McWilliams wrote it that she said in some ways, even the very name defense is somewhat

unfortunate in the sense that it's something to be defeated. And it's a relic of Freud trying to establish the very field itself to a skeptical public. And also, she said, his fondness for military metaphors, but like everyone's been saying, that they're not just defenses. They are necessary to a healthy life. Okay. Yeah, I think the idea of like some defense, right? This is a defense military. Actually, in the Delusions episode, I have a nice military reference, so hopefully not all military references are bad. Have you guys heard the idea of death ground, standing on death ground? Sanzu, the Chinese military writer thousands of years ago wrote about death ground. It was like, He wrote about nine geographical locations,

and the ninth most severe one is called death ground. And essentially it's like when your army is surrounded or they're pushed back against water, and if they get pushed into the water, they'll drown, or they're so deep into enemy territory that there, it's completely dangerous, right? So this is what death ground is. And one of my thoughts was like,

psychologically, if you're schizophrenic or, you know, in a psychotic state, you can inevitably put yourself in your own brain into death ground. Like you're perceiving that you are in death ground. And so this is where you're more likely to actually lash out and get violent. Because you feel like there's no way out, there's no escape. This is the only way for me to move forward, right? And they have found that militaries actually fight a lot more ferociously on death ground. Right?

They're much more likely to be courageous, much more likely to fight through fear. because it's because they have to. So that was my military thing. But you could kind of see that as well. And with the rigidity of these defenses, how the defenses, when they break down, right, you get into a place of psychosis or dissociation. So without defenses, we would be more likely to be psychotic.

we'd more likely to be dissociating. And so the defenses are actually protective against us going into more of a psychotic realm. Okay, I see some hands raised. Ariel. I think that's what makes omnipotent control so fascinating. I think that it really is at a core or at the core level of these other and higher level defenses,

or it's seen in everything, splitting, also, idealization, devaluation. It's very difficult, I think, to separate them out because they are so part of the same whole. I was thinking about it with an omnipitent control. Like, imagine this patient that you described earlier, all of a sudden realizes, sees his life, sees all of his mistakes, all at once, right? Or in that moment, most of us would crumble,

psychologically we'd curl up in a ball and shut down and not move forward at all right so sometimes it's that sort of blissful omnipotence or that hopefulness that keeps us moving forward that you know like that we kind of end up proving it to be right if we believe it long enough like i'm thinking of those a football quarterback that was like he was third string fourth string forever and then he just kept believing himself, right, believing it himself ended up being one of the greatest football players of all time. Tom Brady. Tom Brady, that's it. Yeah, yeah. He was like the sixth round or something. He was like so low. I think he was like, he didn't even start in high school, but he just had this like incredible belief at himself, right? The psychotic level belief. And he just kept,

he kept obsessively studying the game, right, from that belief. Well, what's interesting also, though, is as a provider, if you can together develop a therapeutic working alliance with people who are really, really with their defenses, who are really have a lot of these defenses up, if you can really, sometimes it's a matter of entering into the projection or, I don't want to say getting them to come back, but essentially that, the times when they devalued the most just gives so much to work with. And in a lot of the cases, you know, individuals may make that phone call, oh, I'm done, I'm never coming back, I'm never coming back. The defenses are so interesting to explore if you can get them to come back for what,

you know, is a so-called closure session that ends up being the entree to some of. some of the best work that can happen. And when it happens, if you can see it, and they can get back into the office, it's like a gold mine. It's great, yeah. And I would enthusiastically support that sort of approach of expect that some early devaluations are going to happen,

and you're gonna need to work through them and be patient through that. And they're probably there for good reason. If every previous person was a very painful relationship, then they might imagine that this

might be another painful relationship. All right, so Michelle, talk to us about somatization. All right, somatization. Basically, it happens when psychological distress presents as physical symptoms. So, I think of it like this. When a person

is feeling really stressed or overwhelmed, they can't quite put those feelings into words. So instead, their body reacts in ways that reflect that emotional turmoil. It's commonly seen in early childhood since the ability to recognize and express our emotions is a developmental process. As we grow, we should start to connect those, the physical feelings with our emotions. So somatization, it's common in people who have alixemia, which is the term used to describe difficulty identifying, processing, and describing, emotions. And that has been linked to a history of childhood trauma and even sometimes trauma and adulthood. People with insecure attachments tend to have a higher use of somatization as a defense. And it's commonly seen in people with certain personality traits like neuroticism or negativism. Great. Yeah. Yeah. Keep going. That's good. No, like it might show up in people with a histrionic personality type because they can feel easily overwhelmed by emotions, so they turn those, they turn to somatization as a way to cope with those emotions rather than process them.

Or another example is somebody with narcissistic tendencies might emotionally manage criticism through physical complaints to avoid vulnerability. Some common ways that it shows up that you would see on a regular basis is anxiety showing it up as palpitations, people who are nervous, you know, kind of have. having nausea or butterflies in their stomach, headaches from stress, fatigue from sadness, but sometimes persistent somatization can present in more worrisome disorders like IBS, pseudo seizures, fibromyalgia, though it's not always the cause of them. But when there's no clear medical cause, it can kind of worsen the psychological

and physiological distress from those presentations. In some cases, it is culturally appropriate in different cultures. They kind of present with somatization as a way to, it's normal. It's considered normal in their culture. Yeah, yeah. Think about like after World War I or World War II, there was a lot of like something called shell shock where people had functional movement disorders, right, where they were moving oddly due to the trauma, the PTSD.

was only after Vietnam War that we the normal kind of how we see PTSD kind of came about because there was a lot less social stigma on a mental health issue. So anything else you want to mention on somatization? Just that it is it differs from malingering and fictitious disorder because the physiological symptoms are real, even though sometimes they're, they want to be associated as an emotional presentation, people do experience those physiological symptoms. Yeah, malingering, the patient is flat out lying about something for some gain, you know, usually monetarily or something.

And in fact, just disorder. There's some secondary gain like getting attention or keeping the family together. So, somatization. That's good. It's a good psychological. defense to understand. I think we all can somatomatize from time to time. So I think everyone can have a headache when they're stressed or, you know, some sort of bodily symptoms. But I think there's some people that it's like the primary way of defending against emotion, right? Evan,

let's talk about sexualization. I'm really glad, by the way, Evan, that you chose sexualization as year. Yes, I would not have chosen it if I knew at the time that this would be put on the podcast. So a note on language, they sort of use three different words for this, and they all sort of overlap. They say sometimes sexualization in the literature. They say instinctualization. They say erotidization. And I'm not even, it's not even clear to me that all analysts use those words in the same way. But using Nancy McWilliams, who we're kind of basing this off of, she says eroticization is the process of this when it's not acted out when you don't actually do anything with this defense. It's only internal. That one seemed a little more clear. But so, sexualization is a defense that people use unconsciously to attempt to master or at least temporarily reduce anxiety to restore self-esteem, to offset shame, or distract from a self-esteem. of inner deadness. Sometimes it's used to convert even more dramatic feelings

like terror or great pain into something positive. I think it's also worth mentioning that sexualization is not equal to sexuality at all. Acts of sex, masturbation, sexual expressiveness are not necessarily indicating that there's a defense occurring. It is a defense when it's unconsciously or automatically sort of blocking another emotion or preventing genuine intimacy with another person or even with oneself, I suppose.

