Psychiatry & Psychotherapy Podcast - The Integration of Psychotherapy as a Treatment Modality

Episode Date: August 12, 2022

In today's episode of the podcast, I speak with Dr. Mary Jo Peebles, a renowned psychoanalyst, speaker and author, about the significance of psychotherapy from her most recent book, When Psychotherapy Seems Stuck. Dr. Peebles received her Bachelors of Psychology from Wellesley College and her PhD in clinical psychology from Case Western Reserve University. She currently works at her private practice in Bethesda, Maryland. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do 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. Today I am joined with Mary Jo Peebles. She wrote a book called When Psychotherapy Feel Stuck. She is a PhD who is a psychoanalyst, therapist, writer, teacher, currently in private practice in Bethesda, Maryland.

She was recommended to me by Robert Feinstein, and I have enjoyed her book, and I have yet to read her second book, her earlier book, which was also recommended to me. so I'll have to have her back for a second time. And today we will discuss kind of some of the angst of the world. We will discuss how psychotherapy can help people. Why does psychotherapy take time? What are some of the things that are foundational for how we can operate as psychotherapists and how do we grow as psychotherapists? We will talk about how to take a stance of not knowing,

how to find meaning in the midst of. of working with clients, and I look forward to you enjoying this. We both do not have conflicts of interest. So here we go. Okay. So you're talking about the biological approach to psychiatry? Yeah. Okay. Yeah. So there are some psychiatry residents I meet that have very little psychotherapy training or even value it, right? So the average depressed person, I think only 15% or so. we'll see a therapist, whereas a larger portion will be on medication. So I think that, unfortunately, although there are a lot of therapists out there, there's probably not enough to meet the needs of all of the depressed and anxious people

in the world, especially now post-COVID. Especially now. You know, in my neighborhood, it's hard to, a lot of people are full-up because of COVID. And it's hard on the therapist, too. Is it? It is. It is. I mean, I don't know how this is a divergence, but there was a film festival recently in Trevor City, and they showed, there was a film Bo Burnham inside. He's a comic that I didn't know about started years ago, but he filmed a sort of special for Netflix where it was him being inside for COVID. He was just about to launch a bunch of stuff and then COVID hit. And the fact, just to go back half a step in terms of mental health, he had been a very successful stand-up comic, but too early, too young.

You know, he started in his teens, and he got hit with a lot of claustrophobia, panic attacks, and he had to drop out of the circuit for like five years and get therapy for depression and anxiety. So he was just ready to go back in again and launched in January of 2020. And that's January of 2020. And then COVID hit. So he was sort of in this little room. And it really, the little room sort of captured the rooms that we were all in. And it's a dark, it's comedic, but very dark, you know, 90-minute film.

And I left the theater and people were asking, what do you think? And I said, you know, it was tough because not only are we getting inside his experience of being inside COVID, and being inside your own head and having no feedback from other people. But that brings back what it was like for a person myself to be inside COVID, and then to have been listening to all the people who are inside COVID, which was inside the absence of relationships as we knew them. And so it was like a tumbling of, you know, kind of an exponential magnifying of the difficulty we were having.

I mean, personally, as therapists, I'm saying. Oh, absolutely, yeah. And then when I had COVID, because I had a period of time where I had not thought or feared about COVID very much, but when I actually was in it, I remember some, like, there were some dark nights where I'm, like, anxious in the middle of the night.

Like, am I going to die? Exactly. And it was in my very sort of rational, cognitive brain, I knew for my age group and my, like, demographic. It was about the risk of drive. driving 50 miles a day for a year, which is like not a huge risk of death. But there was something about hearing people's stories throughout the preceding years and this sort of the news coverage and all of that combined and created incredible,

like more panic than I've had probably ever in my life. Yeah, I'm with you. I can remember in March of 2020. 20 when it first began, I would wake up in the morning and take a breath and go, okay, I'm still here. Yeah. And I'm not a naturally anxious person. Yeah. I'm fortunate that way.

So, but it was just so real, you know, it was so devastating. And the images that we saw that were right close at home, you know, the refrigerator trucks and so forth. So, yeah, we, we are being bombarded these days as people. as humans with a lot of really untenable things. The word unprecedented has risen in use since 2015, unprecedented. If we think about that, that's tough because with trauma, David, when there's not a pathway, when there is a pathway, when a lot of people have experienced it before, we can feel socially more held because there are methods that people have developed.

But when there's, when something is unprecedented, then we're really thrown into an existential quarry. I'm not using the word quandary, quarry, you know. So, anyway. Well, I think we can, we can feel like, yeah, isolated and alone in this sort of unprecedented time. You know, I mean, I was reading about the Roman Empire and how around the time of, you know, Marcus Aurelius and stuff, there was lots of plagues. And because, you know, you had lots of people gathering. You had many different places where viruses could breathe that would be brought back to the capital. And you had an increasingly high density of people in cities. And so you had these, these plagues.

And it was probably one of the reasons for the downfall of the empire, actually. So you had, you know, Marcus Rillius writing. about how to cope with that back then and how he coped with it. And so it's not, it's, I think it's part of the history of mankind. I mean, that this, that plagues and horrible viruses decimate large populations. But it's a very unpleasant, you know, at times I think we like to think

we're beyond that with our technology, but we're not. Yeah, that's a good point that we've actually lived in very fortunate times for a 50 or 60 or 80 year time period, relatively fortunate times. And now we're going back through what other people have gone back through. I think that's true. But as a generation, you know, it's like, say, three or four generations being alive right now, we're just not as equipped, you know, as most of the people who have been through the Great Depression, who have lived through World War II, are passing. on. And so we're just, we're just not as familiar and equipped because we've lived in such fortunate times. So it can create, it can create great resilience in us if we keep our eye on what's important, I think. And that's where psychotherapy can really, really help.

