Psychiatry & Psychotherapy Podcast - What is psychodynamic theory?

Episode Date: September 20, 2018

On this week's episode of the podcast, I interviewed Allison Maxwell, a social worker and PhD student of clinical social work. I refer patients to her regularly for psychoanalysis, and she has had a wonderful impact on their mental health journey. What is psychodynamic theory? Psychodynamic therapy is a form of talk therapy where the practitioner work focuses on the patient's emotion, fantasies, dreams, unconscious drives and wishes, early and current life relationships, and the relationship that is forming between the patient and therapist. By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join and discuss this episode with David on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. So welcome back to the podcast. Today I am joined by Allison Maxwell. She is a social worker in progress to get her PhD in clinical social work at the Institute for Clinical Social Work in Chicago. One of the rare schools that give a PhD in kind of more of the psychoanalytic, psychodynamic form of therapy. And she got her MSW at Loma Linda, her BIA, at Los

Sierra, and she's an assistant professor here at the School of Behavioral Health and someone I refer patients to. So there's a kind of a group of therapists, and she's one of them that I really want to get my patients into, especially the patient who is looking for more of deeper work, who's maybe willing to do longer term,

a couple years, maybe in a couple times a week. and she, you know, I send these patients, they're depressed, they're anxious, they're at one place in their life, and then I see them back every like three to four months, and they do a lot better. And so I like to bring on people like Alison Maxwell, who I work with and who are just really good therapists. And so Allison, welcome to the podcast. Thank you. Introduction.

Yeah. And so, Allison, first question is, why in particular did you decide to orient yourself towards more of the psychodynamic theory, the psychoanalytic theory. And maybe what are some of the misconceptions that people have when they hear that? Okay. That's a great question and one that I've thought a lot about. One of the main reasons that I became interested in psychodynamic work is I had a professor in my MSW program, some of you may know of her, Diana Simon.

And she taught a class about psychodynamic. theory. And this is where we kind of dove into what defense mechanisms are, who Freud was, how our patients put things in their unconscious, how patients relate to us, talking about our relationship towards our patients, countertransference, transference, and just I loved this class in comparison to a lot of my other classes, which were good and necessary. This is where I felt really alive and really like, this is the work. This is what I need to know. more about. This is how to really get to the meat of the matter with patients. So I graduated and I went on to become a medical social worker for a couple years. And although I loved that medical environment,

it was more of a launching pad. I had always wanted to be in private practice doing psychotherapy. And I remember calling Diana one night and I said, hey, what was that institute you went to out in Santa Monica about psychoanalytic theory. And she gave me the information. It's in West L.A. And it offers training, ongoing training and ongoing supervision to any kind of mental health professional psychiatrists, MFTs, social workers. And I dove in a little bit more there. I met with people who were psychoanalysts. And I learned what psychoanalysts were. I learned about how we can interpret dreams and use that as part of the work. I read papers from Fairbairn, CoHut, and it just kept growing for me. I thought this is really how I want to practice, and I feel that a lot of patients

go around and they find therapists, they drop out of therapy, they don't know why it didn't connect, they don't know why it didn't work, they're frustrated, and I had always thought, well, you know, maybe they were missing something. Maybe there was something unconscious that wasn't communicated, and the therapist didn't pick up on it because they haven't been trained in it. They're not interested in that. It just wasn't there. So I have found that with my additional training,

that the work that I'm doing with patients has improved tenfold. I mean, I have... With your ongoing training. With my ongoing training, yeah, for sure. I have just noticed a change in the work with patients that I have. And I'm pretty proud of that. It took a lot of kind of grit to go and get this extra training and a lot of courage. And especially since not everyone around me is that interested in it or really endorses it as an evidence-based practice.

And so that's why I appreciate your interest in it. here in the department, I think your patients too are getting an, you know, extra benefit from your knowledge of it. Yeah. So what are, so I think we'll structure this. Maybe we'll talk about some of the misperceptions. And then we'll go into some of the evidence. And then we'll really, and we'll also talk about like what is kind of uniquely psychodynamic therapy. So what are some of the misconceptions about psychodynamic therapy that people have, even therapists. even like psychiatrists. Yeah.