Also, I think important to mention that, like any defense, it's not always harmful. Mick Williams used the example of a woman that may get sexually aroused by having her hair fondled or maybe pulled, and maybe this fetish developed because of something negative, like an abusive parent who amused hair pulling, and the child, again, pretty much fully unconsciously turned this into a process that it became something pleasurable to defend against the fear and the pain that was associated with the punishment. But potentially for some people, that just turns into a healthy part of a consensual sex life with her partner. McWilliams did mention gender differences exist, and so, of course, do exceptions to that difference, but more often,

she said women will sexualize dependency, more often men will sexualize aggression. And really interesting study she mentioned. I couldn't find the study to get the exact numbers, but she did say that there was a study of people who have masochistic sexual preferences, and specifically, like, they need physical pain to experience sexual release. A significant number, she said, of people with that, I guess, fetish, had undergone invasive and painful medical treatments as children. So again, there was something unconscious, transforming their fear and terror into something.

pleasurable and that stayed beyond the actual causal events. A more innocuous note, I thought this was interesting. McWilliams commented on the long association of a, quote, erotic aura around teachers, which she dated to Socrates. And I will mention that that really was striking to me because it immediately made me remember that I have a few memories of being in like first grade, third grade, just sitting in class, like teachers just teaching and just feeling like a tingling sensation. all over my body, and it felt really good.

And this is prepubescence, so I had no idea what it was, but it makes me wonder if that's the kind of thing that she was talking about. I remember I had some really good teachers, and maybe that's just what it was. My sense is the most, the personality style that probably uses this the most is histrionic. It can probably function in opposite ways. They may sometimes sexualize things kind of on purpose,

but without realizing that it's going on to reduce their anxiety or to try to help with low self-esteem. Probably folks in the borderline level of organization of various styles will use this more often than the neurotic level, especially those who, like many people on that level, they will vacillate in relationship between an intense idealization and a devaluation, a devaluation. So I think often in that idealization, there's often a neurotic or a sexual component. I thought a tricky one was that psychopathic people probably use this defense, and they use it in cruel ways. I mean, they can sexualize violence, and that can look like rape. I think in some cases, that can look like arson. But I also got the sense that psychopathic people might use sex in a very intentional way for control, which would probably not count as this defense.

And I threw this in here. I don't know how many people watched arrest development. it was the best pop culture example I could come up with. There's a scene that a man and a woman hook up in a bar and they go home and they have sex. And only later do they realize that she's a lawyer who's actively pursuing a criminal case against the man's family. So, of course, they both have a great deal of anxiety about that, and they sort of look at each other and they say, we can't do this again. And then in their anxiety, they just go back to having sex again. And at the show, there's a few rounds of that.

So they are both alleviating their anxiety and their dread through having sex. Yeah, this is like when sex is not always sex or there's like they're defending against some other emotions, right? Sex is allowing the defense against other more vulnerable emotions. Right. The pairing of sex with things like violence, I think that it's like within more psychopathic individuals, like, sadistic individuals. I don't know if that's a defense necessarily. I think it's, but

that's just personal preference. I would put that more as just ordinary sadism. Sadism, a defense, or sadism, I don't know. Yeah, and especially when you're going into pure sadism, not just like a BDSN can't come to sadism, but with a psychopathic person, this is harmful.

Right. It seems more that. That's more central to their just desire for omnipotent control or just enjoyment of hurting other people. But I think for a lot of people, you know, sex is more than sex. It's comfort. It's, you know, to deal with different emotional things that they don't want to feel. You know, that kind of thing is like more of sexualization. Yeah, anyone else have any thoughts on this before we move on? April, I feel like you have something to say. I kind of did. Did I have a micro expression?

No, I could just, you're, I don't know, just got a sense. Got a sense. So I did mine on acting out. And so I was thinking about sexualization because in a way it almost appears as a defense very similar to like acting out so you know maybe you don't have the ability to symbolize in language how you're feeling and so then you engage in sexual activity in order to you know discharge that energy in some way or take control over that energy so i was trying to think well while evan was talking and you were talking about trying to understand acting out as a defense and

sexualization as a defense and how they be different and how they might overlap. So those are some of my thoughts. And how are they how are they different in your mind? I'm not sure yet.

To me and part of this might be because I was so focused on studying acting out. I'm having a hard time flexibly thinking about how sexualization isn't a form of act out as a defense. So maybe Evan, I don't know if you are able to kind of help me understand that a little bit better. Yeah, I'll try. I know that Nancy McElames began this chapter by

pointing out that some analysts specifically do consider sexualization, a subset of acting out. But there's a couple of distinctions that, again, it doesn't have to be acted out to be sexualization. It can just be happening internally. And there's no actual behavior. And just because of the nature of it, she could categorize it differently because there are just particular extra things to consider around sex and sexuality used defensively. But I think in general that the defenses don't need to be considered as discrete separate categories.

Like there is going to overlap and this is a great example. Yeah. I think that's a good point is they're not always discrete, even though we studied these, you know, thinking about them in a discrete. way, but recognizing there's a lot of overlap here. Yeah, and in the same way she said, and she denotes like levels of character organization or personality styles, we learn about them separately, but she says some people overlap, some people will be in a gray area near the boundaries of these categories.

Right. So I think I think of sexualization is kind of on that, that boundary line of, you know, acting out and sexualization. Yeah, that makes sense. If I could pop in, there's something. else that McWilliams pointed out in this chapter that maybe helps with the distinction is she also talked about in terms of power. And so the ability that we have to access our erotic power, so if feeling powerless or not having a sense of real power in a dynamic, then it's like a unconscious or kind of internalized way of accessing a... a form of power. We do have erotic power and in the compensating in that way. So in that way,

it's not necessarily a behavior, an acting out behavior, but something more internal. Yeah, I think, I think there's a lot of overlap between defenses, actually. And so I'm glad you guys brought up that and how they kind of overlap. And yeah, there's, there's like an aspect of doing something, you know, some of the defenses are more withdrawal. to themselves and some are actually like more extroverted in their nature of going out and demonstrating control or power or omnipotence right going out into the world some are going into the mind to demonstrate those things through fantasy so yeah I was thinking about like the biggest some of broader categories to understand this stuff as well which I think it's helpful to think up through

okay Sheila let's talk about projective identification okay this is complicated. So there's a lot going on with projected identification. There's a lot going on that is inside the mind, but also between people. McWilliams talks about it as a defence that's characteristic in people with a more borderline level of organisation, and particularly it with paranoid personality and dynamics. One thing that the projective identification concerns are representations in the mind of the person who's doing the projecting. And I think it's important to think about what we mean by the representations in the mind.

So kind of the way that that individual's self is represented in their mind, the way that another person is represented in their mind, and the way that the relationship between the people is represented in the mind. And it's important that these representations are not just kind of like images, but. they are kind of filled with emotional resonance as well, which makes it so powerful. So it's about kind of the complexity of everything that's in that person's mind. It's complicated because it's happening at different levels at the same time or it's happening in different ways. So this is something that's happening internally in the mind of the person, but it's also happening between them and someone else and then in the mind of the other person.

at the same time. So there's lots of different things going on all at the same time. McWilliams describes it as a fusing of primitive projection and interjection or mixed up at the same time. She sees it evident in kind of clinical work. So this is going on, this is something that is is happening in healthy ways as well as in kind of clinical situations. So she sees it as in a clinical sense, particularly evident where the client lacks reflective function, where they lack self-awareness, where there's a struggle with a separation of what's their feelings and someone else's. So to try and describe what happens, I'll give that a go to describe what happens in this defence.