But it is important for therapists to understand what a demand it is on their own psyches. Absolutely. I think that's where we sort of were sort of wandering into. You know, we sort of started organically with this, but that's why personal therapy for psychotherapists is so, so, so important. Do you think that most therapists are doing their own personal therapy, or do you think it's, like, do you think they need to hear that message more, maybe now in this time more than ever? What's your sense on that? Yeah, I don't have, I don't like to speak to something I don't have statistics on. in terms of how many therapists, it's a really great question. How many therapists are currently in personal therapy?

When I talk to people, I mean, in the psychoanalytic, psychodynamic world, people tend to go into personal therapy more often. I believe in terms of the trainees I talk to, the early career people I talk to. So I don't know about the other branches of psychotherapy, like the biological branch, you know, oriented, those cognitive branches of mental health, the behavioral branch. I don't know how many of those people go into personal therapy. And those that do, I don't know if they go in, you know, if you're doing depth therapy, if you're seeing somebody over time and you're trying to create structural change

in somebody so that the world really becomes different for them, which is a certain kind of psychotherapy. It's not necessarily the best or the, only, but it's a certain kind. It's very valuable. If you're doing that work, you need to be in a psychotherapy process or have been in a psychotherapy process where your own internal world has been explored so that those nooks and crannies that we tend to want to avoid have been walked into, you know, with a trusted other. And we've looked around and we're maybe not great, don't feel great about those nooks and crannies, but we know them. So when they come up,

we're doing more depth psychotherapy, we're not as afraid and we don't have to use defenses that then affect the patient we're treating and then close off avenues for them. Because just like with children, children can only go as far developmentally in terms of emotional maturation as we've gone unless they get further help outside of home. And patients can only go as far as we've gone. it's hard for them to develop further than the roadmap that we've traversed. And that's humbling and that's okay. But we can improve that by having personal therapy that has some depth to it.

Yeah. So this kind of leads into, you know, why does therapy take time? Okay. Why, yeah, why does it take time? And so when you're talking about this depth therapy, are we talking about just the number of sessions? Are we talking about something else? I guess there might be two questions, but go ahead. Yeah.

Sometimes I like to use the metaphor of, let's say we're, you know, we have a house, and it's a pretty good house, but we want to upgrade it. I mean, we've got kids now. We've got activities that we use, and we want to help the house accommodate that. So we bring in a contractor and they look over the house. And it turns out maybe that all we really need to do is, you know, know, get some new cabinets, you know, maybe paint the walls, maybe get some new windows. Or what if instead we need to do more? Maybe there's some structural damage to the bones of the

building. Maybe we need to move some supporting beams. That's more structural work. That's going to take more time. And there's different kinds of psychotherapy and they range along a kind of a continuum. It's not an either or. And there's nothing wrong with either of them. There's not a best. or worst. It's can you can you know enough to match what your patient needs? So, you know, maybe somebody just need to refresh her on something. Maybe they just need and maybe their time demands only allow them to see you for 10 sessions. And you want to, you know, give them some ideas about where they could go if they keep practicing what you offer them, you know, like 10 sessions. That's, that's very short. It's, it's, it's, you can do something. You can do

something in that amount of time, but it's going to be more like in a house, more like painting a room. It's not going to be structural work. It's not going to be deep structural work, where you are actually rearranging how they've come to believe that people are and how they come to experience themselves in a very mind-body way. So that's more structural work. That's the work that takes time. Yeah. And I can talk more about why it takes time, but let me pause there. Yeah, and I agree we had a, or I've looked at studies and, you know, it's like if you're just looking for minimal effective dose, you know, maybe 10 sessions can get you that, you know, where the OQ outcome questionnaire, 45 is dropping one point per session, right? But there's,

there's a ton of questions on there. And so there's a lot of room for, you know, a year or two years of therapy to do some good. There's, you know, I think when, especially when we're talking about more difficult clients or patients that come in with multiple issues, attachment issues, issues with early childhood trauma, issues with repetitive traumas, usually it's not just one trauma, right? It's like tens of thousands of critical statements that they've heard over decades. That takes time. So, yeah.

That would be complex developmental trauma. You know, in trauma, we talk about simple versus complex. And simple is the briefer, you know, the more it's a single event, briefer duration in your adult life, you know, and it, you know, it only affected a single domain, you know, of your life. Versus that that's more of a simple trauma. maybe you had a car accident when you're 40. But the more an event is chronic.

You know, it's a long duration. It occurs earlier in childhood. It was perpetrated by humans, you know, and it, you know, affected multiple domains of development. Then you're talking about the actual brain development if we want to think biologically even, just biologically, not even your mind. but the brain development is affected, you know, with the ongoing trauma in early childhood by the rushes of adrenaline, the fear, the dread, the cortisol, all of that, you know, and it affects and it affects the mind. You know, how do you make sense out of a parent who is loving and abusive, a caretaker who's

abusive? You know, so all these things, there's a fragmentation that goes on. So that's structural. That's what I mean by structural. damage. Damage to the bones of the development of the psychology, the psychological anatomy of a person, their emotional regulation capacity, their reality testing, their reasoning. These are the bones. And when you get structural damage to those bones, you've got to be very patient and you have to understand what are the building blocks to rebuilding that. So that takes time. That's one of the

reasons it takes time. And there's a couple of others, but that's one of them. Yeah. You talk about in your book, this study where they looked at teaching people braille. Yes. I really, I really like how you summarize that study. And my takeaway was that initially, you know, a lot of, you know, so they did this three hours a day, one hour, teacher training, two hours. A person was studying themselves, and they did that five days a week. And the Friday maps of the brain looked one way. It looked like change had occurred. They were mapping new parts of their brain with touch.

So that they were slowly, like, changing the way the brain would operate so they could read with their finger. Right, right. And then initially on Monday, though, their brain map went back to what it looked like before they started. Right. It was the Monday maps and the Friday maps. And that was in Doidge's book, his 2007 book, and he reported a study by Pascal de Leon. And you're absolutely right. They were studying, they would have an hour of class and two hours of intensive practice.