I think there's a misconception that Freud has been debunked, you know, that his theories were outdated, that he was unethical in some ways. You know, he had very personal relationships with some of his patients, and we would call them dual relationships now. But this was a long time ago, and he was figuring things out. I think he was on to something, And I don't think we need to throw the baby away with the bathwater in a sense.

He was discovering that connecting with patients on an empathic level cured them somehow. And he started off early on with like Joseph Brewer. They were trying to treat hysteria. It was seen as a neurological symptom. And Freud was interested in figuring out what was really going on because they couldn't find what was going on medically. so he did hypnosis and kind of unearthed the unconscious and people sort of resolved these conversion disorder symptoms, these strange mutation, being mute or whatever. So I think the misconception is Freud's been debunked.

It doesn't work. There's no evidence to back it up. It takes too long. And it doesn't help patients move forward. You know, it doesn't help them, you know, change those negative thoughts into positive thoughts. Yeah, and I would say a couple things. Hysteria back then, I think, would be translated as borderline personality disorder, somatization disorder, and PTSD all grouped into one sort of clump. So you got to, that's the, that's the type of patient that people were struggling with back then.

He came along in a time where they really didn't know it. what to do with these people. Right. You know, a couple hundred years before, often these people would be killed as witches. These people would be put in asylums. And, you know, there wasn't a lot of warmth or love or care given to these people. And so, you know, he comes into kind of a time in history where, like,

everyone's thinking neurologically about these types of patients. They're thinking, like, okay, what's going on? They're dissecting brains. Sometimes they're finding syphilis. And so they're like, oh, look, there's a brain abnormality, you know? And he kind of, like, has this other approach that comes from, I would say, both his mentors and the depth of reading throughout all of literature on a single topic. Like, if you look at interpretation of dreams, he's quoting Aristotle and Plato and all of these

ancients. Like, he's pulling from all of them, similar to what I think Shakespeare did. to create his plays. Shakespeare didn't create those stories out of his mind. He pulled them from history. He pulled them from all the books. And I think Freud did something similar. If you read the interpretation of dreams, you'll see that in kind of how he's thinking and how he's processing. Yeah. It's really fascinating, actually. I mean, he's kind of pulling from the human condition, what he has seen and what the world has seen for millennia and trying to really make sense of it. Right. Yeah. And I think in the, you know, the past decades we've gotten really into randomized control trials as a way of discovery, as a way of proving things scientifically. But back then, it was much more a case series.

So we're going to look at a couple patients in depth, their stories, see what they have in common, and see if we can draw information from that. Similar to actually really good qualitative studies. So quantitative is more of the data. But in research now, there's a really big sort of move towards the qualitative, which is interesting because that's really what he was trying to do. Yeah, they were narrative studies. They were narrative studies, yeah. Yeah. And, you know, you could look back at some of his work and you could kind of see his own psychology, biasing some of his conclusions.

And you could also see the cultural pushes. But I think if you kind of understand the historical layout and why. he arrived, it kind of can make sense of why he arrived at his conclusions. So let's talk about some of the, some of the aspects of psychodynamic theory that are maybe like when we think of psychodynamic theory now, we think of these things. Yeah. So for example, focus on affect. So affect, I think we understand it in one way is how does your, literally how does your face look? what's your facial affect, but affect is also an emotional state. It's an emotional state that what's in the room. What is your patient's overall affect? What are they bringing to the room?

Is there, are they flat? Are they emotionally flat? So with psychodynamic practice, that is something you would pay close attention to with the patient. What is that, what are you feeling? I think also psychodynamic practice involves a lot of how do I feel in the room with this patient and it's a reflection off of how they're feeling we call that transference and countertransference so there's a very heavy kind of um i think focus on that as well but but focusing on their emotional state focusing on what are they bringing to the room and can i connect to that and try to figure out what that's about so i think that's what i understand focusing the affect being and i think in psychosional dynamic theory, we think that you can have multiple emotions going on at the same time.