So one person is projecting from their mind something that is disturbing. And it might be a disturbing representation of themselves or someone else or a relationship, but there is kind of a disturbing effect that they have. It's intolerable in their mind. So unconsciously it is put into the mind of another person. And I think that the into is really important, this kind of Melanie Klein in the beginning of defining projective identification talks about the projection being into,

not just onto another person. The into is important because of what happens in the mind of the other person. but the projector rids themselves of this disturbing effect in their mind. And because of the way they then behave and interact with the other person, the other person begins to feel that this is their stuff, that this is their disturbing effect, and they behave accordingly. So it's gone into their mind and then their behavior brings it out. And then it goes through that behavior back into the mind.

mind of the person who projected it in the first place. So there's Ogden describes this as, I think, which is a really interesting term for, I think, describes it as a relational interpenetration of subjectivities. It's like this is going on between two people at the same time. And also simultaneously between parts of the person who's done the projection within their own mind at the same time. Can I say something about that? That penetrating. So imagine the person that's projecting into you this kind of like foreign thing. They're penetrating your mind and getting you to kind of like identify with it. Right. So this primitive, these primitive affects, these primitive things that maybe are very foreign for you. Maybe you've never felt these things. And then they're because

they're penetrating you with this stuff through. various complex sets of behaviors, they get you to identify with it. And that feels very foreign to you and that can feel very distressing to you. And all of a sudden, you are playing a role that you have identified with. You have identified with their projection. You're playing this role that you are not used to. So that's why it's so distressing for the provider to be a part of this. Yeah, really distressing in clinical practice to feel. this thing that doesn't feel like yourself. So, so kind of a recent example of this for me in practice was with a new client who I met for the first time. After kind of setting up a couple of

sessions that hadn't, that hadn't gone ahead, they'd been cancelled so that something had been happening before we actually got to meet. This client arrived late. The then took a phone call in the corridor. And this is a, you know, kind of a set of offices where there's, there's meetings with other therapists going on in other rooms. So it's a quiet area. And once into the session and settled into just beginning to get to understand what's going on for this person and trying to get, for me to get a picture of that they, you know,

of their interactions. There was something really difficult that was about kind of this person deflecting from the very gentle introductory type questions to start to understand them. And I started to get inside more and more irritated, hostile, feeling like I wanted to really be quite punishing of this person, being really careful about what I could. said and feeling quite disturbed by the end of it. After the session, I kind of was quite kind of agitated, needed to spend some time walking around, getting some fresh air, looking at the sky, and really reflecting on what was going on that I was taking in this desire to persecute

this person. What was that about what's in their mind about relational situations with other people, perhaps where they've been abused, and really thinking about what's it playing into of mine as well, because the other part of this is inevitably, when we feel identified with a projection from someone else, what's coming up is something in some way, in some small part, perhaps, of something disavowed of our own,

getting played into this mix. So I'm also reflecting on that, and thought really hard about, okay, Porter, I need to talk about in supervision around this situation that's come up. So that, that for me, is a kind of clinical example of kind of where this can be really distressed then. But like every other defence, this is happening at all levels in different forms and can involve kind of very positive emotions as well. So maybe we can pause and just kind of point out, I can point out a couple things you did really well there, Sheila. First of all, you noticed it consciously, right? You notice, okay, there's a couple things leading me to start to feel this way, right?

He's missed a couple initial appointments, which, by the way, if you're out there and you want to be a good patient, try to make the first appointments on time, try to be there. You know, so he's missed a couple first appointments. He's loud. He's interrupting other clinicians even. And then when he comes in, there's a surgeon. an air about him that is eliciting, you know. So there's like, so think about the projective identification. There's multiple things that this person is doing, not just one thing, not just multiple things.

That's now eliciting in Sheila, this response. Now, if Sheila had never learned about projective identification, she would be thinking, I just don't want to treat this person. But for some people, you are getting into their trauma. You're feeling what it felt like maybe for this person to feel rejected growing up. And now you are feeling and identifying with this kind of internal rejection, this internal rejection of this person, right? So if this person was viciously rejected by his father, you're feeling like rejecting him like the father because he's projecting that rejection onto you. So hopefully this is a little bit more understandable by. But if you as the listener are struggling with this,

this is going to take you a little bit of time to get your mind around. And that's okay. This is one of the more difficult psychological concepts. And I think a really nice description of where it happens in a really positive way is like kind of we walk into a room at a party. So maybe April and Oriole did last week and just kind of felt the sense of joy. that was going on. Yeah, so we take in really positive things from other people as well.

And maybe that's a very similar process, but in a positive way. Oh, yeah. Or like, I don't know if you've had this experience when you go to, when you have a new friend that's in love and you're hanging out with them and you just feel that.

Like, you feel, it's like you almost join that celebration, right? It's so fun, yeah, that's good. Thank you for working on this. one, Sheila, this is a tough one. Sheila from England, so if you're in England and you need to get therapist, Sheila Coles

right there, there you go. Okay, so let's go through extreme dissociation. I did. So extreme dissociation. It's an unconscious protective strategy to manage overwhelming

and intense emotional experiences, separating the self from impending obliteration arising from the outer world, resulting in a high degree of interpersonal sacrifice. It's quite a mouthful. Essentially, the core mechanism of this is a compartmentalization of the experience into South States. It's essentially cutting off awareness, that awareness from unbearable pain, terror, horror that can overwhelm the capacity to cope. And it has a utility in terms of its adaptiveness with survival and tolerance, but it comes

at an emotional cause, which is essentially an interpersonal sacrifice. just to distinguish, you know, I think McWilliams, she uses extreme dissociation as an example, but the difference is that dissociation is a normal reaction that we can all commonly experience as well. It's a normal reaction to trauma, and it exists on a continuum from normal to devastating. And she cited Dr. Ira Brenner in one of the first. of the research, contemporary clinical literature that suggests that dissociation is far more prevalence as a psychological defense than what earlier psychoanalytic theory had originally assumed. And so what Dr. Brenner's work highlighted is that the dissociation itself, it exists on

a continuum. And so the research suggested that it's not just too limited to rare psychiatric syndromes, but is more of a widespread adaptive mechanism that can shape a personality organization. Where extreme dissociation is most associated with is dissociative identity disorder and borderline personality disorder. So in my clinical work, where I have seen extreme dissociation is in dissociative identity states

where a person suddenly speaks in a different tone, a voice, posture, and personality, and have very, actually no memory of recollection of what just happened in that moment. And it's very distinctive, actually. Some people may experience this gap in the memory, and it feels like they time travel. They essentially also can feel like coming out of their body,

where it feels like an out-of-body experience for them. So an example of this is like depersonalization during trial, A person detaches from their body or sense of self during their traumatic event, it just feels like they're watching themselves from the outside. It's like it's like when a person feels like they weren't really there and that their body wasn't theirs. In, you know, more specifically, in the work that I do, many people have shared about. their histories with sexual trauma and how dissociation helped them cope with the overwhelming emotional experience. So the, you know, sometimes discussing the traumatic material itself can feel emotionally activating. And the person can suddenly feel detached or numb or distant

or feeling like they're not present in the moment as they're describing the experience. So overall, it's serving as a protective mechanism that once helped the individual injured the emotional experiences that felt so intolerable and is allowing them to continue to function while the emotions and the memories still remain compartment. compartmentalized.

Very good. Johan, thank you so much. Johan Ortizzo from California. I appreciate you sharing. I think I actually just recorded an episode on DID. I don't know if it'll come out before or after this episode with some Harvard experts on it. And you covered a lot of the things compartmentalization.