That's three hours a day, Monday through Friday. And they would, with transcranial magnetic stimulation, they would map the brain on Monday and map the brain on Friday over and over again. Monday maps, Friday maps. And like you said, by Friday, there had been change. And that wasn't furious. was change. But then the frustrating thing was that after two days of doing nothing, on Monday, the Monday map looked again like a Monday map. It has lost the changes in the Friday map.

Until about six months, there's about six months of doing this, then the Monday map looked like the Friday maps. It held. But you've got to remember that six months, was like 390 hours of them working at Braille. Yeah. And then it took until like 10 months of this work for those Friday maps to hold across two months of not doing any Braille. And 10 months was like 650 hours. So if you're doing like psychotherapy one, an hour a week,

let's say you have a couple weeks off for vacation. You know, it's like 13 years. Right. We've got to think of something other than going into therapy, having the therapy and going home. I mean, this is across the board. I'm sorry. Go ahead. No, no.

You know, I think, and that's where you bring up, like, how does a patient do work outside of therapy, right? So that they're not just doing the work in that one hour. Right. But maybe they're trying to integrate some of those things into the rest of the. their life. Yes, yes, yes. And everything, your listeners who are really more immersed in biological psychiatry, you know, know about the brain and know about the growth of dendrites and know about how multimodal learning, you know, densifies, you know, and Tronik talked about this. It densifies the sort of neural, you know, the interrelated neural firings, the density of the web of mapping, you know,

of what happens when something takes place. So that we're not just, you know, as therapists, this is why I am an integrationist. You know, I'm a psychoanalyst. I'm a trained psychoanalyst. So I obviously have a very deep psychodynamic background. But all these other, you know, the biological background, the behavioral studies, the cognitive studies,

they're all true. But we have to integrate that in our knowledge. It's not either or. It's not, we're beyond turf battles. If we want to be, you know, sophisticated psychotherapist, it's going beyond turf battles. It's, that's really not helpful for patients. It's how do you understand these different truths that have been developed with a nice body of empirical research? And so it's not just with cognitive therapy, it's how you think, you know, and that's important.

but we are a body and a mind, we have appropriate receptive feedback, we have to walk through stuff in multiple situations across time to really nail it. Any sport you take up, it's the same thing. You can hear your coach in your head, but you've got to go through the matches.

You've got to go through the clinics. You've got to compete, even just to learn how to compete. So you have to get all that feedback in a multimodal way. It's the same, psychotherapy. So, you know, I do a lot. I do not a lot. I do some role play sometimes in psychotherapy, just to give that feel for them of what it sounds like when I say something and they're being the

other person. You know, I really value and track and I don't give homework, but I listen to and I ask about, well, how did you say it to them then? And what happened next? Outside the therapy. It's not just all about me. I'm central, you know, our relationship is central because that's what's happening in the room. But it's also about what's happening outside the room. Because it's walking through life and getting that feedback that potentiates, it adds the extra to the work that you do in the hour.

Yeah. That's good. That's good. So you talk about kind of like the house and how there's this structural damage. and how, you know, therapy will take more time. How do you communicate that to clients maybe who want something faster? You know, it's like nowadays people want, they want magic. They want something that's like instantaneous.

How do you like persuade them or do you persuade them? How do you talk to people who are in that mindset that they want something faster? Mm-hmm. I think there's a couple of things, David. I always fall back on just being honest, you know, and not being judgmental about what they want or don't want. I mean, what they want is what they want. I mean, they're coming.

And that makes sense, given our culture, to want something quick. I'm not, you know, concerned about that. But what I always meet with people, you know, I tell them over the phone when they call that, let's meet for a couple sessions, you know, at least one session for you to get a feel for me. But, you know, let's meet for a couple sessions for us to understand. And here's what you're bringing in. Let's say you're bringing in, I mean, make up something for me. What would a person bring in and say they bring it in?

Let's say they're bringing in anxiety about the future. Okay, anxiety about the future. And so then I get to talking with them, and they're talking with me spontaneously. So the stories they bring in spontaneously, it could go either way. Let's say I'm going to contrast two different ways. one would be a person who says, you know, I'm concerned about the future because of the recent political scene and what happened at the Capitol, you know, and we start to talk and they've had a pretty good life, you know, they've got great attachment, they've got good relationships, a solid,

stable marriage job. It's just that this has been a ripple. And maybe it's touched this or that, but nothing really structural. And so that's one, let's say that's one person. Then you have a person over here who says, yeah, this is thrown, you know, they start to tell their stories and it turns out that their mother was depressed. And they can remember, you know, lying in bed at night, just wondering, listening for the sounds in the house. Maybe their father was a Vietnam vet and woke up screaming during the night and it interrupted

their sleep. And you start to hear how this current situation is really opening up unheeled and sort of fractures from the past. So if you contrast these two imaginary people, and they both end up saying, but I don't have much time. Right. And I want something quick. You would say something like, you know, and you maybe use the house metaphor, and I'd lay it out. and I'd say, here's what I think, you know, would help to be done. I understand you may not want to do that.

Tell me more about what, you know, how you feel about that. And I would spell out why it needs to take more time or why it needs to take or why it could take less time. And then I'll always fall back on something that happened to me when I went to interview for the postdoc at Menegers. Okay. And it's a two or three day process, which in the old old days used to involve getting psychologically tested yourself.

Which was, no, it didn't when I was going on. But it was a two or three day process. And there were interviews with multiple people. And then there was something called the clinical interview. It was called the clinical interview. And so, you know, you've been through this round of stuff. You go into the clinical interview, and I was really fortunate to have a wonderful fellow who interviewed me. His name was Peter Novotny.

