Psychiatry & Psychotherapy Podcast - Psychodynamic Psychotherapy with Jonathan Shedler, PhD

Episode Date: April 5, 2022

In this episode, Dr. Puder interviews Jonathan Shedler, Ph.D. Their conversation covers the ideal length of therapy treatment, the efficacy of psychodynamic therapy, and the role of psychodynamic processes in multiple therapeutic modalities. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds.

All right, welcome back to the podcast. Before we begin, I want to make an announcement. that we are continuing to have webinars. So if you hear this a year from now, you could go on to Psychiatrypodcast.com backslash webinar and see what we have in the future. We have two currently, one April 22nd and one May 1st. The April 22nd will be going over the big five. You know, you will be able to understand your own personality. We will be sending people before the webinar a one-hour assessment where you can do the gold standard on the big five. And then May 1st, Dr. Danny is going to be doing one on racial trauma.

And she is an expert in this. And any of the proceeds for her webinar will go to support her podcast. So I'm hoping that we can raise enough funds to support her for the next year. Editing is expensive. And this will be helpful to her. So if you go to that, all proceeds will go to her. And now on to the episode. Welcome back to the podcast. I am joined today with Jonathan Shedler. He's a PhD internationally known author, lecture consultant, master clinician. He wrote a pivotal paper called The Efficacy of psychodynamic psychotherapy. And he also is the creator of the Shedler-Westin assessment procedure for personality diagnosis and clinical case formulation. he is constantly writing and tweeting and he's prolific on Twitter

and I was thinking if you ever tweet this episode people could like comment and then maybe we could use some of those comments in a subsequent episode so if you're listening to this go check out Jonathan Shedler on Twitter that's Jonathan Shedler S-H-E-D-L-E-R before we start

do you have any conflicts of interest to disclose? I don't okay neither do I I'm one of those rare people in the mental health professions who's not on the payroll of some industry. Oh, yeah, they have been trying to entice me, and I have so far declined. I'm sure. So I wanted to start with one tweet that you put out. It's actually your pinned a tweet.

Could we look at this together? Sure. Kind of, because I think it's, there's something about this, especially in our moment, right? Okay, here it goes. One of the most important things I've learned. Severe personality problems find camouflage. No one thinks I'm a sadist or I'm a malignant narcissist. They find a belief system, social group that validates their most hateful, destructive impulses and construes them as virtues.

The most toxic hateful people in the world are 100. 100% convinced, they fight for what is true and right. They find a way to give free reign to their cruelty, to attack, to treat others cruelly and viciously, and they find allies to cheer them on, who also believe they're on the side of all that is true and good. For colleagues looking for more of a theoretical explanation, the psychological processes are splitting, projection, and projective identification. Splitting means not recognizing one's own capacity for hate, cruelty, and destructiveness.

The person is blind to the bad in themselves. Instead, they project the badness onto some designated other. And this is the other person. Via the defense projection is now seen as a repository of all that is bad and evil, and necessarily necessary to destroy.

That's the projection. The person now feels fully justified in unleashing their viciousness and hate on the other person who is now seen via projection as someone monstrous who must be destroyed. If the person who is projected on responds with provocation with anger, and this is now seen as further confirmation

of how hateful and is, And destructive they are. This is what is called projective identification. The end result is that the person can deny their own sadism, cruelty, and hate while simultaneously acting it out without further restraint and feel themselves to be 100% on the side of truth and right as they do it. Quite a bit packed into there, isn't there? Do you want to tell me about this tweet?

where would you like me to start i mean the big picture is people have the mistaken sense that psychoanalytic or psychodynamic theory and therapy is something you know mysterious or obscure or arcane and in fact it deals with the phenomena of you know the phenomena of everyday life the things that we deal with are all around us and inside of all of us there's nothing There's nothing rare or esoteric or unusual about it. I mean, we have a way of understanding things about the life of the mind, about human connection and interaction. And it really applies everywhere. It's not just applicable to a certain kind of therapy for a certain kind of person.

It's applicable to psychotherapy in general, and it's applicable to life in general. Yeah. Yeah, I was thinking about this, and I was thinking, Now, this was a tweet that was in 2021, September 24th. So it's a while ago, right? And so we're like, as you were listening to this, you were probably thinking he tweeted this out more recently, right? It's kind of evergreen, isn't it? Yeah.

Because, okay, so you asked me to talk about it. People, we deal with this all the time. First of all, let me just give you a little. little background about this issue of camouflage. I learned this very, very early in my career. I was a brand new graduate student. I was, you know, 20-something in my early 20s. And I was in a clinical placement. And I just had the opportunity to shadow a psychiatrist for, you know, for a while and sit in on his interviews with patients. And there was one that stuck out and really made an impression on me. And we were trying to decide.