Talk about that quite a bit. I think I once heard, and I have found this to be true, clinically that you cannot have PTSD without some dissociation. There will always be dissociation in the midst of the life or death moment that leads to PTSD. And so when you are talking to someone about their trauma, they will inevitably dissociate a little bit in a different way, different people dissociate in different ways. And so learning how to sit with someone in the midst of that is learning how to be a therapist. Joanne, when you have patients who are dissociating,

how do you sit with them? How do you help them? So when a patient is dissociating, first I have to be able to identify in the moment. I do a quick check-in just to see if they're here with me. And I do, essentially, I try to ground them in the present moment. And depending on what I understand of the individual and their history, I generally tend to work from a perspective where I'm bringing them to the here and now

and not trying to chip at the defense or not trying to, you know, explore an area that may be emotionally disturbing for them. my belief is that when the person is ready to process some emotional traumatic experiences, they will take me there. So it's coming much more wagerian and much more person-centered. That's good, yeah. I think that there's a gentleness, which I hear from you and that, of allowing them the control over what they share or don't share,

which, you know, dissociation is sometimes the lack of control, the lack of, and then there's coming to the here and now, dissociation is the opposite of the here and now. So it's bringing them back into the experience. I would add, sometimes patients appreciate different things to bring them out of dissociation, and so you kind of have to find what helps the particular person. I have one person that just wanted empathy or just wanted me to be, with them. They didn't want anything extra beyond that. And that was what was helpful, right? Other people almost like need to get up and walk around or they need to, you know, different things

somatically to bring them into the here now. So yeah, anyone, I'm looking at your face is trying to read if there's any desire to jump in here and add something on dissociation. I actually wanted to see if you could talk a little bit about Johan, just about the kind of transfer into experience with a person who's engaging in a more dissociated defense. I think that's helpful to understand how a clinician might experience that. That's a really great question. And it really just depends from person to person. And one example I could think about actually was when a patient was describing one of their experiences,

it felt as if they weren't having any emotion. They were just talking about it. And I began to feel all sorts of emotions. I felt angry. I felt sad. I felt rageful. I felt a lot of emotions stirring up internally. And I think that's really important because prior to describing the experience,

I wasn't feeling all that emotional material. So something is being induced. Something is coming up for me. And recognizing that this material that I'm holding is possibly something that maybe the patient is unaware of or unconscious to. So that's maybe just like an example. I think there's many different countertransferences that clinician can experience.

That's great. And if I could put words to what you just said, it sounds a little bit like projective identification. You're identifying with something that they can't quite identify with. But this is a little bit different too because they're in a state of dissociation. And so it's like sometimes as a provider,

it gives you a hint at the disavowed what from the memory they were unable to express. So it's like you're empathically experiencing something that they were unable to experience in the memory. Danny, jump in. Yeah, I just wanted to, you know, I wonder if this could be helpful. But as you know, I'm not a therapist,

but I work in as a medical provider and often men management or assistance with kind of diagnostic work in primary care settings. And something Nancy pointed out in this chapter as well is that for like for the non-dissociating person, they may see the dissociation in their close other as presenting as moody, unstable, being a liar, I think she said, untrustworthy. And so in my work, I've started including dissociation experiences, kind of in that differential when referrals come through for mood swings or ADHD and really kind of digging in and trying to see if what is being reported by the patient from what they're hearing from their loved ones or others in their life is

not kind of the coming back after that amnesiac kind of period and then reacting or behaving in a way that presents it's a mood swing or are not remembering or being told again and again and I thought that was a good element that she included and has been really helpful to me. Really helpful, yeah. I'm wondering April, because I know you do a lot of psychological testing too, how do you differentiate dissociation issues from ADHD, from, you know, other things that could look like dissociation? Yeah. So that's a great question.

You know, we do a really thorough clinical interview. That's really the first step going through full history. Anytime, you know, trauma is coming up, we're automatically looking at, like you said, there's no PTSD without some dissociation. So, you know, a lot of times during that clinical interview, we'll have a traumatic experience get disclosed. And it's never been disclosed to, you know, their medical provider or, you know, somebody or the prescriber. And so that's really helpful just getting a real thorough clinical interview

about their experience, how their close relationships, you know, people around them, how they experience them, you know, feedback that they get from friends, family, you know, things of that nature, periods of time, like Johan was saying, where there's an absence of memory, you know, I'm going through the clinical interview and they can't really give me any information about their experiences. That's a kind of a key indicator for me of maybe there's dissociation going on. And then, of course, we go into all of the assessment and screening tools. you know, so like the DES2 is a tool that we use to screen out, dissociative experiences, and really lean on those along with the clinical interview,

and then reports from, you know, other providers who have seen them going through those and trying to put together a picture of whether or not this is happening. Excellent, yeah. And one of the things we talk about in the DID episode is that for childhood trauma specifically kids who maybe are prone to a little bit more of a dissociative process and with a combination of a lot of childhood trauma

you know it's almost like the identity is fractured in a you know the core sense of self right and as a provider you're you're holding and you're discovering and you're putting back together or the pieces of that but yeah so I think at the severity of the trauma right and the repetitive of the trauma the type of the trauma the interpersonal trauma increases magnifies the degree of dissociation that someone's going to have or how easily they might

dissociate in the future so great well thank you so much joan i appreciate any more thoughts joan kind of floating around your head on dissociation i think it's going to come up but oftentimes with dissociation it is confused um with repression and splitting, but there is going to be, I think the next person who's going to talk about splitting can distinguish that differentiation. Great. Okay. Let's go to splitting. I know. That was a good intro. Heidi, welcome the podcast. Heidi, Lynn.

Yes. Thank you for being here. Yeah, so I'm going to talk about splitting. And splitting on a very surface level is a defense. that helps people to organize their experiences in a very simple and polarized way. So when I was thinking about splitting, I think in a lot of cases like young children learn this as a defense and as a way to organize the world and organize their understanding of how their, maybe how their family behaves or even how they should react to situations. So it is a very primitive defense.

it allows people to categorize these like contradictory experiences that they might come in counter with in order to reduce their anxiety and manage their own internal self-esteem. So we see this defends a lot, it's got a lot of notoriety with borderline personality organization, narcissistic personality disorder. and I work with a lot of clients with obsessive compulsive disorder and I was thinking of how in many ways folks that have obsessive compulsive personality disorder they have a lot of this rigid thinking in the way that, especially if their experiences are the way that they're thinking is egosentonic, you know, the way that my perfectionism allows me to.

encounter the world, they might have a lot of internal splitting in the way that they approach things. When it comes to how splitting is shown, I liked how you said, you know, some defenses come across as very extroverted. And, you know, as a psychiatric nurse working on the floor, we often would talk about splitting. And when we had patients come onto the unit and there was a lot of valuing and devaluing. Often it came, came to a head when it came to boundaries or rules on the unit. One, you know, one nurse might allow a behavior, another one would not. And so you had this splitting amongst the team. And so there was often this talk among team members of how do we how do we combat that in the way that we care for the people

that come on to our units. And so the downsides of splitting is that it can cause a lot of chaos and conflict, both if you're working on a psychiatric unit, but if you are in a relationship, say even with somebody that has even traits of OCPD, perhaps the way that they compartmentalize their experiences or engage in the world can be really frustrating

to deal with. if you were the spouse of somebody, that they have a very set way that they see the world and see things that need to be done. So those are some of the big things that I was thinking about. When it comes, I'm thinking about how it intertwines with dissociation. And I think one of the things that Nancy talked about is that splitting often involves a distortion of reality. And when I'm thinking about I have some individuals that have dissociative identity disorder.

And when they are in dissociative states, it does change the way that they are perceiving, you know, maybe the plan that that we made as a team. We had a team meeting and discussed the plan of what was going to happen and objectives. and when they are in dissociative states, that plan's all bad. That is out the window. And so a lot of times we're having to come together to help integrate and acknowledge these different parts in order for that person to have a sense of cohesive whole. We're all working together in order to move things along for your betterment. And so I think that that's where I've seen some.

splitting occur with extreme dissociative states. I'd be interested to hear if other people have thoughts on that as well. When I think about splitting a dissociation, like let's say you're idealizing a person, you're splitting off the bad that you may have the critique, right? And you're dissociating that part out, right? So it's like you're disavowing, you're not allowing the critique, someone who's in a kind of a more distressed, stressed out state may go from idealizing to devaluing back and forth within an hour. So it could be kind of rapid switching from idealization to devaluation. So it's like they're dissociating from the bad and then they're dissociating from the good and only seeing the bad. So in that way, I could see kind of like

some dissociation linkage. I thought it was also interesting. Nancy brought up how, you know, even in our society, we see splitting as a way for different groups to gain momentum, both in people joining along with their ideas, that we've seen it with different authoritarian leaders.