Absolutely. Yeah. So you could have emotions of anger and emotions of love in the same memory. Yeah. We might call that jealousy. You could have guilt as well that you feel angry. And so there can be lots of different emotions going on at the same time and they can be conflicting. And that's where I think there's a richness of being able to. sort of disentangle and empathize, like, you know, it would make sense that you would feel

jealous or that you would feel some guilt about feeling this. That would be hard to feel guilt. And so you're, so as someone who's psychodamically oriented, you're focusing on how do I empathize with the distress that's in the room, with the emotion that's in the room, or the distress that comes from having the emotion. Mm-hmm. Mm-hmm. Exactly. And then with the, a good way to think about countertransferences, as you're listening to the person's story, what is the sum total of emotional reaction that you're having? So are you feeling sad now? Right.

Are you feeling angry? And then how do you use that information to help the patient and to connect with the patient? Exactly. So it's not just about like intellectual. intellectually understanding what the person's feeling. It's about how do I create an emotional connection with this person in the midst of them feeling a certain way. Right. And then transference.

So define transference as you see it. So transference is the feelings that a patient will bring in the room towards you. whatever you represent to them, they're going to have a reaction. So let's maybe use an example. So they had, let's say, an abusive, angry father. Sure. And then you remind them of that father. They're coming to see me.

I'm a large human being. So let's say they had an abusive father. And upon seeing me, you know, I'm a large human being. being six five, you know, and something about my body shape and maybe in a male immediately triggers them towards remembering their abusive father. Right. So that's classic transference reaction. Right. Yeah. And I would say it's transference is is more than that though. I kind of, I like it's like the complete reaction. Yeah. The complete reaction the patient has towards you. Yeah.

both from their past and from what you're actually doing, what you're actually doing. Yeah. So if I actually am aloof and distant, you know, then they could have a reaction towards that. Yeah. That is a real reaction. That's not, it's not me pointing out to them, oh, you're having this because of something in your past. No, no, you're distressed that you're having. That would be distressful to experience me as aloof and distant.

Right. That's a good way to put it. It's the complete reaction that the patient's going to have towards their therapist and everything that that therapist encompasses, whether it's part of how you present, it's part of the way it could be your micro expressions, it could be how you dress, how you interact with them. They're going to have a reaction to you as a person. Yeah.

And then I think another unique point is that there is an unconscious process going on. Fantasies. On both ends. I'm going to go there. Okay, go there, yeah. We're all human beings. So just as our patients, we are also human. And we're going to have reactions towards them.

That's called countertransference. Our reaction towards their personhood and what they represent, what they bring to the room, how they treat us, how they interact with us. But unconscious, the unconscious is, it exists in all of us. exists in our patients and it exists in us. And there may be an interplay between our unconscious needs, wants, wishes, and the patients that could sometimes maybe create, I see this when it's not addressed and it's not looked at. And I think this is what happens a lot in therapy with people that aren't thinking this way necessarily that they don't understand why they don't like this patient, why it's not working, or why the patient isn't improving. I think that

there's a lot of this unconscious stuff that hasn't been brought out, hasn't been discussed, and needs to be. And so then there's the question of like, well, how do you access that? It's very uncomfortable. That's why people avoid it. It's very uncomfortable. So you have a story about someone? I do.

I have a story about a patient who I believe that there was a lot of unconscious material going on between both of us that if it didn't get properly addressed, then he would have left treatment and it would have just been a kind of, I think, a bust. And he would have gone on doing what he does to everybody and continuing to have the same issue. So I'll change a couple variables about this person. Let's just say I was, you know, seeing him in my private practice. And he was dealing with a lot of... of issues with women and kind of similar patterns with women, with women, drugs, sex, anger,

rejection, self-destruction pattern starts all over again. And so he comes in, and the very first session, I noticed right away that I feel very uncomfortable, I feel very intimidated. And I think that's what he wanted me to feel. You know, he was wanting me to feel that way. Because what would it mean for me to have, I don't know, authority? And that puts him in a vulnerable position, right? And already I'm thinking this way, okay, he's trying to gain control in the room

because not having control is scary. Okay, you know, I try to put on my analyst hat. And we go on like this for months. And he's very resistant to any kind of interpretations I make about his behavior, about maybe pointing out where he might be vulnerable. He gets very angry when I talk about vulnerability. There was even a session where he lashed out at me verbally, said I was stupid and sounded pathetic because I had addressed that he was missing sessions.