I say we, I was just a student, but the clinic, the psychiatrist was trying to decide, was this person psychotic. Were they delusional? And, you know, sitting in the interview, what we got from the patient was that he spoke to God and God spoke to him. And, you know, and I watched this psychiatrist try in every way he knew how to, to try to, you know, clarify what does the patient really mean by spoke? to God? Is he literally, is he literally hearing a voice that he experiences is coming from outside? Is he hearing auditory, you know, hallucinations? Or, you know, is he speaking, you know, in a way that's kind of culturally normative within, you know, within his church, within his subculture? And the thing that really grabbed me was, I couldn't tell. And I didn't know whether

the psychiatrist could tell or not. But then I later wrote his report. And he basically said in the report, you know, well, the patient may be having auditory hallucinations, you know, or he might be part of a Christian community where this is, you know, where this is normative. And he just is flat out and said, I can't tell. And what I took away from that was an insight that applies far beyond psychosis. It really, really applies to any kind of, I mean, any kind of mental health disturbance. that disturbance finds camouflage. We find some community that seems to normalize and validate, you know, the thing that's

most dysfunctional, right? And that it applies across the board. And we can see this playing out just, you know, in life every day. So you had a guest a few weeks ago, Dr. Rob Weinstein. who edited a book about personality disorders. And I wrote one of the chapters in the book. And he was talking about borderline personality disorder. And for a lot of people, a lot of the time,

it's much preferable to find camouflage where the characteristics or the symptoms of borderline personality disorder are normalized and validated. We see that in our culture all the time. So, you know, what does that mean if you're a clinician or what does this mean if you're just a person going about your life? You know, you suddenly find yourself the target, the object of, you know, intense, vicious hatred by somebody who doesn't even know you. There is a stranger to you.

How did I suddenly get to be so important to this person? How is it that this other person is treating me like sort of. somebody they know intimately, they know everything about me. How is it that they seem to know my thoughts, my motives, and intentions, but in fact, I'm a stranger to them. Well, this is where the psychoanalytic concept of projection comes in. And the idea is, you know, I mean, good and bad are hypothetical construct. People are not good or bad. People have the capacity to be very good in some ways and very bad in other ways. And that's true for every human being. It's the nature of the human condition. And a psychologically healthier or more mature psychology recognizes

these contradictory impulses in ourselves, the desire to take care of others, you know, to help, to be compassionate, to be kind, the desire to harm others, to inflict pain, to damage and destroy. We recognize. We recognize. this. And ideally, you know, these conflicting impulses or, you know, desires that we have by virtue of being human are kind of integrated so that, you know, so that, you know, the totality of all of the desires tends to keep the most extreme ones in check. And we recognize them as part of ourselves. As we get into the range of personality pathology, that can be. capacity isn't there. We tend to be aware of certain states or feelings or desires in ourselves.

And the negative ones, the hateful, destructive ones get projected onto other people. Or it doesn't even have to be a person. It could be, you know, an institution or, you know, a concept. But, you know, the bad, you know, the capacity for bad is not in me. It's out there. that's the projection. Projective identification takes the projection a step further. Projective identification means I can now unleash all my hatred without restraint on that other person or that other thing that seems to be the embodiment of all that's evil. And I can treat the other person so absolutely badly. I can treat them so horribly that they react to it and they become angry or they become enraged and in turn.

So in a way, I've made the projection become true. That's what the tweet is about. Yeah. So I think the way that I understand projective identification is that because you are projecting this stuff into the other person, the other person eventually can identify and become a little bit different than they normally would be. And I think we can all as therapists learn that this happens to us as well. like we could, like if we start to become a little bit different towards a patient that we normally wouldn't, you know, we normally wouldn't act out or we normally wouldn't want to maybe cross a boundary

or collude in some way with a patient. And so when that's happening, are we becoming, are we identifying with a projection, right? Is that what you're talking about? There's a wonderful, there's a wonderful phrase that was stuck in my mind. I don't know who said it originally, but I know I read it. It's in one of Glenn Gabbard's books. And he talks about the experience, the clinicians in therapy will describe the experiences, like having their mind colonized by something alien. It's not subtle. It's actually pretty extreme, where the clinician catches themselves, thinking things, feeling things, reacting in ways that are really out of character for them. This is not who I am.