So splitting is something that we see in our clinical work, but we also see it in our everyday, everyday society. So I thought that was worth noticing. I think it takes less energy to have like a middle road kind of view on something. It takes more psychological energy to have nuance. It's easier, I think, to just go all bad or all good on, like, and I think we can enjoy going all good on our sports team and all bad on the opposite team, right? Yeah.

Political party. people who are politically oriented because of the consumption of the media that they consume will agree with most of the viewpoints of that political party. That's kind of a splitting of sorts. It's not primitive necessarily, but when you have a more primitive personality who is at the top of the ticket, so to speak, sometimes they will split in the way that they use their words, in the way that they drive a wedge. They see wedges where there is no wedge. They go all bad on anyone who does not completely idealize them.

Anyone who dissents from any part of their plan is completely shunned. And if you switch with some of these leaders to idealizing them again, they'll go all good on you immediately, which can be confusing. Or they could stay all bad. They could carry a chip. They could carry that resentment chip, right? So, Ariel, what are you thinking?

Yeah, sure. And as both of you brought that up, one thing came to mind. First, Heidi, you were talking about the cohesive whole and how splitting occurs in a society. And then you were just talking about with the sports teams. And where that converged for me was actually on a, it could be something that came up was a commercial. I believe it might have been around the Super Bowl time. And there was. And there was. you know, one fan who, they were rival fans and there was, pick your rival. Let's just say Eagles versus Giants, which is what we have. So there is a Giants, you know, team of guys sitting at the bar, everyone's watching the game, and then in walks the Eagles fan sits down, wants to have a drink. Everyone walks at him like he has three eyeballs. But, um, Then when you see the Eagles fan and the Giants fans together in a foreign country, they realize that they're all united by virtue of their nationality. So again, it's that splitting within a context. And I would argue also that the nuance or the togetherness is actually where there is harmony. It's almost like if we asked any of those fans, okay, but what actually is bad about the other?

Why are you using splitting? We can't actually put a finger on what is bad about a fan just because they're from a different team. So I don't know that we actually want to devalue the other. So when we have the luxury of being outside of a context, outside of society that expects us to split in a sense, we actually can unite and come together. And that's also a beautiful other side of splitting. And your comment about, you know, the social cohesive whole. So it can play out in some ways. And then depending on the context, it just goes away.

I think that Dr. Peter also, I believe it was Dr. Yomans who brought up in one of the podcasts. We also have the Yankees and the Red Sox here on the East Coast. And it was that example of how you can be best friends even married. One's from Boston, once from New York. You're going to hate each other for two hours. But when you walk out of the stadium, you're your partners in love. So I love your examples and your explanation of that as well, Heidi. Thank you.

That was really helpful. Yeah, splitting. And does this bring up any other thoughts for anyone else? I one thought I had was on psychological safety. So there's research studies on like NICUs where like they look at the psychological safety, which is how easily do you give negative feedback to the authority structure? And what they have found is that you have better patient outcomes when there's a higher level of psychological safety. And so I looked at this in the research when I did the connection index and such.

And I found that it's not a given that there's going to be psychological safety. And I would say when you have a more authoritarian leader, the psychological safety is completely zero, right? Like, you cannot give them negative feedback or the amount of, especially publicly, right? Maybe privately, maybe you use your words in such a way to not make them look bad, you know, but, you know, and you're kind of like trying to coax them towards the truth. But in a more healthy system, there isn't that much of a weight to the necessity of hiding the truth from a leader, right? So I will aspire to be psychologically safe. And I wonder if like the piece of that is that when there's psychological safety, people can handle the gray. When it's when it's an all or nothing,

There's no safety to figure out, does my opinion, does my feedback completely fit in to their vision, their thought process? And so people avoid it. They avoid voicing that. Right. And you could see if a leader idealizes himself completely, right? if they like to stay completely psychotically idealized, any form of truth that would be seen as a slight devaluation or a slight insult to the ego would be catastrophic to that individual.

And they make it incredibly angry and defensive and devalue the person in front of them. Would you say that those who have splitting as one of their main primary defenses have low, reflective functioning? By the very nature, they would be around, like, if they have splitting in their adult attachment interview, it goes around a three, it scores around a three. And so, yeah, it is low reflective function by the very nature of the splitting. Holding the nuance is actually a lot harder, which is why, you know, if a patient has only negative views towards a parent,

I'm not going to sit there and tell them that they're splitting. I'm not going to sit there and tell them and tell them that they're only devaluing and they need to find the gray. But with empathy and with time, I've seen most patients move towards seeing a little bit more gray, the good and the bad. You don't want them to flip from devaluation idealization, right? Which is like if they get the sense

that you are upset at them devaluing their parent, then it may flip to idealization, which is not what you want to promote either, right? So it's like there's a developmental pathway that usually arrives at some knowledge of the gray. That being said, some parents are completely, like, it's also the potential, right? Like that there are people that should be devalued mostly, right? Like if someone was like, well, Epstein, you know, like, I feel like Epstein was kind of good. And it's like, no, no, no.

It's like, right? Like we need to devalue certain people and we need to have categories for that as well. April, why don't you take me through acting out now? Let's talk about April. Yeah, let me pull up my information here. Dr. April, Staples, Haleyness. All right.

So acting out is a primitive defense where some feelings aren't able to be. symbolized into words and so they are acted out. So another way Nancy McWilliams talks about this is enactment, which is a word that a lot of us have used as we've gone through this cohort, you know, having a patient enact these old patterns and behavior that they aren't aware of. So they haven't symbolized that behavior into words yet. So this defense helps them to have agency over the these feelings that they haven't yet verbalized. So they still exist in this unconscious space or this

nonverbal space. And they can be both positive and negative, right? So some of them can be self-destructive. For example, maybe somebody experienced a lot of feelings of shame. That shame wasn't able to be verbalized. And so it's enacted in the form of bullying, right? Um, asserting power over other people. And, but the unconscious, you know, kind of drive there is this feeling of shame that has not been, you know, symbolized into words. It can also move into a growth enhancing process. So maybe somebody has spent a lot of time, you know, with a group of friends and they're

feeling ignored and they're feeling like, you know, there's no place for them. and then, you know, they abruptly speak up finally for themselves. They act out this, you know, I want to take control. I want to speak up. I want to, you know, have a place here. They might not necessarily know that it's coming from this feeling of not feeling a part of the group or not feeling seen or, you know, things like that. But the behavior ends up, you know, kind of speaking for them. So when there's no words, the behavior speaks.

essentially. And so therapists can experience this, you know, with our patients where we are kind of participate in an enactment with our patients or, you know, our patients act out these kind of patterns of behavior or these ways of being that they engage in their other relationships. And we find ourselves in this enactment with them. And we have to kind of try to figure out what is being acted out here. And so that can be really helpful, really confusing for us at first to figure out what is getting enacted in the interaction that we're having with our patients. And so, yeah, I guess just kind of summarize it out. It's a process by which a person acts out a pre-verbal or unconscious feeling.

And it allows them to experience a sense of control or relieves the anxiety that is, you know, present due to not being able to verbalize what's actually happening. Really well said, yeah. It's a fear of abandonment. They get sabotage, so they do something to sabotage the relationship, feeling powerless. Maybe they could be a bully or feeling shame.

They could be a bully. Not to say that that would abdicate the moral responsibility of that act, but they're acting out other deeper things, right? Grant, go ahead. What are you thinking? This came up recently in a session. I was talking and this person was expressing a lot of this painful relationship that this person had with the thing.

very close relative who's sick and then goes away, comes back, and is talking about their, their, you know, their activities in last week, and then expressed how they had this truly emotionally, like, wonderful experience, having a great kind of back and forth with a person who had a similar illness than the person who they're related to. to that they have a bad relationship with and did not put that together at all. And when talking about it, they were just expressing how relieving it was to hug and to be with that person who was experiencing something almost identical to what was going on in their personal life. And so kind of what April was saying is that it's this enactment is a very unaware process.