And he said that I was the needy one. him to come in. And I really struggled with this case. And there was actually a moment in our session where he was so intense that I felt like I was about to cry. And he noticed that and said, whoa, are you okay? And I said, actually, no. And I think that's where I said, that's where we were kind of addressing these unconscious situations. And my, I don't, I don't. I, I don't, I, Yeah, let me put it another way so it's a little bit more clear to people maybe who aren't sort of thinking along these lines is instead of just reacting towards this person. Right. Which was very easy to do.

And just being like, God, this guy is such a chauvinist and he's, you know, blah, blah, blah. You start to think along the lines psychodynamically of like, what is the gap that I don't understand? And the meaning of why he's trying to do these little power plays. And if I can sort of reflect upon the meaning of these power plays, you know, like, and why he's so determined on maintaining his sense of power and control, maybe then I can understand psychodynamically, like, what is the deficit that keeps him from connecting with other people outside of this therapy office? Yes.

Because when someone, tries to elevate themselves power-wise with you. It's almost a way of saying, like, we're not equals. And because we're not equals, we're not going to really connect here. Right. And so it's like a little bit of like emotional distance that allows the person to maintain their sense of, I would say like the false projected image of themselves. Sure. Yeah. So it's like that image of themselves that they want other people to believe and they'll fight to keep that image at all costs. At all costs. And so it's like there's the true person that starts to leak through, the imperfect person. And so as you try to address vulnerability

with him, he's like he bristles because he's like the image that I have it under control that I can get any woman that I want is sort of like the machismo, kind of like thing that's allowed him to interact in the world. Yeah. And be safe in the world, maybe. Yeah. Exactly. I think you put it well. And talking about how there's unconscious on both ends, you know, I think dealing with a patient like that was difficult for me because of my own stuff, you know, my own history and my own, even my own going back to my own childhood, you know, where I have to be amenable and I need to not, like, I need to not cause friction in the home. and I need to fix everything, fix everything and avoid conflict.

And there was no way I was going to avoid conflict with this patient because he was pretty aggressive and pretty ready for a fight. And I think any, if I had been thinking about him in a very literal, like, cognitive behavioral way, like let's change these behaviors. I mean, there were problems. There was drinking. There was drugs. there was things that needed to be really addressed that way.

But I didn't think that any of that would get resolved if we hadn't addressed, if we're not going to address the behavior behind them. And so. And it's not like he hadn't tried before. Right. Oh, he had been in therapy several times. Who had had different types of therapies before. Yeah.

That didn't go as deep and didn't like have that relational component, the heavy relational component. And often these people will come in with me and they'll have. read like mind over mood or some CBT stuff and they'll be practicing that stuff. Yeah. With all their might. With all their might. On their own. They'll be doing mood logs on their own.

And then it's just like, but they, but it's the relationship. Right. That I think is very, very healing. Exactly. I think that's the main thing. And with this patient, we, you know, we are not in, we're not practicing anymore. I'm not seeing him any longer. but I think that I made a difference.

I'd like to think that I did because, and it wasn't anything that I said. It wasn't like an intervention. It wasn't like you said, a mood log. It wasn't referring him to an AA meeting. It was in that particular session where he noticed that he deeply hurt me. And he cared. He cared.

He cared. And he went on to profoundly apologize and say that he does this to everyone in his life, everyone that he cares about. And he's sorry. And I think that stuck with him. I think he realized how he affects other people. And it was through our relationship. I was like the springboard, you know.

And I was in consultation about this patient because really struggled with this one. And I just, every week, I'm like, okay, I'm sort of allowing myself to be used in a way that he needs to he needs to work through this with someone. And this relationship, this therapeutic context is a place where we can play this out. So there's what we call enactment in this therapeutic relationship. He would enact a lot of things with me about how he treats people and the way he treated me. And I think once he realized that he's hurtful, that changed. Yeah.