This is not how I think or feel or function with them when I'm with patients. And all of a sudden, right, it's like my mind has been colonized by something else to the extent, you know, to such an extent, it's hard to think your own thoughts or feel your own feelings. It's extreme and it's dramatic and it happens in psychotherapy all the time. And the work on the part of the therapist is, number of, number one, can I recognize that this is what's going on? Can I recognize that something has pulled or pushed, you know, or provoked me into responding in a way that's really quite different from how I would normally respond to things? Can I recognize it? And then having recognized it,

can I find a way, can I find my way back to thinking my own thoughts and my own feelings? and then be able to make use of what happened in the interaction constructively, right, as a way as a way to gain some insight and help the patient gain some insight into, you know, number one, what's going on internally in their own mind and their own emotional life, and number two, how this plays out interpersonally in relationships with other people. Of course, I wrote the tweet on social media. Somebody somewhere said, you know, Twitter is the world's, biggest and longest running experiment and projected identification,

because it's just going on left and right all the time. And unlike in therapy, what you can't do on social media is do what therapists do all the time, just basically say, well, wait a minute, you know, let's slow down and think about what's happening here between the two of us. Social media doesn't allow for that. Right. It's, I think one aspect that I want to zoom in on of this tweet, which I think is like really important, which if this episode becomes about this tweet, that would be hilarious.

But this idea of how with prolonged therapy, you become more aware of your shadow, the kind of the dark impulses, and the shame is reduced enough so that you can look at them, but then not react to them in the same way maybe that you would if you couldn't see them clearly. If it's like unconscious, you'll react, and in the reaction, you can potentially have these more darker impulses become destructive. Yeah. I mean, you know, everybody has destructive impulses. It's not even psychologically interesting to say it. I mean, it's just a fact that there's not a human alive, or at least I should say there's not a human in life who's, you know, meaningfully in touch with their inner life.

you know, who doesn't, some of the time, have revenge fantasies, you know, have fantasies about hurting someone, have fantasies about murdering someone? I mean, the issue is that, you know, for most people, most of the time, they remain in the realm of fantasies. Fanties are free, right? So we can accept them as a part of ourselves. We understand this is part of what it means to be human. There's nothing shameful about it, right? But there's a very clear distinction, ideally, you know, in a healthier person functioning in a healthy way, there's a clear distinction between fantasy versus action. And as you get into, you know, as you get into more serious kinds of personality disturbance, the boundaries between fantasy and action start to get very murky, right? And, you know,

you get people, I mean, this is really the essence of projection and projective, identification. You get people who can't recognize their own capacity for hate and repeatedly see it somewhere else outside of them. And then if they proceed to act on that perception, right, and actually act destructively toward the other person, then you have a pretty big problem. And, you know, you could argue that society as a whole right now is kind of slipping toward a more primitive mode of psychological functioning societally. Yeah, and I think, of course we are, because prolonged stress, isolation,

fear of the future, like everyone is experiencing that more than usual, right? So, of course, we're all stressed out. Of course we're all booked out and slightly burned out. If you're a mental health professional at this point and you're feeling great, you've come through the last couple years and, you know, like, that's great. That's wonderful. But a lot of us are very tired, right?

A lot of us are kind of a little bit more. But I think there's something else going on. And I think it partly has to do with, I think it has to do with the internet, you know, the instant accessibility to tens or hundreds or thousands or millions of people, you know, with a keystroke. I think it has something to do with social media. I mean, one of the roles of society has always been. I mean, what makes a civilization is that society exercises some control, some restraints on our most destructive impulses.

And now absolutely anybody, you know, with a couple of mouse clicks, can find, you know, a subculture that's going to support them and cheer them on. You know, find, you know, find the most hateful person and, you know, fill in the blank, you know, the thing that the hate is directed toward. And, you know, there's an online community that will affirm, validate, and cheer on the person's most, you know, destructive and hateful impulses. And I think that's, I think there's something new happening in, in the culture. It's not that it's never happened before. I mean, you know, there have been.

I mean, there have been historical catastrophes. There's been war. There's been genocide. But I think what's different now is the average person, you know, anywhere, you know, sitting in their bedroom or their parents' basement, you know, can plug in to the sort of wellspring of hatred. Anyone, anywhere, any time. Yeah. And be told, you know, be affirmed and supported and reinforced. For giving themselves, yeah, be reinforced in the behavioral sense, right,

for giving themselves over to their most hateful impulses. Attention, especially with attention increasing, there was that recent sort of thing with Facebook that came out where they knew that some of their stuff was leading to bad outcomes, but they kind of like tried to hide it up. And in a previous episode I did, I actually looked at all of the research that they used to present that social media is good.

And actually, that's not true, right? Especially after you get around like three hours or four hours, it's like all mental well-being starts to decline. You know, if you're doing it like three, if you're doing it beyond somewhere around like an hour, it starts to kind of like, that's where like the decline starts to happen. So I do think that it preceded COVID. I mean, there was an increase in suicidality in adolescence,

especially in the previous decade, right? And a lot of this is new. It's a new experiment that, we're all going through. It's not a great experiment. Wow. Well, this is a good time for psychotherapy, right? And so I was reading your article about how long psychotherapy takes. And I think that we all could sort of hear this and really mowver. There's something about the APA coming out with that statement that you kind of wrote about how like, you know, there's this ideal of 10 sessions or something? Did they stand by that or were they behind that?