And I talked about wanting to get into psychoanalysis, but that I was concerned because the postdoc was only two years long. And I didn't know what would, you know, could I really complete an analysis? And he said, you know, let's see. You know, we could see. We can see what happens. We can see what might take place. And this was back in the late 70s when that was a very radical answer because the only good analysis was a completed analysis

which completed the transference neurosis. But he said, let's see. In other words, we can do a piece of work. And that's okay. Just like, you know, when you go into see your internist, you can do a piece of work. And if it's a good experience, you can come back and build on that. if you have somebody that knows how the house is built and what needs to be repaired first,

even though it may not be the most invisible thing, but they know the building blocks. You're in with somebody like that. They can do that work, and then that will prepare you for the next piece of work when you're ready for that. And then you see what evolves in the therapy work itself. But I never try to persuade people unless I'm really, I will tell them, I'm concerned. about what's going on. And I am concerned, given what you told me, if we don't do some work now,

that this could get worse. I'll be very honest with them. But I won't try to persuade them so they feel guilty or bad about their decision. Yeah. What do you say to people who, like, you know, it costs money, good therapy? And, like, let's say they haven't valued therapy

in the cost of therapy prior. You know, for them, maybe buying a $40,000 or a $20,000 car is like, okay, that they wouldn't overly think that, right? But there's something about going to therapy, which it's like they don't really quite understand why it would be valued in the way that it is valued. Do you ever come up against that? Definitely. Yeah, no, definitely. It's harder when you have somebody who truly doesn't have any funds or resources. harder. And I think most therapists will have a little bit of room in their practice for some,

you know, blower fee work. But let's say somebody who, you know, just has some discretionary income and has chosen in their lifestyle to spend it on other things. And so it's going to be a sacrifice, but it's moving funds, not trying to create funds where they aren't there. Let's talk about that kind of a person. Okay. Perhaps. And I might tell you. I might tell you. I might tally up and there's a recent, and I can't remember the name of it, there's a recent act that Congress passed where you actually have to, it's a disclosure thing, a form that you have to give patients now when you begin with them that gives an estimate of the cost of the therapy over the course of it, at least over a year, you know, or over six months. And so you can tally that up

quickly in your head, roughly. Let's say, you know, you come up with $20,000 and you say, I don't know, I hear what you're saying, you know, but you, excuse me for, you know, bringing it back to this, George, but, you know, you talked about that trip to China, you know, with the family. And I don't know what it costs, but that's probably about $20,000, $25,000. And that was really important because it created important memories for the kids, important memories for the family. It's a really good bonding experience. What if, however, we were to talk about $25,000,

creating shifts in yourself that will allow you to be able to be present with your son and the way you've been talking about wanting to be more patient and having even a maybe more satisfying marriage, would you pay $25,000 for that? Would you pay $40,000 for that over five years? Would you pay $100,000 for that over five years? You know, let's think about it that way. Would you make an investment in yourself in that way?

And again, I'm not being a snake oil seller. You know, it's about, I'm talking to a certain person of a certain means right now, obviously. But I'm shifting their thinking to would you invest that in yourself and, David, in your future? sure. I like how you talk about it being a emotional IRA. Yeah. You know, it's kind of like, for me, strength training is kind of like that as well. Yes. It's like strength training, like once you get stronger, it's really hard to lose your strength. Like it takes years and years to lose your strength. You know, if you look at someone who's lifted for five years and then they stop lifting for five years, they still look stronger than the average person.

And so like strength training is kind of like an IRA of sorts. And I think I think therapy is as well because good, good therapy continues after the therapy is finished. Exactly. Outcomes continue to get better. We've actually looked at this in the, I run an IOP program, IOP partial program. So we get people in 40 sessions, three-hour sessions. So it's like 120 hours. And we've looked at 24-hour, you know,

cortisol and those kind of like stress hormones. And it decreases on the last day of treatment. And then it continues to decrease months after treatment is done. That's lovely. So that's how we know systemic change has happened. Yep. Because it's continued to decrease. Exactly. No, I'm glad that that is so wise. I mean, it used to be that outcome research would only measure the outcome. I remember Herb Schlesinger back in the 70s talked about. about just what you're saying, that we set a process in motion. We set a process, a therapist will set a process in motion that continues after the therapy.

Yeah. And you know, this is where you get into, I mean, anyone can stop smoking, anyone can lose weight. But it's the therapies that treat and address the factors that are gonna help them sustain that change. So what do they look like a year later, two years later, three years later? And if you can shift that trajectory, and then we talk about the planes that shift their trajectory, just a couple of degrees of the boats coming over from Europe.

You know, you can, instead of ending up in New York, you can end up in the Caribbean. You know, if you just by one or two degrees, if you shift that trajectory. Because it's, it's, you use the word systemic. In a family, if one person, person changes, it changes everybody else's behavior. And then that becomes a new feedback loop for the changed behavior. And it's the same with your patients who are leaving the program. If they're behaving differently with people outside, they're going to get different responses, which will potentiate and continue that change within themselves. So that's what we mean by shifting

the trajectory of a person's development. Yeah. Okay. So what are some important ways to communicate that increased connectedness with clients? So kind of like shifting from like, okay, we're working on creating a connection with clients. Is there things that you found to be more helpful in creating that connection over time? Mm-hmm. Mm-hmm. Yeah, I think it goes to the humanistic branch of, you know,

psychiatry, psychotherapy, you know, we are the, we are the instrument. You know, we're creating a relationship, so it's simply creating a relationship, which means that those Carl Rogers, going back to Carl Rogers, really in the 30s and 40s, you know, empathy, warmth, and genuineness, and what does that mean? You know, empathy is that you're open to understanding the person non-judgmentally, that you don't have an agenda, that you have sort of, regulate, your own biases inside, you know, to open up to the humanity in people. Like Kerry Stack-Sullivan would talk about we're more alike than we are different. You know, that's the source of empathy.