So enactments happen, whether we like it or not. And it's unconscious. We get pulled into these dramas and we take part in some of the patterns of patients' lives that they previously have had. So patients will evoke sort of a similar situation in order to potentially have a different outcome. So it's like if you're not aware that these things can happen, you may get pulled into them and then, you know, give up some of the boundaries that keep us safe as practitioners. you know, enter into dual relationships, allow someone to do something, which we would normally not any,

we would not let any other patient do to us. Right. Or like, so that sort of slight verbal abusiveness that can sort of pop up is to sort of, whoa, what just happened there? Let's take a look at that. I've had a number of patients who start to get passive-aggressive, and it's just like that anger towards me starts to leak out.

And it's like, well, we could just pretend that that didn't happen or we could take a look at that and see what that is. And I think that's so much more fruitful for the patient to, I don't know, be asked to talk about that. Someone noticed and let's talk about it. And it's so fascinating what actually comes up sometimes when you ask about maybe a passive-aggressive comment or something. It could be completely from left field. And often the patient didn't mean to do the passive-aggressive comment. It's not like they're being vindictive on purpose or competitive on purpose.

And so those things start to leak out. And it's like as a practitioner of this method, you may not let those pass. You may look at how maybe it was adaptive for him to have this role. And so I like to think of it as like, and that can reduce the shame enough so that he can really take a look at it if you see it as adaptive. Wow. Okay, there's a lot there. Yes. But I think we need to jump into some of the studies.

Okay. So there are really good studies on short-term psychodynamic psychotherapy, mentalization-based therapy, which is based off of psychodamic principles, transference-focused therapy. And so I think it might be worth talking about these just a little bit. Sure. And why we're not just theoretically coming to these conclusions. but we're basing our conclusions on why we think this is valuable based on science and studies.

Okay. Shall I go for this part? You can lead the way, but I do have a few I could talk about as well. Okay, so, and I'm going to put a link to some of this stuff in the blog that will go with this podcast. So if people are curious about actually looking at this and challenged by it, I'll say, yeah, that's how. when I first heard this stuff and I was like, really? It works that well. I looked at the science and that's how I sort of drew my conclusions.

So one is mentalization-based therapy, which is an offshoot of psychodynamic theory. And it basically is focused on emotion and helping the person, the patient, often with borderline personality disorder, do they accurately mentalize their own experience, their own emotions, goals, desires, dreams, and do they accurately mentalize your emotions, thoughts, beliefs? So in the future, I'll do a whole lecture on or a whole dialogue of mentalization-based therapy. But the studies for this are really powerful, and they follow these people for years.

And these are some of the sickest of sick people, you know, people in and out of psychiatric hospitals, multiple suicide attempts. And after five, in one five-year study, these people, you know, were off of most of their medications. They were no longer going into the psychiatric hospital very frequently. And their mood symptoms were a lot better. They were a lot more functional in life. And in these studies, they look at the effect size.

And the effect size ranges from like one to two in a lot of these studies. So an effect size, and I've talked about this before, but just. for repetition. It's the, if you look at the group that was under treatment compared to the control group, how far did the treatment group move away from the control group? So did they move away one standard deviation? And that would be an effect size of one or two standard deviations. That would be an effect size of two.

So in a lot of these psychodynamic studies, they're finding an effect size of one or more. and short-term psychodynamic psychotherapy as well. That's the Shedler article. Yeah, the Shedler article is, he summarizes this stuff really well. Yeah. And that's probably the one I'm going to link in the blog. But for short-term psychodynamic psychotherapy, once again, affect sizes of like one to, and some long-term psychodynamics therapy,

affects size of 1.8. And so this is very good. you know, the other sort of group that I want to talk about is transference-focused psychotherapy. Because I think this isn't underutilized and under... People don't know the evidence for like dialectical behavioral therapy for borderline personality disorder. But transference-focused therapy has been compared to dialectical behavioral therapy and both had fairly equivalent results. and there's

you know some potential to argue that transference focus therapy got to some more of the core sort of conflicts in the people but both were were fairly efficacious so transference focus therapy is another one of the

psychodynamic therapies that has been manualized enough to do research off of it and had really good outcomes yeah there's actually quite a bit of research and I know we don't have time to get into all of it here, but there's lots of studies available to continue to reinforce

that psychodynamic therapy is evidence-based. There's tons of studies, but I feel it in my own work. I see it work all the time. And it's so just, it's so gratifying, and it's so, I don't know, it's just very meaningful. But there's a lot of studies, the main one being that I think, a new, someone new to this, someone interested in this would be to read about Jonathan Shedler. His whole website is, I guess you'll link it, but his whole website has tons of studies that