Well, there's two APAs, but in this respect, there's the American Psychological Association, the American Psychiatric Association. But in this case, there seem to be pretty aligned. And I mean, what's going on is there's just such a bifurcation, such a division between what academic researchers are doing and the clinical reality on the ground. And we're, you know, making clinical practice recommendations based on just bizarrely artificial studies coming out with, you know, just just bizarrely unhelpful recommendations about how to treat people. And so here's what's going on. It's incredibly difficult.

It's, you know, it's methodologically complex. It's resource intensive. It cost a tremendous amount. of money to study psychotherapy in the context of a research trial. And, you know, what that means is researchers have just declared, it's not a scientific finding. It was an assumption they made before they ever did any research. They've just declared, we're going to study eight session or 12 session or at the most 16 session therapies. And so we have, you know, all this research literature, hundreds and hundreds of studies on just, say, treating depression alone. And they're all

based on, you know, on treatments of less than 16 sessions. And it's not, I want to maybe, maybe I'm repeating myself, but it's really important. It's not a scientific finding that you can treat people effectively in 16 sessions or 12 sessions. That was an assumption the researchers made before they began the study, before they collected any data. And so now what people are saying is, well, it's evidence-based. These therapies are evidence-based because research has been done. Well, yeah, there's a lot less research being done on therapies of meaningful duration, right, because it's incredibly difficult to do that.

But, I mean, think of the absurdity of this. You know, if you have a study that looks at a certain kind of therapy and it's, 12 sessions, and there's some evidence that it would be effective, how does it make sense to say, well, the 12-session version of the therapy is effective, but if we were to extend that longer, you know, 20 sessions or 40 sessions, that's not scientifically validated. You know, that can't be part of the treatment guidelines. It just doesn't really make sense. So the question becomes, and then there's this slight of hand, right, where people, say it's evidence-based because research was done. But when they say evidence, when the researchers

say evidence, and when they talk to journalists and journalists write about evidence, and it filters down into college undergraduate textbooks, what they mean by evidence is that there's a group difference, you know, in a randomized research trial. And, you know, the group that got, you know, whatever treatment of interest, the group that got the treatment, overall, on average, did somewhat better, usually not much, than the group, a control group that got no treatment or got a sham treatment, and we say the treatment was effective,

the treatment works. But then if you, but that's not a question that's relevant to clinicians or to patients. If you drill down and the question becomes, you know, okay, there's a group difference, but do people who get the treatment get well? And the answer that comes from, you know, scientific studies is absolutely crystal clear.

The same research that people cite to say, a brief, say brief CBT, you know, eight or 12 sessions of CBT is effective. The very, very same studies show that the overwhelming majority of people who get these treatments don't get well and don't stay well. So there's a bit of a slight of hand going on in how we present and disseminate research, both in the mental health professions and, you know, and to the public at large. Yeah. And so I think you're the hypothesis, if I can summarize kind of what I think your big points are here,

is that number one, longer psychotherapy works better than short-term psychotherapy? It's not a hypothesis. It's an empirical fact. So, sorry to interrupt, I just so important. You know, there's three ways of doing studies. Right. So what the researchers who are studying so-called evidence-based therapy are not doing is starting with the question, how long does therapy realistically take, you know, for a meaningful number of people to get meaningful benefits? The research is just not asking that question. There's a whole other body of research that does ask that question, and there's three ways to do it. You can ask patients who have had therapy, who've had effective therapy, how long did it take before the therapy started

to have meaningful benefits? You can ask clinicians the same question. Turns out you get surprisingly similar answers from patients and clinicians, or you can actually track patients in over the course of time. You could administer standardized outcome measures at intervals throughout the therapy and ask the question, you know, how long does the therapy take before, say, 50% of the patients, you know, so show some clinically meaningful level of improvement. And, you know, we know the answers to that. I mean, I mean, treatment benefits. Right, on average, everyone is different, but on average, clinically meaningful benefits begin at around the six-month mark and continue for one to two years afterward, depending on

the person. So these studies of evidence-based therapies that are the basis for APA, both APA's, practice guidelines, all of these studies are of therapies that are over, right, before meaningful clinical benefits even begin. Yep. Yep. And just to kind of summarize this, your pivotal article that you did for the audience who maybe haven't read it, and if you want to read it, I'll link it on this, the show notes

and in the article that I'm going to write on this. But the basic cases that you make is that therapy is effective. Largely, you know, it doesn't matter if you're doing CBT or psychodynamic therapy. Like all therapy is effective to some. degree. And it seems that the things that make longer-term therapy successful have more psychodynamic foundations, meaning a focus on emotion, a focus on the relationship between you and the client. Yeah, and those are empirical findings too. And, you know, there's really, we talk about the science practice schism. There's much less of a schism between practicing

therapists, CBT therapists or psychodynamic therapists. You know, real therapists operating in the real world understand that therapy takes time. People don't come packaged with, you know, single DSM disorder categories. People are complex. We need to create a relationship with the patient, right, over time. So therapists understand that. The actual schism is between practicing clinicians and researchers who, who operate in parallel universes.