You know, the genuineness has to do with your own authenticity, your own honesty. There are no gimmicks, David, that can make trust happen. There are no gimmicks that can make the relationship happen. There's no particular words I can speak because they're going to see my face. They're going to see the creases in my lips and my eyes. They're going to see things that I have no control over involuntary, you know, muscle movements. They're going to be able to discern at some level how honest I'm being about relationship, you know, about caring about them. You know, if a patient says, do you really care about me?

Often a response I have is, well, what's your experience? you know, what do you see? And I say to them, you see more about me than I know is happening. So what's your experience? What do you notice? And that helps them put into words, you know, what it feels like to be with someone who respects them, respects a word that comes up a lot when I ask people that. Just the fact of respecting their point of view.

So, you know, I think you may be referring a little bit to, in my book I talked about how we say things matters. But I don't mean that in terms, I don't know if that applies as much to how do we foster connection and relatedness, because that more depends on the trust. And trust is earned. You can't buy trust, you can't manufacture trust. It's earned by hundreds of interactions that even as a,

a therapist, you may not be aware of which ones had that import, that it shifted it for the patient. So that's an answer to how we develop connection and goes back to personal therapy, not being afraid to be open and honest, you know, with the person in front of us. I'm not talking about self-disclosure, but I'm talking about just being able to stay open because your own anxiety, you know, is understood and you're able to calm that. You're able to be able to be. be compassionate towards yourself around that. Does that answer your question?

To put it in another way, I think what you were saying is like there's so many, you know, with the mirror neuron system, so we feel other people's experience. Yes.

And so, you know, I can always tell when there's a disconnect. Like I'm at a car dealership is probably the largest disconnect, right? Where you can feel their intent towards you, you know, like, how do I move more money from your bank account into my bank account, right? Right. And then if that's at the core of their internal world, you'll feel that.

Yeah. Like when I'm around someone who's very sort of bent on making a lot of money, I will start to think more about making money. You know, my mirror neuron system, being a more sensitive soul, you know, being someone who doesn't like, I like nature. That's, that's what I like. And so it's like, when I'm around people, I feel somewhat what they're feeling. I feel their intention. Maybe it's more conscious than my patients feel it. But I think everyone has that ability, except maybe a psychopath. I think they have less of that ability. So the patients are feeling your intention. And so the words may matter to some degree, but they can tell at the end of the day, does this?

person really care about me. Yeah. And they can tell you, yes, that you, I feel that you really respect me. Yeah. By the way that you listen, by the way that you reflectively ask questions, they can tell that you respect them. I think in my own therapy journey, it took me a while to conceptualize, and this probably says something about me, that my therapist would actually have empathy.

Like, it was almost like a surprise. to me when I experienced that, no, I think this person actually has real empathy. They're not just fabricating words to appear empathic. Right. No, I get it. I get it. And there's probably, if you were pressed, which you wouldn't have to do now, but there were probably no little points.

There are probably little moments where you can say it became the aha. And there were all those, like a little vignette between the two. little interchange. And there were countless ones that came before that, but it was that tipping point, the aha. You know, yeah, there's not like a specific, like I said this and then she said this, and I was like, oh, wow, I'm feeling empathy from her. I don't know if I have like a specific memory of that. I think it was just, I remember being in the room and I remember being like, like yeah i think this person actually does oh you know what actually there was a there was a moment there was a moment okay it's coming back see see how like free association works are absolutely absolutely

i think i said something like are you behaving the way that you're behaving because of the professional context the relationship you know like or how do i know that you like actually care because i'm paying you for this right right and um she said something like like this is a real relationship and I'm you know I I am a real person and I just just because there's a professional aspect to it and you know it's because you're you're paying me doesn't take away that we have a real relationship yeah yeah and it was probably even that moment of how she said it and it must there was a feeling it hung in the room probably because that sounds like a moment of deep intimacy, you know, deep connection emotionally as well as it's the word she said was probably

how she said them as well, that just embodied the very thing she was saying. Yeah, absolutely. It's hard for, like, it's interesting to say that because as I was saying it, I was thinking about how someone might hear it. Yeah. And someone might hear it and they might be like, okay, I'm going to remember to say that. Exactly. And I was also thinking, like, the way that I'm saying it, I'm not a very good actor. I was such a poor actor that I couldn't even get into basic acting class at UC Berkeley when I tried out, right? So acting is not my thing. So as I'm sort of trying to relay it, I'm missing maybe how it was said or like the pauses or the feeling that I felt from her as I heard it being true. Like this is true. Right. And that's what we can't

manufacture. I mean, unless one is a psychopath, you know, psychopath or true psychopath, they can manufacture that. But the rest of us can't. And it's the energy. It's, it's, it's, it's the, it's the, it's the, it's the, it's the way the person's holding their body. It's even, you know, respiration rates, blood pressure, um, yeah, yovanic skin response. These things are attuned to, in, psychotherapy, you know, there are studies where people rate the therapist and the patient rate

the alliance, but they're also hooked up to, you know, biofeedback measures like, you know, respiration rate, like blood pressure, like galvanic skin response. And when those things align, those sessions are rated more highly in terms of empathy, perceived empathy, felt empathy. So all of these things are happening. that can't be taught in school. We can't manufacture this. What we can do is get to know ourselves in a compassionate way and become more whole people who can be more open

so that we can be in relationship in a healing and caring kind of way without artifice. Yeah. I think this goes back to one of my concerns about the psychotherapy, where I see psychotherapy training and the community and a lot of people graduating is they are sort of clinging on to these like techniques, so to speak without doing the deeper work to inside themselves. And so I'll send, you know, I've sent, because I run a med management clinic