link. There's an article called the efficacy of psychodynamic psychotherapy where basically he compares psychodynamic practice to other therapies and down the road patients report a greater sense of wellness, happiness, resolution of symptoms longer term than those who received other types of therapies. And I think, I mean, what more could we want for our patients than that? One of the interesting things is it seems like in most of the studies that are psychodynamic, people continue to get better after the therapy is done. So that's one thing I look at like overall functionality, like is there a deteriorating effect

once the therapy is done? Or do the patients continue to have what I would call first order change? You know, that kind of like, they continue to get better once the therapy is done. And that's one thing that I've seen in the psychodynamic therapy. I think what we do is we rebuild,

in a sense, we rebuild their ego through the relationship. If you could just put it in one way, you know, through having a reparative relationship with a therapist so much, you know, is accomplished. Yeah, and I think the other interesting thing is a lot of the patients turn outwards once they've turned inwards, which is a little bit counterintuitive.

Like you're going to therapy, you're talking about yourself, sometimes for a year or two or longer. And then it's like you see these patients and all of a sudden they turn outwards and they do things to serve humankind, mankind. And that's really powerful. I want to say one thing because it was really struck me. I was talking to one of my consultants, he's an analyst in Chicago, and I was talking about this patient that I have. And I said, I don't know what I'm doing for her. She just comes every week and talks, and I listen. But she's pretty cohesive. I said, but I just don't know what I'm doing. He said, you're giving her a space to grow up.

you're giving her a space to figure out who she is with an empathic mother, not who she is with a critical drug-addicted mother. And I just thought that that was so profound. And I kind of laid off on myself a little bit, like, okay, you don't have to do this. Like, you don't have a magic wand, but she's coming every week because she wants to. And it's not even no much about what I say. It's about she's here for the relationship. And I've seen her grow into a very, like, just a cohesive young woman.

Yeah, and I would say with that also, like, psychodynamic theory, it doesn't end when someone has, you know, no more depression. Right. And I think a lot of people, a lot of therapists are oriented this way. Maybe they don't put the label of psychodynamic on them. But it's really about how do I help this person thrive? thrive in relationships, you know, thrive interpersonally, find meaningful work, all of these things. And people get stuck. I remember I personally did this type of work.

I had a couple different therapists, but the last two were more psychodynamicly oriented. And I feel like there were things keeping me from launching the podcast. stuff like that, you know, launching my own sort of things that I knew I would be good at if I were to do it. And I like had a drive to do, but it's like things were holding me back. Yeah. You know, and so those kind of things like how do you find meaningful work? How do you do things that you know where you're calling, but you feel stuck or maybe inhibited to do for whatever reason? And gosh, I could probably.

Yeah, this is like 10 more podcasts. I could go into like why it was hard to launch. But yeah, but very briefly, it's always been very easy for me to help other people in their sort of agendas. Yeah. Because that's the way things were developmentally to some degree as a younger child. But it's harder for me to do something on my own, out of my own giftedness. Yeah. This is very much your own thing.

Right. Yeah. It's vulnerable too. It's real. Yeah. Putting myself out there, right? Yeah. So, yeah, what about you?

Like, do you have any sort of personal or interpersonal sort of growth that you've seen from yourself in analysis? Sure, yeah, I'll talk a little bit about that. So I had been in therapy with a therapist and, we'll see, locally for about five years. and although it was helpful at times, I often felt the relationship was very, like, she was kind of punitive, and when I wouldn't do her homework assignments, she would get kind of frustrated with me.

Her big thing was, you know, just grow up and, like, just grow up and your problems will be solved. I'm like, uh, okay. You know, I have a lot of, there's things in my family that there's some enmeshment, there's a lot of just things that are complicated, and I am very close to my family. I love them. But it's, there were just, I just felt very stymied and kind of felt like a bad patient. Like I was stupid and there's something fundamentally wrong with me. And eventually, through my program in Chicago, I sort of learned about like how

these analysts were thinking about their patients. And I thought, you know what, I got to do it. I got, I need to see an analyst, someone who's analytically trained, someone who can really get there with me. And I was really scared because I didn't want to fall apart, break down. I didn't want to get into therapy again because it wasn't the best experience for me the first time. There were good things about it, but it wasn't overall what I needed. I didn't get better in a sense. I didn't meet my goals.