To address your specific question, yeah, in studies of CBT, manualized CBT conducted in the studies I'm thinking of according to Aaron Beck's Cognitive therapy treatment manual, it turns out it's not actually the specific cognitive interventions in the manual that account for outcome. It turns out it has things to do with, it has to do with things like. the quality of the relationship between the therapist and the patient. It has to do with recognizing defensive processes as they arise in the therapy. And it has to do with using the therapy relationship itself as a window into the kinds of relationship patterns and problems that show up in other places in the person's life.

Those are actually empirical findings. You know, so when people say this brand of therapy is effective, this brand, bat brand, the story is actually far more complicated because the active ingredients in actual treatments are not necessarily what, you know, researchers and practice guidelines are spinning them to be. Right. But you tweeted out that you wish you had kind of invented your own brand of therapy because then you'd probably be much more wealthy at this point, you know? And I think I tweeted back at you.

Yeah, but I think I would respect you. I respect you more because of the stance you've taken. I remember that, yeah. That was a few days. And let me unpack that a bit for, you know, for listeners. You know, there's certain fundamental principles of human psychology that, you know, that are at the heart of all therapy approaches that are effective. And there's really no incentive in the research world to publish about that,

make that case, you know, study that. The incentive is to invent something new, or at least something that you can claim is new, right? Brand it, right? Turn it into a three or four letter acronym, and there's, you know, hundreds of them. And then you go and promote your therapy as if you've discovered something, you know, completely new and different. And yet it turns out again and again and again. I mean, the active ingredients are fundamental principles of human psychology that are incorporated to a greater or lesser extent in the acronym therapy.

So, you know, I kind of take a dim view of this proliferation of acronyms and selling therapies like brands. when the truth of the matter is, right, they become commodities. But the truth of the matter is that the one thing that's central to therapy being effective, all kinds of therapy being effective, the thing that's central is the kind of relationship that the clinician and the patient are able to form. And that can't be turned into a commodity. Right. You can't commodify.

You can't commodify, you know, a human attachment. Right. A real relationship. And it takes time. I mean, it's going to be, you know, you can do fine. You can make a good living being a therapist. You're never going to be super wealthy. You just aren't. Unless you start, unless you, unless you start a cottage industry around a therapy brand name and then you can make money from, you know, selling courses and workshops and seminars and books and right the right then you're you know you're not making money by being a therapist you're making money by selling a brand which is really something quite different yeah yeah i remember when i went to the first uh i went to a big psychotherapy conference

i won't say the name but i i think day three it dawned on me what every person was doing there was they would give just enough to tantalize your appetite to like, wow, this person has something of value. And I'm insecure because I'm a new therapist, so I really need something of value. And then, you know, they promote their workshop, which is kind of like, you know, where they make their money. And so, you know, nothing against people who do that. I think, like, you can take away a lot from some of these workshops. I've been to some of them. but at the same time what we're talking about is there's common factors which you can sure which which

are more basic and also very hard to um it's like hard to do without actually practicing doing it getting receiving supervision and then actually being in therapy yourself those are the those are the pillars of it right so i i actually believe there's a such a such a thing as a master clinician right You have to have a certain aptitude for it, and you have to really, really work hard and for a long time to develop expertise. And, I mean, you just hit the highlights of it. I mean, it takes three things. You know, one is there's no substitute for experience. You really have to, you know, spend your hours treating patients doing the work.

You know, it's a version of the 10,000 hour rule. You know, if you're not willing to spend 10,000 can argue about what the actual number is, but, you know, meaningful time doing it, you know, you're not an expert and you probably shouldn't be out there promoting and selling yourself as an expert. And so you need, you need practice experience. You need quality supervision. Right. So learning psychotherapy is essentially an apprenticeship model where, you know, you spend your time with your patients. you discuss the patients on an ongoing basis with a senior, hopefully expert colleague who can help you understand what's going on psychologically and how to work with it. And the third thing is that your own personal therapy is essential because all of the concepts that we talk about and that we use in psychotherapy, you're not concepts that apply just to patients.

It's like patients aren't some, you know, separate class of human beings, right? Psychological concepts and principles apply to people, to human beings, and they apply to us. And, you know, unless we see these, unless we see them ourselves in our own life, unless we come to, you know, really deeply know ourselves in our own therapy, you know, there's a way these concepts are just sort of academic theories, right? They're not, they're not lived experience that you can actually use and apply. in a meaningful way in doing therapy. We have to see it in ourselves, right? So we started off talking about projection and projectivated vacation.