They have very little awareness of what's going on, but they're trying their best to express it in some way. And, yeah, so I always appreciate the point of how unconscious this is. Great, yeah. And we had someone else had their hand up. Erica. I think it's interesting how acting out, like many defenses has come into the common parlance and people toss this word out. people that are in treatment, people that are not in treatment. And I have a lot of patients who will describe themselves, oh, I acted out. And what they mean by that is sort of a return to a compulsion,

like I went on a shopping spree or I bought a bag of Freeto's or so they'll use the term acting out as a way to describe an indiscretion that could almost fit or does fit under the category of compulsion. So again, we have this overlap and jumbling of defenses, but I, I like how there's the common parlance and what the individual means by it. Similar will splitting. People use that term a lot and it means very different things. So it's interesting as psychology and mental health become more of the zeitgeist and more of what we talk about globally.

We have to watch what all these terms mean and who's using that and what the intent is. It's very interesting. Yeah, I think that's actually really important to, discuss because, you know, if it is a primitive defense that's occurring, you know, and acting out, it's going to be completely unconscious to the person. They're not actually going to say, I'm acting out, because that indicates awareness of what is happening and why it's happening. So the primitive part of this is that there's a lack of awareness about why this behavior is getting enacted. It's occurring out of their conscious awareness. And that's where therapy

becomes helpful because once the therapist is in this enactment, the hope is that the therapist can catch the enactment happening and then bring it into the conscious awareness of the patient and say, oh, you know, I'm noticing that you're engaging with me in this way, you know, and try to be curious about if this enactment has happened before and where it's coming from. So it's not a defense, a primitive defense, if it's in the conscious awareness of the patient. It really has to be, it really is an unconscious process that's happening. And that's by definition what makes it a primitive defense. Excellent. Yeah. So your curiosity, your sort of gentle inquisitiveness reduces the shame,

allows for some exploration of what might be going on, what might be underneath the enactment, the acting out. Very good. Did someone else have their hand raised? Johan, did you? I did. But I think, you know, April, you actually start to answer my question. You know, acting out in a therapy setting is seen in many different ways,

whether if it's a patient that's like missing a session all of a sudden from like the previous session or over the weekend they suddenly get into this really intense fight with their partner or I've also had patients who have done like impulsive behaviors drinking heavily and so that gets brought into the session if you have the opportunity I was curious about like your approach in terms of some of the situations, how you would bring that into conscious awareness for the patient, and what does that approach look like? Yeah, I think this is something that I'm definitely still practicing and working on.

I wouldn't consider myself an expert here. But one of the phrases that I do like, I think it was Nancy McWilliams, correct me if I'm wrong, Dr. Peter, But at some point we had read or we had a podcast, you know, listening to a podcast where we heard, you know, to strike while the iron is cold, right? And basically, you know, there's a lot of wisdom that I think in an art that comes to knowing when to approach the enactment and bring it up to the patient, recognizing do they have the capacity to take in misinformation, because if we, if we kind of see them too soon or reveal something that we're

seeing too soon, that can be very dysregulating and overwhelming, and it will almost turn those defenses up, you know, really, really quickly. So I, I kind of like to go inch by inch, you know, just kind of a little, a little bit at a time as much as I can, instead of saying things like, you know, here's the enactment that you're engaging in with me, right? So I can give a small example. You know, I've had patients in the past where, you know, I might ask them a question. And every time, you know, we're talking, there's this kind of way of communicating with me where I start to feel like, did I ask this in a way that was aggressive? Did I?

Because I feel like they're defending against me. And then I start questioning my own sense of tone. I start questioning, did I ask the question, like, in a harsh way? You know, and then I'm, then I'm starting to worry that I'm inducing shame in them or that I'm, you know, not doing a good job in the here and now. And so that's usually a lot of information for me about perhaps how they engage or act out this same way of communicating with their partners or with their friends. You know, perhaps this is how their friends feel or their partners feel when they're

trying to ask them a question. And so a lot of times I'll just, I'll do a small like, I just, I just want to want to make sure that, you know, I didn't offend you with that question or I tried to ask them how it's feeling. You know, was it, how did you feel? with me asking you that question, right? Was it difficult, you know, for you to have to answer that question? I find any number of ways to bring up that emotion in the room without actually saying, I think there's an enactment happening in the room. And so, yeah, I'm still practicing that, but I've found that to be really helpful.

I'm sure there's other people who have good practice at this who can provide maybe some better feedback there. Just to emphasize something you said, April, to strike when the iron is cold means that, you know, the enactment may happen in one session and the next session they're coming in. They're more regulated. They're more calm. You can come back to, hey, let's, can we talk about like last session? Something happened between us, you know?

So you're striking when the iron is cold there because you're not necessarily trying to do the insight work during the heat of the moment. During the heat of the moment, maybe you're trying to give more empathy, trying to make sure you understand their perspective. Okay. Ariel. Yeah, April, it sounds like you're really exploring the resistance piece that is so core in acting out.

It's almost like you're exploring the countertranspillar. part of your patient's resistance, there's something that's being acted out in order to prevent others from coming in, or rather the patient from coming into the self and acknowledging and feeling that which they are trying to resist. And you're picking up on that and how one in a relationship with a person who's using that as their defense might feel such a distance, feel such a resistance, feel such a, what am I not getting here? You know, what does this person have that I don't have? Why am I feeling like this right now?

So, which would also fall back into the bullying, pushing people away, putting out the negative onto the other and bringing in some of the other defenses. But the countertransference piece as well and then striking when the iron is cold, bringing it up in session sounds like a really good process that's working for you very well. when you allow that sort of reflection piece in between when it's hot and when it's cold especially.

Danny, you can say that out loud, you know? Yeah, I'm happy to. Just to interject, I'm so impressed. I'm here in this podcast with y'all, and I am learning so much. I feel like I'm over here with popcorn and vigorously taking notes. So just very impressive. Congratulations, everybody. Evan, what were you going to say?

You have more with that? Yeah, I was thinking on this defense especially, as well as maybe some of the earlier ones, I was thinking about maybe the newer therapist who's listening to this and feeling like this is really hard to figure out how to enact that maybe something that, or maybe myself, like, a year or two ago, that especially when trying to highlight maybe you're observing that an acting out's going on in a session with a client. And I think it's, it is valuable to wait until the iron's cold.

But if you frame it tentatively, if you frame it gently, if you frame it like maybe this is going on and you don't just put it out there, if they're not ready to hear it typically, then they'll just say no. And you move on and you wait for a better opportunity to that as long as you're putting these things in it, like, maybe this is interesting to you kind of way. Like, it's not a big mistake. if they're just not ready to hear it yet and you can try again at a later date or maybe they'll probably be another enactment of a similar sort and you'll have another opportunity. Thank you Evan. Yeah, that's good. You don't have to, right? You don't feel the pressure. Don't necessarily feel the pressure. And Danny, I agree. I was listening to Danny also and I'm like,

man, maybe I need to restructure the cohort a little bit to be more of a, you know, how do we split up the topic so that everyone presents a little bit of the topic every week. Like, that's, it's fun. It's enjoyable. So, I agree. I'm learning a lot from you guys, as always. Okay, shall we move on to the next defense of interest?