And so I started working with a psychoanalyst. He's 88 years old. And I'm like, I tell him all the time, I said, I have no. idea how you're like so old but like you're just a baller um and and i just i think that was so profound for me because i was very close to my grandfather and he died around 88 and i think uh so much positive transfers there exactly i'm like i've got my grandpa back yes yes and um he's trained with like all the old school guys i love that kind of stuff and he we've been meeting twice a week um in person in chicago obviously no i'm not chicago twice a week but we do he he's like

He's so cool. He does Skype with me, you know, or FaceTime or Zoom. And we meet that way, but I've also met him in person many times in Chicago. And I can't really put it to words, but he's just able, he'll say some, he's just, he's been so empathic and he's able to make sense of my mess. You know, I can say this mess in a session. I'm like, I don't even know what I'm getting at here. And he's like, well, and this is like, it gives, it. gives me, for me, it's given me permission just to be myself, which so often I've critical of or has been rejected or has been like, you know, there's a lot of shame about sometimes the way I do things or who I am. And he's just like, well, let's not worry about what we're getting at. You're getting at it. I'm listening. Just keep going. I'm like, wow, that, just that was like, wow, okay, are you sure? Okay. And then sometimes at the end of a session, he'll say, like, I think what you were saying here, you know, you were telling me in all the ways that recently said he said you're telling me all the ways that that you have been vulnerable and fallen

apart and he's like I think what you're really telling me is like what you're afraid of here between you and I was like oh my gosh yes and just having someone who's so just patient and willing to look at things with me I'm very curious about myself and about the interaction with him I know I'm not a typical patient because I have all this training but he's he's willing to go there with me. I feel like I've had such a sense of wellness this year that I really haven't attained in terms of just if you want to get like down to like symptomology, like less anxiety, more confidence in my decision making, more sense, just a better sense of who I am as an adult, as a woman, as not a little girl anymore, these sorts of things that I had to grow. And I really just,

I don't know, it's been really, really profound for me. Yeah, there's a couple things that kind of jump out to me as you share this. One is with your first therapist, there were moments of shame that you experienced in the room that were not attuned to, accounted for, empathized with, seeing. And that's like one thing for the starting sort of resident level type of thing. Like notice when there's shame in the room. And don't be so big to think that you couldn't have caused that. Right.

Totally. So that's the first thing that jumps from my mind. The second thing is with this older man, you have an experience of preemptively thinking that you're going to experience shame from sharing something. Right. And in the midst of that, he is kind, curious, empathic, which allows you to kind of like continue to tell your story. Yeah. It really was profound. It's so small, but not.

I don't, how he just was, yeah. But it's, it's, and, and to, to come to that place, it's not just a bunch of techniques. Like, I don't think you could take, like, a computer and give them all the techniques to be able to do that. And they would, it would be able to do that, you know, with, like, AI in the future. Yeah. There's going to be, like, there's going to be, you know, there's going to be, you know, there's going to be an AI that is, is, is, trained to do all the things that a therapist would do, right? Sure.

But it's not going to do the same thing because you're having a mere neuron experience with this other person as well. Human to human. You are feeling to some degree what his brain is doing and it's not judgmental. And you can't hide that. Like if you are feeling judgmental towards the people you are treating, it will be experienced by them. And you can grow or not grow.

Right. And you can grow and work through that in your own mind and in your own process and through supervision. You can work through that judgmentalness. And then people won't experience that. And you won't experience it as well. And that can be very, that can lead to burnout. That can lead to not enjoying what you do for work. So when I tell the residents, like what is, like, I think one of the best things for burnout is good supervision.

And actually learning to connect with your patients to the point that they will, show up and have gratitude. Yeah. And you will experience that gratitude. Yeah. Yeah, that's great advice. That's true. Wow.