I mean, I think, you know, you and I described it pretty clearly. Anyone listening would be like, yeah, you know, that makes sense. I've seen other people do it. It changes everything when you're in your own psychotherapy and you catch yourself. Your therapist helps you to catch yourself

in the middle of engaging in a projection. And the thing that's most, you know, sort of jarring and striking, and transformative about it is the realization that you were completely deaf, dumb, and blind to it until in the context of the therapy relationship, your therapist was able to help you recognize it. Yeah. I think I've been seeing it. It's the third therapist I've had and I've seen here for a long time. And what's been helpful is I sometimes come to therapy thinking that what I'm about to share is shameful and going to be too much.

It's like raw. It's like the thoughts that you have that you don't really want to share with anyone. And you share it anyways because it's like you have to share what is coming out, right? If you want to make sort of... Well, you don't have to share anything,

but if you want to benefit from the therapy, it's a good idea to try to. I choose to share. And it's like, because she is psychodynamically, psychoanalytically trained, it's like there is no, I don't experience judgment. And I don't, I experience curiosity and empathy and warmth. And it's surprising. The empathy and warmth are probably the most surprising things.

Yeah, and psychotherapy depends on empathy. And not empathy. The term is misused and distorted. And I mean, people say empathy and what they really mean is coddling, sympathy, validating, affirming. That's not what empathy is. Empathy is because we're more human than otherwise. You know, in a sense, there's nothing in the realm of human emotional experience that is completely alien to any of us. Empathy is empathy is the therapist's capacity to, you know, feel and understand, not understand cognitively intellectually, but feel, because they can recognize it in themselves, to feel something of what your experience is like.

And then, of course, it's not about judging or shaming or scolding, right, when it's in the context of recognizing all of these things are in the realm of human. and experience. Now, how can we understand them? How can we make use of that understanding in ways that could make your life easier or better or richer? Yeah. Yeah. Okay.

In normal day practice, here's one thing that gets in the way of empathy. It's envy. And I'm curious how you've experienced this with your success. Like, do you ever share a success with someone? And the first thing that you initially see on their face is like a flash of anger. And then maybe like some contemptuous or it doesn't even be contemptuous. It could be just like, kind of like, oh, I wish I had. Or, you know, like, there's a close line between envy and admiration.

I'd be curious, like, what your thoughts are on like. I'm imagining you get a certain amount of that because of the success of your podcast. At times, yeah. or other. You know, it's, yeah, and I'm curious, like, it takes away sometimes my enthusiasm, if I'm enthusiastic about something. And then the first, it's like if I experience envy as kind of like the initial response, I notice it now.

And I kind of, I think I can have empathy for their envy sometimes or desire. And we started by talking about projection. So think about how it would make a way. world of difference if you or somebody with the capacity or somebody who would work to develop the capacity to recognize that envy in yourself, to not say no, that's not me. I'm not that kind of person to recognize, you know, I wish that was me. I'm a little resentful that this other person is having these successes and I'm not. You know, there's a part of me that would like to take them down a notch and put myself up a notch. I think of the world of difference it would make.

If you have the capacity to recognize that in yourself, you know, see it in the mix of all of the other, you know, nuanced and complex feelings that you're having at the same time, right? And then, you know, out of that awareness comes the capacity to make a choice. You know, am I going to act on the envy? Am I going to try to, am I going to try to do something to diminish you? Or am I going to recognize the impulse in myself? And then just, hey, that's really cool what you've done. I'm really interested in this. I'd like to learn more about it.

Maybe I'll learn something from you that I don't know that might be helpful to me. So, you know, envy is always is in the mix. But if we deny it in ourselves, right? If we drive it underground, if it becomes unconscious, then we tend to act on it, you know, in indirect ways that are often destructive. So, you know, psychotherapy or the kind of therapy you and I are talking about now is really about knowing ourselves more fully, right, so that we can live our lives more freely so that we can have choices about things that otherwise would, you know, otherwise are sort of automatic and not a matter of choice,

and ultimately, to be a better version of ourselves. Yeah. Yeah. Do you think, okay, so you kind of mentioned to know yourself, right? And do you think that the knowing is the effective component of what makes psychotherapy work? Oh, that's a very complicated question. Now, I don't think it's the component, right? I mean, there's endless debate about this and the psychoanalysis.