and a psychotherapy clinic, the med management patients, I'll send them to other therapists. And sometimes they'll do like these techniques that are like, you know, taught more in a, like these techniques are outside of therapeutic alliance. And so you just need to do these techniques. And they'll come back to me and the patients will say stuff like, you know, all I, I didn't feel like they really heard me. I didn't feel like they really heard my story. And so I think what you're asking and what I'm asking is actually a lot harder. Yeah. And in our culture where we want to go to like take this, you know, 10 hours, seminar and you'll be trained in this new technique. It's like it's a lot harder to actually do the

work yourself. Right. To be able to do the work that we're talking about. Do you have any thoughts around that? Yeah, I do. I go back to that we are the instrument. We need to learn the techniques, absolutely. But we're the instruments. We have to, if we're going to do, if we're going to make psychotherapy a career, we have to fine-tune our own instrument. Then the techniques that we utilize will be utilized meaningfully. The other thing is I think it's really important, you know, to when one's learning how to do psychotherapy, a couple things, not one thing, let's say two or three things. You know, one is understand the history of the field so that you can see how, if you're going to go learn techniques, maybe you can throw me out, maybe you can

pitch me like at a workshop that would be a technique one would learn what would that be? Some of the like there's like a bunch of like sensory motor EMDR or like tapping different tapping things. Perfect, perfect. You have to know what that is composed of and how it even fits into psychological development. You have to understand psychological development of the human mind and cognitive development and then the history of psychotherapy and how, let's say EMDR is composed of components of psychodynamic therapy, hypnosis, and cognitive therapy. It's composed of those dynamics. You know, it's composed of those pieces. So it's not like it's a treatment in and of itself.

It's a compilation, it's an integration of a couple of techniques. but you have to understand how you have to understand development from a biological point of view, how the brain develops, but then how also personality develops. You have to understand child development to be able to treat adults. And that's why a couple of these courses that may be a semester long or a year long are really important foundational building blocks. Then you can take the weekend workshop and fit that. in to a foundation that you have. So you have to know the history of the field.

You have to know developmental psychology. You have to know, really, I think, for a good clinician, good psychotherapist, learn a little bit about how enough of statistics, just of skimming knowledge of it, so you can read empirical literature with a discriminating eye, you know, so that you can, you know, even if it's just starting with, you know, you've interviewed Jonathan Shelley, even if it's just starting with this 2010 paper about the efficacy of psychotherapy, you know, and the fallacies in that, even just getting a glimpse of that so that you can read the literature, because otherwise we are just going from, you know, snake oil salesmen, the snake hall salesman. I don't want to, I'm not belittling the techniques, but I am cautioning against, you know, weekend workshops as your foundation. They cannot be a, foundation. They're the add-ons. They're the bells and whistles. Well, I think, I think my point is that techniques are best done in the context of what we're talking about, where you are the instrument,

where you are doing your own work. Yes. Where you know some of the areas that maybe will make empathy hard for you to give in certain situations. And like how your own, kind of attachment patterns and transference and, you know, works out in different relationships where then you can know how to be aware of that and have some sort of appreciation for it going on in sessions, but not allow it to be distracting or to guide you miss empathizing or characterizing someone and thus creating narratives for them that didn't exist before. I love that. Yeah. Yeah. I think maybe what I'm just adding, I'm just adding a piece that the knowledge, that the knowledge foundation. So self as a personal instrument doing that work, essential. The knowledge foundation, foundational knowledge about development and about, you know.

Yeah, absolutely. And then, then the techniques. And I appreciate as well learning some basic statistics because, As you read, you need to be able to not be able to be brainwashed. I think... Exactly. Exactly. You know, if you don't understand statistics,

then you can be persuaded by the next charismatic therapist, that their approach is so much better. Whereas I think, you know, modalities maybe make up 15, 20% of outcomes. The therapist, is so much more powerful so that you could be, you know, I think it's very therapist-specific rather than modality-specific. And so the question is, like, well, how do we grow as therapists? That's what I think you're speaking to.

Yeah, it's a really good point. It reminds me of there were the movies, and I bet people could find them online. It was a patient called Gloria, and that was a pseudonym. And I think they were back in the 50s or 60s, but Three famous therapists interviewed the same patient. I think Fritz Perl's was one of them. Carl Rogers was one of them. And there was a cognitive behavioral therapist.

Back? Was it back? I wonder if it was Beck, but I'm not certain it was back. Okay. But anyway, what ended up happening is they were more alike than they were different. In an interesting kind of way. You could see the different approaches and techniques, but they were more

and Hans struck did a lot of work on that. Again, the early work in psychotherapy factors and what are the mutative factors of change. But that just what you're saying, exactly what you're saying, that it's, that the weight of the therapist carried a bulk of the weight in terms of outcome

as opposed to a specific modality. Yeah. I want to also get your sense on how do you approach a patient who is not very aware of their subjective sensations, physical or emotional? Yeah. Yeah. You comment, you have a line in the book that this is quote, literally, you mentioned a client

who literally experienced no subjective sensations, physical or emotional. She learned to deaden her receptors because registering sensations led to hurt. So how might you start to help them feel safe in their body and their experience? You know, it's so interesting we're coming back to what's happening in the room between the two of us because it's watching for the look on their face as they say something. And for example, you know, your eyes just glazed, glazed up. It looks like there were tears. What are you feeling? What do you know? What do you know? noticing. And I'm not looking, you know, emotions are a higher level. I'm talking about even starting

with physical sensations, physical experience, and then emotions are built on top of that. Or your cheeks just flushed or you're quiet just now what's happening in the room. And so it begins with someone who is that deadened. It really begins in the room. And it begins with asking questions, being curious, tracking them, and putting words to that by saying, I just notice that. So there's a lot going on in that moment. They're getting feedback from somebody that something just moved on them. And then that gives, it's like a little bit of a biofeedback thing, you know, because they get

the wording from me and in real time, something just happened. And so they search for what that is inside. Just like in biofeedback, when we learn to regulate our blood pressure, we're hooked up. And maybe there's a program where a balloon goes up or something when we get the right blood pressure. But we don't feel it right away. We can't, this is involuntary. So the feedback of that balloon going up and then going down starts to give us, oh, something has just happened inside of me. What is that thing?