So thank you for sharing that. Any thoughts on my thoughts? On your thoughts about what you shared with? On your thoughts? No. I mean, I think that, you know, I really appreciate what you bring to the psychiatry program here. I think the residents need to hear this kind of stuff. I think bringing Dr. Taran from Pasadena is such a gift.

And I think what you said about how my therapist was just listening with like patience and empathic and like lack of judgment, that maybe was the healing in that moment. Like that was what I needed in that moment. It wasn't an intervention. It wasn't it wasn't just grow up, Allison. Just geez, with your source. stories. You don't make sense in therapy. That's how I always felt with my other therapist. And it's like he could follow my emotional state and just kind of let it be and know like maybe that's just what I need to do

right now is just run on and tell a story. I hear a lot of people say like, my patients are boring. They just talk. I'm like, well, that's what they're supposed to do. And just kind of being aware of like, this is what they need. So just let them do it. And when I hear that from residents or I hear that in my own mind like, okay, what's going on in the session? What's the meaning that I'm not understanding? Where's the distress that I haven't empathized with? Right. And, you know, boredom comes from just not understanding.

But it also comes if the patient is dissociating, you will feel a little bit disconnected as well. Or even sleepy. You'll feel sleepy. You might even fall asleep. Yep. So if they're dissociating, what emotion are they dissociating away from? And how can you reduce the shame so that they can express the emotion they're dissociating right from?

Totally. So there's a lot of things to think about in those moments, in those sort of moments where you're having those countertransferential feelings that can help you sort of ground yourself in the experience. So you can continue to have an empathic ear, have a listening ear. Yeah, I can give a quick example of that, and then we can move on. But this was a really profound moment for me with a patient where every time she would come in, she was only 26. But she had like all these ailments, and she walked very, like a little old lady, and she was, she'd come in with her slippers and her walker.

And in session, she was just so whispery and desperate. And I would start to feel really sleepy to the point where I maybe was. dozing in and out of consciousness, but it was never a dress. And I thought, well, this is, you know, got to be awkward for her, but she never said anything. And eventually I thought, instead of thinking, oh, she's so boring, she's not going to get better, you know, I'm just, I thought, well, maybe this is like a projective identification. Like, she's wanting me to feel what she feels and she can't put it to words. And I thought, I feel kind of dead. Like, this room is just dead. And so one time I said to her, I said, you know, I think, I'm wondering if

she was pretty suicidal. And actually, I said, I wonder if you feel like you're already dead. And she just started crying. And I'm like, there it is. So all the studies in the world, you can read them, but that's it right there. You know, to me, that's the work and that is. Tell me a little bit more about this. So she was crying.

And then what did she say after? I'm just kind of curious. She cried and she said, yeah, I do. I do feel like I'm dead. She just affirmed it. Like the words were the same. She goes, I feel dead. Do you think it helped her to feel felt by you?

Yeah, absolutely. What did that result in, if anything? You know, the next week she seemed a little more alive and awake, and it's like we could talk about the deadness, why she feels dead, why she wants to die, how she enacts this sense of deadness in her life, you know, through kind of like hype, you know, She was in bed a lot.

She didn't reach out or engage with many people. She was convinced she had a deadly, you know, a deadly illness. And there was stuff that went back, you know, sexual trauma, difficult family dynamics. So I think just having her, having that moment kind of allowed her to open up more. And know, like, hey, this is a trusting person. This person gets me. That's a deep thing. No one's ever put that to words.

When someone has had a relational trauma, either the deficit of connection when they needed or the sexual trauma, often I think it's a relational healing that's going to need to take place. Right. And if it doesn't get to that point, they may just be bumping from treatment to treatment. Right. If it never gets there.

They need to get into a relationship with a real person who can hear and understand their distress. Yeah. And that's powerful. So you create a relational sort of emotional epiphany of sorts, which starts to untangle the trauma. Yeah. One of my professors in Chicago said something that always sticks with me.

She said, listen to the music behind the words. So I try to do that always. I think it's a good place to leave it. Yeah. All right. Thank you for coming on. You're welcome. Thanks for having me. In the show notes, I'll have a link to the blog episode and different places to interact with this content if you want and throw up a question and we'll try to answer it.

And yeah, thank you for coming on. Thank you. It's been good. Yeah, thank you.