world. A lot of things go on in therapy, knowing or insight is one of the things that happens. But it's also inseparable from something else that's happening. And so our earliest relationships, our earliest formative relationships become templates for our subsequent relationships. In one way or another, we tend to repeat, recreate these templates, these relationship patterns, throughout our lives. Now we're in therapy. We're in a new relationship. And two things are happening in that relationship. One is we're making use of the relationship to pay attention and to notice and reflect on things about ourselves that we ordinarily brush aside or minimize or discount. And so that's one thing. That's the insight component. But the other thing that's

happening is we are having a new and different kind of relationship. And that, new relationship then becomes another template, another way that relationships can be. And, you know, just to give a pretty crude example, I mean, people who come to therapy, people in general, you know, human relationships are different, difficult. You know, none of us get out of childhood and adolescence unscathed. I mean, everybody has the experience of, you know, risking vulnerability, you know, intimacy in a relationship. And, you know, having the other person, having the other person take advantage of that

in some way or having the other person use it against you in some way, right? Intimacy is difficult and scary. So a lot of people come into therapy and they've never had a genuinely intimate relationship that they've never had a genuinely intimate relationship. that didn't end up hurting them in some way. So they're having a new experience. I'm in being in a relationship. I can be vulnerable.

I can unmask myself and show the sides of myself that I wouldn't normally do in the rest of my life. And, you know, number one, nothing terrible happens. You know, number two, the other person doesn't take advantage of what they now know and see about me, to retaliate against me or to hurt me or to, you know, do it back to me. The other person is, the therapist, is interested, curious, empathic. So now, you know, now I'm having an experience that for a lot of people coming into therapy and a lot of people, period, has not really been part of the realm of their experience. So one of the things that comes out of this is a whole different capacity for connection

and intimacy with other people in other relationships in your life, you know, with your partner, with your friends, with your children, with your relatives, right? Another way of being in a relationship that previously wasn't part of your templates. Beautifully. That goes hand in hand with understanding. Beautifully said. Yeah. That's really good.

So my mentor, Dr. Tar, was taught by Franz Alexander. And he's the one that actually introduced you to me when I was a resident. We went through your article and talked about psychodynamic therapy. So it's really a pleasure meeting you now face to face as someone I'm still learning from. And getting to hear from you firsthand, there's something valuable about hearing people speak, you know, what kind of like their years of experience have given them. And so I hope my audience is grateful to have that. Well, thank you. I'm grateful for the conversation. That's good, yeah. You know, there's so much more. I feel like there's so much more we could discuss. I want to hit,

is there anything else that's kind of in your mind that you want to get out to my audience, to mental health professionals today before we close up? There's a lot. You started by talking about my paper on the efficacy of psychodynamic psychotherapy. We didn't really get into it. I know, I know. I want to. I want to, though.

And that could be frustrating, right? Maybe we'll have to do another episode. I guess what I wanted to say is, you know, there's a lot of rhetoric out there about, you know, you hear a lot of terms. You should get evidence-based therapy, you know, this therapy. It's always a brand with letters, you know, this acronym. This is the gold standard. This is empirically validated. These are best practices.

And of course, none of these words actually have any scientific meaning. Gold standard isn't a scientific term. It's a PR term. It's a marketing term. Anyway, I guess what I'd like to get out before we stop is there's kind of a master narrative in the profession. And the master narrative is, you know, there are these evidence-based. therapies and they've been proven superior. And what's, you know, you've not said explicitly, but it's always implicit. They've been proven superior to how we did therapy in the old days,

meaning psychodynamic or psychoanalytic therapy. That's been debunked, it's passe, no, it's, it's not, you know, it's not scientifically supported. And there's a, there's just a yawning chasm between this narrative, the rhetoric, And the reality is what I, what I demonstrated in the paper that we've been referring to, is that, you know, first of all, the evidence that psychodynamic or psychoanalytic therapies are effective is absolutely as robust as it is for any of the therapies that are promoted, branded, marketed as evidence-based. Psychodynamic is an evidence-based therapy. But in the narrative, the term evidence-based is used as a kind of a marketing term.

It's used to exclude psychodynamic therapy. But the actual scientific research shows that psychodynamic therapies are at least as effective in the short run and apparently more effective in the long run, the benefits last. So that's one thing. And the second thing is that other forms of therapy, when they're effective, are effective because of what you called common factors, right? But I would say, actually, the common factors are psychodynamic factors. The common factors, all of them emerged out of a psychodynamic tradition.

The idea of two people sitting together on a regular basis to discuss the experience of one of the people, right, in a certain kind of, you know, in a certain kind of therapeutic frame, right? I mean, this started in the psychoanalytic tradition. So, I mean, people are getting sold a kind of a bill of goods about what makes for good therapy and our professional organizations, both APAs, have bought into it to some extent. Yeah, yeah. And we talk about this with your colleague who you co-wrote that book with, how there's like actually six therapies that work for borderline personality disorder,

although anyone on a board test would answer DBT for depression. On a board answer, we're trained. Answer CBT. Whereas like there's just as much evidence for psychodynamic therapy. I agree that a lot of the common factors are psychodynamic factors. And I think there are a lot of different psychoanalytic theories, but I think the modern psychodynamic perspective is more in a long. with those core factors, and that probably begs a longer conversation on how it got to that