And we start to look and we start to hear and notice. Yeah. So your moment to moment in session curiosity of their physical changes, bodily changes, even if they can't put words like this is an emotion. Yes. That kind of gives you a sense or starts to give them a sense of their subjectivity. Yes. Their experience.

Yeah, very well put. And then you build on that. Like I have an example in the book where wordlessly a patient just lifted her hands when I asked her what's going on. And she's something like this. I said, oh, her fingers, you can't, our listeners can't see me. Her fingers, she lifted her hands, both hands, and her fingers were trembling. And I said, oh, you're trembling inside. And she nodded.

And then she had words for, I'm trembling inside. It's a very intelligent person, but they needed those building blocks of physical movement, physical sensation, wordless showing, me naming. And this is how emotion is built. These are the building blocks of emotional knowledge, emotional awareness. So it sounds like you have like a lot of curiosity, a lot of sort of questions around, you know, what's going to. on in the session. How do you keep, how do you keep from like assuming or jumping to conclusions on what it might mean? Yeah, no, it's a really good question. I think it's really important because, you know, I have a natural curiosity. Probably most people that go into this field have a natural curiosity.

You know, otherwise they'd be doing something different, I think. And there are times where we can be taught that we need that the goal and maybe it's implicitly taught or maybe it's explicitly taught that the goal is to figure out what's going on with the patient and tell them and that's an interpretation and that's sometimes we're taught that that's the best thing that we get to this point where we see the link between the past and the present and we pointed out and they're done You know, we've hit the jackpot. We're actually telling the patient that we're certain that that's what's going on inside their own mind. And I think that's an unhealthy, unhappy way to do psychotherapy.

Because ideally, if we want to change that trajectory, we want to help the patient learn their own mind and become the purveyor and the explorer of their own inner world. And how do we do that? We help them become curious. We ask them questions, and we don't assume we know. Because the minute we assume we know, we're basing that on what we already know. And what we already know is limited. You know, we can develop hypotheses, and I think that's a good word to hold on to,

hypotheses rather than conclusions. And cognitive behavioral therapy is really good about talking about this, and their training at least, is that, you know, you develop hypotheses, about what's going on with your patient. And then you gather evidence. You listen. You know, does this build, you can say, I've said to people, you know, I'm having a thought.

You know, I'm not sure of what you just said was connected to what you're trying to tell me about your dad. I mean, what about that seems right to you? What about that pings? What about that doesn't quite fit? So, see, I'm getting feedback from them about my opinion. but also I'm stimulating them to think and them to feel inside themselves for what is pinging or not. They become discerning receptors to what another person says and does that match what's going on in my mind because we want to help people develop a sense of their own minds.

And if we circle way, way back around to the beginning, and I don't know if the beginning will beyond the podcast, but when you and I were talking about, you know, unprecedented and the pandemic and all of that, one of the things that's going on a lot in this heated up world, heated up emotionally, heated up climate-wise, heated up fear-wise, is that people are gravitating towards someone who says, I've got the answer. And we are all vulnerable to do kind of a mind control. And we just call it that. people have called it cults, but it's a common thing that happens, is that when we're anxious, we look for an answer. Instead of learning how to tolerate the anxiety, so we open up our lens

to many possibilities and then develop our instruments so that we can start to discern about which one fits the facts as we know them. Yeah, I think about that as kind of like our clan-like mentality, which dates back probably tens of thousands of years of genetic hardwiring, right? So we in a time of fear unknown, you know, are looking for that sort of clan-like persona with who's confident. The problem is, is that, you know, back when you were in a clan of 70 people, you would know who that person was, you would have been around them so much that you knew their

character. Nowadays, the people that we trust are the people that we see with the confidence without any context of them in their real life. And so I think we're more easily persuaded to trust someone who's more narcissistic, which is their confidence is larger than their competency, right? It's really well put. Yeah. And they can manufacture. sure that confidence, that confidence, anybody can look charismatic for 15 minutes or an hour. But like, I really liked what you said. What are they looking like in the rest of their life? What's going on behind the closed doors?

Because to know a person, to know their character, we have to see what their integrity is, integrity like integer, whole number. What is the internal consistency, the wholeness of them, across a lot of different circumstances? You know, when you disagree with somebody, how do they respond? Yeah. I also think there's an archetypal, like, wartime clan leader and an archetypal peace time clan leader. Wow. So they're often two very different personalities.

So the wartime leader is a little bit more psychopathic, whereas the peacetime leader is that is more of, like, the high empathy, you know, kind of like high deep. understanding, you know, peacemaker, you know, because when the clan is at war, you need that sort of rallying call, you know, a fearless leader. When you're at a time of peace, you need that person that's bringing the clan together and keeping the clan from fracturing, right? What would you think of rather than psychopathic? What about maybe a little more authoritarian? You know, because it's because there has to be a more singular focus. Well, I think of, when I say psychopathic, I mean, what I mean is someone who is going to have less fear in the face of death. Okay.

So someone who in the face of actual physical battle will be less likely to dissociate. Well, what about a Buddhist monk has very little fear in the face of death? I'm thinking specifically in like a wartime archetypal clan leader is someone who would be more of the Buddhist monk who was also the warrior, right? Yeah, that's what I'm trying to integrate a little bit on those qualities because sometimes people really follow the person who can go in the trenches and lead. Like you say, isn't afraid of death, but also is aware of the. humanity of the people he's leading. So that would be the dark side of the psychopath, right? The dark side of the psychopath is that if they're too psychopathic,

then they will treat humans, even the people that are the closest to them as insects, and they will not care. Okay. And inevitably, that person meets their demise in a clan because that person, like, is not, you know, like in the ape world, for example, they found that the alpha ape is usually spending most of the time grooming other male apes. And so a large portion of their day is massaging, picking bugs out of other male apes, which creates alliances. If the ape is, if the alpha ape, the head ape, is shorter and less big, then they spend even more time grooming

other male apes, right? Okay. Because the male apes are the ones that are going to team up potentially and oust him. And the most dangerous time in a zoo for the alpha ape is when he gets sick and taken out, then a new alpha comes in. Then when he comes back, it's incredibly dangerous for him. There could be two or three, you know, two or three apes versus one always win, usually. Okay.