Maybe we'll go to Grant. Okay, so I have projection. And I think projection, interjection and then projective identification, the way that Dr. McWilliams kind of groups them in and explains it was very helpful to me. A lot of your listeners are obviously in the mental health field, so we read about this a lot,

but the way that Dr. McWilliams kind of goes through it helped me really grasp it. So I'll try to do my best to kind of put it in my own words. But with all the primitive defenses at their core, there's an issue or a permeation between self and the world. And so with that in mind, you try to take that principle and apply it to each of these primitive defenses. With projection, interjection, and then at the far end of projection identification, it's very easily to see. If you think about what happens in an infant, when an infant experiences pain, they don't understand that the pain is coming from,

within or without, outside, whether it's, you know, an upset stomach or that they're being swaddled too tightly. They just know, hey, I'm in pain. This is not good. And so from that, and as the infant matures and develops, you, they develop the ability to have projection, interjection. And so if you think about it that way, I think when you start building on further, like when you think about projective identification, when Sheila beautifully explained, it might help frame it better where there's a permeation. So it's also helpful to kind of think of them in a spectrum of the amount of permeation. So at a relatively healthy level, projection can be a good thing. And then at its far more extreme permeation between self and outside world, then you have

this projective identification that can be at times very painful to the other and the self. So just to do a definition, though, projection of what it is in particular, as we all know, It's a process in which the inside or what you're feeling or experiencing inside is misunderstood as coming from the outside. So kind of the stereotypical, I'm not mad, you're mad kind of experience. But as Dr. McWilliams beautifully brought out, there's a healthy aspect to this. She brought up empathy, which was a new kind of way for me to think about that. And I thought that was really a nice point. I'll just try to briefly kind of relate it.

But she mentions that to understand someone else's experience, you can't go into that person. So what do you have to? What resources can you do? Well, you easily can reference a past experience or emotion that you felt and then assign that to that person. And by doing so, you're having this kind of emotional reciprocity and being able to have empathy for that person and a very similar psychic kind of dynamic is done with intuition. And so that's a nice point because it proves that these defenses are not always defensive, but that they are just ways of handling the world around you.

And then, of course, you have the negative aspect of it where you are disowning these negative emotions and putting them on to other, which doesn't feel good. for the other person. Or you could put your positive things on other people. True, true, yeah. You could project your positive. I need to do more of that.

Don't you? Don't you do that, Grant? I could see you doing more of that one. I try. I'm projecting on Grant that he projects his positivity on other people, imagining other people to be positive, because you're

a very positive person, Grant. And I hope that's not just my on you that you're positive. I'll gladly interject that and make that true. One thing I thought that was helpful, like even before this cohort in reading, listening, I would often hear about these defenses and be like, okay, I need to, how do I make sense of this? I need to kind of solidify this.

Something that helped me, sorry, was I think for me, what's helpful in the differentiation between projection and then projective identification is the force to make the projection reality. So with someone who is just projecting, they can project, but maybe there's some resistance, right? Like, no, that's not true. Okay, let's talk about it. Whereas a projective identification, it is imperative that that person has to disenvow what's inside and has to make it reality, because if it wouldn't happen, that would be so painful. And that was helpful for me to kind of conceptualize, but also to give a lot of empathy for patients who are going through a projective identification kind of episode or spell that it really is distressing. It's kind of,

it's painful. They need that to be reality. How might someone who's paranoid project their paranoia? Or what is paranoia? Others can definitely comment on this. I did think about this briefly. I have someone who I know well, who I believe kind of may be false into that paranoid, personality kind of

typology and I find that there's a true disinvowing of their own fear and a rejection of it and because when that happens it often is

thrown where these worst case scenarios are being put on others or motive is put on others but if I stay with that person long enough, it ends up that the conversation tends to go back to that there's just

fear inside of that person. And rightfully so, you go back into the childhood and you see this perfect explanation as to not trusting authority or being fearful. That's kind of how I look at it, but maybe others would have kind of a better explanation, but that's how I see it. Paranoia is like, I'm incredibly fearful, but the world is out to get me, right? The world is persecuting me. The world is embodying the fearfulness against me. And if, yeah, that's the projection of the fear.

So others are hostile. Others are angry at me. You know, you may have a patient at some point that says, like, I'm sitting here and I think that you, you hate me, right? Yeah. That's that they, they're projecting on you. One thing I'll say is that I think this was on a podcast that maybe Dr. McWilliams talked about

that I found very helpful was with particular paranoid personality type, if you were to confront or disagree with. their paranoias, they become more distrusting at first. You would need to almost kind of work along with a little bit or have more kind of truthfulness or more transparency, maybe, I think, is how she put it. And it brings down that amount of angst. Right. There's a statement that there's some people that own feel truth in negative critique or if you're too positive it's like if they almost like none of that registers they only register the negative are yeah so what you just said about only registering

the negative something was coming up for me there but just backing up a little bit with the paranoia and I'm thinking about my patients really high on the psychotic side of the organization with the paranoia and the projection. And also your comment about how you really have to kind of be patient with that. You have to let it kind of come out. Otherwise, there will be that fear that you two are shutting them down. thinking about this was a case a long time ago no longer a patient i've changed some things to not give away the identification i've the the concept of the world is a video game we're all playing in a video game and we're all being manipulated we're all being um put into these little mazes

and moved around and and um we have no no say everyone's watching us all of the time and yes, while this individual had full-blown psychotic illness at the same time, this is a human being with whom I'm doing a very psychodynamic style of psychotherapy. And, you know, you just feel the terror, you feel the fear, you feel the everything that this person is lacking in control, lacking in trust of others and this self-deprecating torment that's going on within. And there's one individual where I really, really experienced it. But that experience and looking at the projection with the paranoia is one of the, I can say I'd be interested to hear other people's opinions of working with people on the more psychotic range was very, really explained.

that people who are like very, very high on the psychotic end are dealing with issues of normalcy just like everyone else. It really helps to like destigmatize that when we just recognize the level of fear that is in individuals no matter what their level of attachment to reality. There is that element of fear and shame and lack of control. and powerlessness and literally just feeling like your life is one big manipulation by a power that you just don't have. Find that to be really fascinating about this defense and really entering into it and really holding empathy and space for our patients or parts of ourselves who are feeling that fear and feeling that power struggle. Yeah. And in the psychotic realm, what we're really referring to is no insight into the delusion.

It becomes a delusion, the projection. The projection becomes a massive delusion of like, it's not that the CIA could be spying on me. The CIA is spying on me. Correct. And wants to kill me. Yes, absolutely. And to not challenge that. Not to support it in the sense that I think in general there's a notion of,

Oh, don't argue with someone's delusion. Well, no. It's to be supportive in terms of getting into the projection and working through the projection that makes a difference. Yeah. Erica, jump in. The point about paranoid structure and paranoid personality and disorder, Nancy McWilliams makes a point to say that extreme withdrawal is one of the defenses that. they utilize or draw upon towards fear or her term unjustified suspicion. So there we have, again, that note of lost-based, lost touch with reality.

So it's an extreme withdrawal to avoid fear for something that is distorted in the difference between how they're saying it and what it really is. So I thought that was an interesting link. great i i know we have one one more to get through so let's just jump to the last one intro objection is it interjection projection projection introduction that's it yeah interjection with april april take it away that's me all right so interjection um is basically the the opposing part of projection so projection is you know taking something within and putting it out interjection is taking something outside of yourself and interjecting it, or Nancy McWilliams used the word swallowing, a swallowing

of affect, of behavior, of ideas, cognitions, things like that, to the point that you don't recognize them as the other, as something that has come from outside of you, you start to identify with it. And so it feels like your thought, your affect, your behavior. And this can happen in a healthy way. It's an important part of, you know, development where we learn internalized love, internalize comfort, safety from, you know, our caregivers, people, our spouses, our friends. We interject all those positive things about them. So an introdicted voice in a healthy example might be, you know, you're having a bad day, things are tough. Maybe you're nervous about this podcast today. And then you hear a voice that says,

it's all right. You're doing your best. You know, you're going to do great. It's going to be fine. Right. So perhaps at some point in time you had a primary attachment, secure attachment with somebody who you have intradicted that, you know, that voice, that supportive, loving, caring voice on the opposite and on like the negative aspect or the unhealthy parts, you know, Nancy McWilliams discusses, you know, we can engage in interjecting parts of our abusers, you know, or negative aspects. And so identification with the abuser would be, we begin to take on the behaviors,