place, right? Well, we could start with something very basic, the quality of the relationship, meaning, you know, not to the doctor and the patient or the therapist and the patient, you know, like each other or get along, right? A working alliance actually is much more specific. It means that there's a shared mutual understanding about the purpose of the purpose of the work and the methods that we're going to use in achieving that purpose. It's an alliance around, you know, a shared understanding of the job that we're here to do. So when I say the

quality of the relationship, I mean to mean it to include that. Well, if you have, you know, a psychologically healthy person who, you know, connects well with others, who has the capacity to form, you know, to form, you know, meaningful, positive connections with other people, then damn near anybody can create a good working alliance and a good quality of relationship. But that's not the only kind of people we treat. A lot of the people we treat have, you know, real difficulties in relating to other people, and having mutual relationships with other people, meaning relationships that work for two. And right, so now you take somebody who does not, you know, doesn't have the capacity

to form good relationships and the enter therapy. What happens? Well, that's where the therapist's skill and understanding comes in. And, you know, for one, you mentioned personal therapy. For one thing, you have a hell of a lot better chance of finding your way, you know, through all of these challenges, finding your way to a way of being and connecting with this patient, if you really, really, you know, understand yourself in a deep level, right? And you're not, you're not reacting to the patient's, the patient's slights, the patient's

attacks, the patient's ways of distancing from you, right? I mean, you think about what a world of difference it can make. The patient comes in and they do all of the things. things that tend to destroy all of their other relationships. And the therapist, instead of doing back the things that other people tend to do with them, the therapist is like noticing what's going on between two of you, commenting on it, getting curious about why things are happening the way they are. Well, those are psychoanalytic skills. What do you call them that or not? Yeah. Yeah, that's so good, so good. It's like the,

How do you deal magnanimously with transference from someone, you know, when they get, when someone gets irritable at you, or like today I had a patient tell me that he had thought about torturing me. And I was more curious about it. And it was like an expression of anger and disconnection and a lack of empathy that he experienced from me. He experiences these thoughts for other people as well. But it largely, there was a life. There was also the transference of the life.

trajectory of there was many incidents where he had felt the unempathic, a total unempathic experience from other people. And so now I was becoming just another person in this long list. But as to someone psychodynamically oriented, I was able to empathize with how distressing that was for him to experience, because he didn't want to experience these thoughts. You know, there was part of his experience, but not his full experience. But then also the pain of the lack of empathy. And so we were able to kind of repair that moment of disconnection that occurred. Yeah.

So it makes a world of difference. The therapist does something that's different from what most other people, most other people that you're a patient, most other people we encounter in our life do when they're feeling, you know, when they're feeling attacked or harshly criticized. The normal human reaction is we either withdraw and disengage or retaliate, counterattack. I mean, it just changes everything. If the therapist response is something along the lines of, you know, you're really angry with me. I must have failed you in some way. I must have said something or done something that was really disappointing or hurtful. Tell me about that.

It changes everything. Yeah. Yeah. With connection, right? Connection at the end of the day. It's actually very difficult to connect with people ongoing. There's, you know, so much of what we see day in by day and day out is like disconnected families, disconnected friendships, disconnected relationships or people wanting to grasp. Disconnection.

in culture and in society. Yeah. And yeah, so it's like, you know, it's easy reading that initial tweet, kind of coming back full circle, to think, to think like, oh, that's someone else, right? That's someone else who projects. I don't project. I'm the one who watches the projector. I'm the one who, I'm the one who observes the narcissist, you know? Well, the thing that's funny about the tweet, I mean, obviously, I wrote it, you know, thinking about and wanting to come and.

on the culture wars. And if you read the comments to that tweet, it's really interesting. So people on both sides of the political spectrum, you know, commented and replied. And the funny thing is, which I really like the people on the extreme ends of the political spectrum, like people on both ends are absolutely 100% convinced

that I wrote the tweet about the people on the other end of the spectrum. Oh, yeah. Oh yeah, no, I'm sure that's happened even in this episode. I'm sure people are imagining, oh, this is that group. You know, it's like the outsider. It's like, well, you know, I think we're all capable of some projection, but we all need also compassion for the projection that we do maybe. And if we have envy, you know, I know I have envy from time to time. It's like I need to process that and compassion for that. And if I'm struggling with, you know, anger, or disappointment or sadness, you know? It's like we all need that empathic experience. And so I appreciate you. I just want to reaffirm like, it's like, it's like cool to meet you. I know you're like, it's like, you know, you read a lot of someone's thoughts and you appreciate them.

And I think through your article, I actually looked at every little citation. And I went through those articles as well. And I would love to do more episodes with you. So we'll have you back. And it's just great meeting you. Well, that would be great. Thank you. It's a great conversation. I'd be happy to continue it.