My point in this is the archetypal wartime league. leader needs to have enough fearlessness. And I think you're right that there are other ways of becoming more fearless, right? To be able to fight, to be able to stand, to be able to be confident. Yes. But what I'm saying is that in our time and age, though, number one, we don't really know who those people are. Yeah. Because it's, we're watching people on screens.

Yes. Rarely interacting with the people themselves. Yes. Yes. And two, the other problem is that someone who is, people are very adept at the appearance of rather than the reality of. So they might have the appearance of success and confidence more than they have, you know, and their interpersonal relationships with friends and family members could be absolutely disastrous. but they could appear to be persuasive, have it together on a...

Well, so it makes me think about with psychotherapy, it goes back to what we're talking about earlier, about how do you, you know, how can, when you're in the room with a patient as a therapist, you don't have a screen to hide behind, and you don't have, you know, you don't have Photoshop, you don't have filters, you don't have sound bites. there's dynamics happening in real time that are unpredictable.

Absolutely. And I think this comes back to like, do we want to become, do we want to improve our ability to be an actual instrument that can create change that's meaningful? Or do we want just the appearance, the facade of it? Exactly. And I don't think the latter works for long-term change. change in a person. You know, if we try to manufacture something, just like your patient said in your

outcome study, I don't think it was an outcome study. It was the study where they came back and reported. And they said, I don't think the person was really understanding me. They could tell the difference. And it wasn't something that they then internalized and embodied in themselves. They didn't let it imprint on them in themselves. Yeah, I think this is a good place to wrap it up. Okay, we're getting a little bit esoteric here.

No, no, I like it. I like it. No, it's, I think to summarize what you were summarizing, which is kind of, I think, the thrust of what we've been talking about is, you know, you could be, you could, you could almost become too lopsided thinking that a specific technique is what is going to make the change. Where I think both, both in your sort of practical understanding and then I think where the data, is it says that actually it's more the therapist who is acting as the instrument, who is not coming from an authoritative place with their clients, but sometimes often a place of not

knowing. Right. And a place where they're allowing the person to explore their own internal experience, where you as the therapist maybe are able to be empathic, warm, genuine without gimmicks, because gimmicks don't work because people can really feel into your true experience. That's right. The relationship is central as long as we don't get lopsided the other way, that it's not just a really caring person, but also their foundation of knowledge about psychological

development, about child development, about how the brain works, how the mind works. They have to have that foundation of knowledge and do the personal work of their own interior. then they will be really the purveyors of techniques. They will know how the techniques can facilitate as opposed to drive the therapy, facilitate the work of change as opposed to somehow driving it magically. Yeah. Yeah.

I definitely think in a culture that is becoming less and less apt to read books, I think we have to resist that in our own professional development and learning the things like you said, child development, not, you know, child development, one of the books I love is Edtronic's book. I don't know if you've read that one. Yes, I love that. It's incredible. Talks about the still-faced experiment, but he goes way beyond it. Yes.

He goes way beyond it. Yeah, he began working with Brazelton back in the day. Yeah. The pediatrician, yeah. Yeah, or Beatrice Beebe. I loved her books. excellent, excellent work and it's empirical work.

It's direct observational work. She was the one who did for my listeners. She videotaped kids and their mothers at four months and then again looked at their attachment at a year and a half and she was able to find correlations

between what was going on at four months and a year and a half. So she sort of bridged attachment back to there's micro moments going on between the mother and the infant early on, which also there's micro moments going on between us and the patients. So there's so much to learn there. Exactly. And if we know that body of knowledge, then we understand better in a deeper, richer way,

what's going on between us and our patients. Yeah. And I think that kind of comes to one of my last questions that we didn't exactly hit on. How do we find meaning in our work when times are tough? And I think sometimes having that body of knowledge has kept meaning for me. that it is these small moments of change. Yes. Yes. And it is, as you say, it's very personal how we find meaning.

You know, for me, there's sort of a, the imagery of light in the darkness, you know, the candles of light is really pervasive for me that no matter how dark the world gets, a candle of light. And if we build those candles of light, I like to bring light into the darkness. I really believe in the transcendence of the human spirit. and if there's something being something noble and good about that and beautiful and that we are capable of the greatest destruction but we're also capable of the greatest creativity and i like to you know i like to you know wage battle on the side of the light you know and and and that just

and that plus my natural curiosity and and i think there's a natural love that we all have and it's So, you know, for me, David, everyone deserves to be heard. And not everyone can be heard. Not everyone has that luxury. But when I commit to a patient, that's what I bring into the sessions, is no matter how a rasple, they may be in that moment, you know, how can I hear them so that something gets heard and healed and soothed? And that's very important.

And that brings meaning to me when it has been a difficult day. Yeah. So there's micro moments of connection, right? You hearing them, them feeling deeply heard. Yes. Which leads to secure attachment. Beatrice's a BB showed that it's the micro moments of the mother mirroring the infant. Infant smiles, mother smiles, infant sad, mother looks concerned.

Those micro moments lead to secure attachment. Your micro moments with your patients are leading to secure attachments as well. Right. And that creates structural change inside of them so that they can go out into the world in a new way. And then that creates better attachments than other people with whom they may interact. So it's sending those ripples out. That's the meaning for me. That's awesome.

Well, thank you so much for coming on. You're very welcome. Really appreciate it. Thank you for the opportunity.