the beliefs, the ideas, thoughts of the abuser. And this becomes adaptive because it's taking an unconscious, um, powerlessness, anxiety and giving the psyche a sense of control. Um,

if I can be like my, like my, you know, abuser, I can predict that behavior. I can maybe keep myself safe, creates a sense of power, you know, within the psyche. And keeping in mind, this is not conscious. Again, it's an unconscious process. So, you know, identifying with the abuser taking on is not a conscious thing that happens. It's a process that allows the psyche to remain whole, to not have to wrestle with this powerlessness that they experience. being in this abusive situation. So the interjected voice that might come from, you know, an unhealthy relationship or a situation where a child maybe had parents that weren't as supportive

in loving and caring, they might grow up. And then as adults, when they are trying to rest, for example, they might hear a voice that says, you're lazy, you're worthless, you don't try hard off. And they kind of take in this voice as their own voice, that it's their thoughts, not recognizing that this has actually been interjected. It's been swallowed or taken in from outside of them. And so one of the best examples are an example that I thought of that I thought was kind of fun. And this is a, I guess, you know, kind of in a more healthy range is in the movie Inside Out, you know, Riley's parents are frequently telling Riley, you're our happy girl, right? You're, you've got to be happy. Just do your best. And they're kind of always

positive and always kind of trying to get her to disavow her sadness, right? And disavow her anger. And so you see this in the movie where joy is always at odds with all of the other emotions and trying to just take over Riley's internal world. And so Riley has interjected this belief from her parents that she should be happy all the time, that Riley is a happy girl, right? And so that's kind of a fun way of understanding interjection is it's just the taking in of affect, beliefs, ideas

from outside of us and then believing that there are at some point. Yeah, and one thing I want to say just for anyone who's listening, like, because you could think like, oh, do people who, you know, let's say boys who are molested at a young age, do they become future abusive molesters because they've interjected that trauma? Actually, the rate is very low. It's in one cohort, I remember it's about 3% of people that have been sexually molested boys that will become later people that will do something similar. So the majority do not,

but many more than that 3% can have intrusive, is sometimes obsessive, almost like an OCD level obsession of, I'm going to hurt another boy, right? So they could be kind of an unwanted distressing thought, which would be kind of an interjection of that trauma, trauma that they would be the abuser, not because they want to abuse, not that they be not if not because they are abusing, but because they're they've interjected a piece of

that. Um, I had another, uh, client, I'm going to change the details a little bit, but she, after being abused as a child, thought she was abusing herself when she would masturbate. she thought she was molesting herself. So she became the abuser towards herself. Before the event, the sexual violation, she believed she was just playing with herself afterwards she's molesting herself.

So in a lot of people like this, therapy can really help them untangle this and decrease the shame, to understand why they might put themselves as the abusive role in their mind, in their fantasy mind, right? Yeah, so one of the things they thought was helpful is thinking about the countertransference, you know, that you might experience when somebody is, you know, communicating an interjected belief or idea or, you know, something like that. And one of the things I read was, you know, the therapist might find themselves thinking the interjected thought. So maybe there's a patient that's really frustrating to you. And you're having an experience where you're thinking, why won't they just do it? Why are they being lazy? You know,

why are they X, Y, and Z? That question of why are they lazy or why aren't they trying or whatever thoughts, questions that might come up, that actually might be introjected material that you are kind of getting access to from that patient. And that can be really helpful for then being able to ask the patient, you know, can you tell me more about this, you know, these questions you have about this or, you know, if they start communicating some of their experience, it allows you to kind of ask them where they first heard that or how they came to believe that or, you know, kind of be curious about their narratives that they have about their own behavior. And that can be really, really helpful, I think.

Excellent. Excellent. Anyone confused on this one yet? This is a tough one to understand becoming the aggressor in your own mind, siding with the aggressor, not necessarily. becoming aggressive but in your own mind interjecting maybe the components right

of what is going on I think it's very helpful I think the quote that was on the document from Fairbairn helps a lot for someone who interjects a lot which often is someone who's a depressive style better to be a sinner in a world ruled by God than to live in a world ruled by the devil It's just, this defense, it doesn't usually, I think, help empower the person, but it gives them a sense of having some more control than they actually have.

And I think there's some comfort in that, even though it's usually actually disempowering in terms of their actions. It's also like a, it's almost like in medical school, you learn about a disease sometimes and you start to think like, oh, do I have this disease? You're kind of like interjecting the disease into you, right? So you as the listener of these defenses might be saying, oh, do I have this problem? I have this, oh, do I have this defense? Right? It's also a way of kind of mastery.

So of kind of trying to make sense of something. There can be a dissociation away from the anger pointed in the direction towards the perpetrator, which sometimes will come out more as therapy progresses. Like you'll feel more angry at the person that did the actual bad thing, right? Yeah, and thank you for bringing that up, Evan, because I think that, you know, Nancy actually talks about how interjection is primarily associated with like a depressive personality style. And she actually highlighted it.

She said, in working with intrajectively depressive patients, one can practically hear the internalized object speaking. when a client says something like, it must be because I'm selfish, that the therapist can ask who is saying that. So the patient kind of takes on these qualities that they think led to the abuse because if it's their fault, then it's potentially something they can fix versus having to accept or acknowledge that the situation they were in was, you know, somebody that was just abusive. So it's adaptive in that way for them to help give them, reduce anxiety, give them kind of a continuity of self,

kind of an illusion of control. Right. Like an abusive, a patient with domestic violence going on, their spouse is abusing alcohol. It's not the spouse's problem. It's like, man, what could I have done different? differently when my spouse came home drunk, that could have not elicited them to be so angry at me.

I must have been such a bad wife. I must have been, you know, like, the house must have not been clean enough. So there, and as a therapist, you're listening to this, and you may be thinking like, this is nothing to do with you. Like, what are you talking about, right? Or if you're a friend or a family member

of someone going through that. Yeah, and, you know, to add to this, from the acclining perspective, infants interject the good and bad objects. And so if, for example, if a caregiver is nurturing, the child is interjecting the good object. On the other hand, if the caregiver is harsh, the child is interjecting the persecutory object. And so, you know, in the example that you both were talking about, the child is essentially has these mental representations of a persecutory object and a devalued self-other. So they're devaluing themselves in certain situations.

So these two mental representations are internalized. On a more positive now, an example I want to provide is teachers can also play a very positive in terms of a child's upbringing. And so teachers can have these positive messages that can be internalized. And so there's some research behind teachers having a more positive message on students. So, for example, if a teacher is highlighting a student's intelligence and how good they are, there's a behavioral aspect to that. But in this regard, they're creating this message.

that's being internalized, and the child takes that on. Now, we don't know if the child's IQ is actually really smart, but they continue to take that on, and it shapes the way they navigate their academic journey. Yeah, we need, it's like, like I see these sports parents, there's one in particular after a game, just completely railing on their kid every mistake. That gets internalized.

The kid's not going to enjoy sports. long term, you know, a couple years in, they're going to get burned out. It's like, compare that with like a parent who is positive, right, emphasizing the good that the kid did, but also I would say not creating a delusional child. Like, I'm, you are, everyone was not passing to you under every condition. And the refs were calling everything. And the only reason you lost is because of everyone else, right? That's creating a delusion of sorts. But to say, like, hey, like, we're going to continue to work hard. We're going to continue to take steps towards, you know, improving, you know, and our hard work is going to pay off, right?

That kind of message. So it's like positive with a, with, there's many steps to the top of the mountain. I would say that combination of things allows for thriving. So they can enter, they can interject a positive force, but also a sense of like, okay, I can work hard and obtain my goals. Sort of that, um, here's journey. reject the hero's journey, so to speak. Okay, guys, we are coming to the end of our time here. We'll leave it here for today. Once again, thanks for being a part of this. And if you're listening still, congratulations. You understand psychological defenses more. We'll put up the transcript on the website, psychiatrypodcast.com. Okay, we'll leave it there for today.