Existential Psychotherapy Part 2: Freedom

Preston: [00:00:00] I responded to a therapy video on TikTok the other day where I, this person was making a joke, but they're like, how come therapists aren't telling people to go beast mode? You know, I'm actually convinced therapy's fake, because if therapists really cared, they'd be telling me to go beast mode. 

Margaret: You sent a text to me that was like, I feel like you could do something with this.

And I was like, I appreciate your confidence in me, but I couldn't have done it better than your Beast Mode video. 

Preston: Thank you. Yeah. Margaret's just not certified in beast mode therapy yet. 

Margaret: I'm triple certified bitch. Yeah. 

Preston: Sorry. Sorry. I wasn't familiar with your game. How to be patient. Welcome back to How to Be Patient.

We're renewal less. How to and a little more. What is I'm Preston and I'm a psychiatry resident. 

Margaret: Why are you saying Yeah. I'm Margaret. I'm a psychiatry fellow 

Preston: because, because we're doing that intro thing now. Oh, 

Margaret: right. 

Preston: It's, it's our intro. 

Margaret: I did re-listen to that. Shout out that podcast. 

Preston: Yeah. Too scared to 

Margaret: watch.

Too scared. Didn't watch. Still didn't listen. Sorry. Scared 

Preston: for me to listen. So. Really? 

Margaret: So you're [00:01:00] the number one, number one promo fan. 

Preston: Just 

Margaret: non sponsor every episode. 

Preston: I just plugged 

Margaret: them. Okay. We're sorry guys. We're getting back into it. We got like two comments that we're like, I like when you ramble, you guys, I love the banter.

And now we're like, I 

Preston: know. It's just like fanning the plane. It's terrible. So this is the, the second in a series of four, we are talking about existential psychotherapy. Last time we talked about death. So if you're dying to listen to that episode, you can go back a couple once and it's labeled. This one is part two and we'll be talking about freedom 

Margaret: Tell existential episode also because I'm, I'm on the couch.

Preston: Yeah. And I'm at my office. 

Margaret: We're in, 

Preston: yeah, symbolically 

Margaret: we're in existentialism mode. 

Preston: So before we, we get into all like the, uh, dark academia. Exactly. Axioms, which is, it's, I'm in a fashion era. Okay. It's what we've been using. We're gonna do our icebreaker. And one question I had for you, Margaret, is what is a crossroads that you recall?

Coming to recently, and it's okay if it's literally like [00:02:00] Easton Madison or something. 

Margaret: Wait, what is that? Is that a street 

Preston: New York? Like literally, I don't know what streets are in Boston. Okay. Okay. It's like, you know, like Sam Adams Avenue and crab walk or something. Whatever you crab. 

Margaret: Um, I feel a recent crossroads, which shout out Britney Spears Crossroads.

Great movie, Preston. You've never seen it. I'm sure of that. I 

Preston: I was 

Margaret: there. Solidarity. Shout out. Great movie. Um, a crossroads I've recently come to, I think is, I'm trying to think of one that's not boring. Do you have one off the top of your head? Can you go first? Do you know 

one, 

Preston: but boring is good too.

Boring's not 

Margaret: bad. I mean, maybe it's not boring, but like with doing the podcast and doing some other stuff with like, like doing fellowship full-time, but then some other kind of like. Clinical things and social media stuff and like less, like less that part 'cause that's [00:03:00] been happening for the last couple years.

But I came to a crossroads I think in some clinical care in terms of moonlighting versus not, and I'm not totally stopping like moonlighting, which for our nons psychiatrist listing this is like when you go as a doctor, like on the weekend to a hospital or in psychiatry, you go and you're like there for the weekend and you round on everyone and stuff.

And it's a needed role, um, for multiple reasons, but it's like not the way I like to practice psychiatry. And I think the crossroads I've come to and decided on recently is like giving my shifts for moonlighting away in the future because it's just like one of the more burnout inducing things for me.

And while it's really great and I'm glad I have the opportunities to do it. I've been doing it for the last few years and like making it so I'm on call basically like every other weekend or every third weekend. The last couple years. Yeah. And now being in fellowship, it's like the burnout is too much.

And so that crossroads was like [00:04:00] kind of just like, what care do I like to give? And then like, do I need to be like hustling this much to pay off my loans at whatever rate? And the answer, at least the next six months is like, we're gonna give those shifts away to other people who can 

Preston: Gotcha. 

Margaret: Use them and are less burnt out than me.

Preston: So you're, you're weighing both sides, but as of right now, the payoff is greater to you to give away the shifts then to try to hold onto them? Yes. 

Margaret: Yeah. 

Preston: Okay. I see. And this is under the presumption that it's impossible to simultaneously moonlight and not moonlight at the same time you have to do one, 

Margaret: correct?

Yeah. 

Preston: You, you don't have a time Turner. You're not like. Her Mindy Granger or something. That would be cool though. Think about much moonlighting you could do. She 

Margaret: would. A lot of money would Girl Girly was stressed though. She was. She was stressed in that book. 

Preston: Yeah, she's get this thing away from me. Yeah, I'm tired of it.

Margaret: It's like I'm actually crashing out right now. 

Preston: Yeah. 

Margaret: I think it's also like that, like money is good for it and again, it's like a needed role, but like it is something that generates [00:05:00] burnout for me. 'cause it's like not patients who I know and like it's frustrating I think for the patients to, this is not just in psychiatry, but like the weekend in the hospital is a different team often than the people on the weekdays because people on the weekdays need a day off.

But I think it's also kind of clinical for me of just like, this doesn't make me feel like woo-hoo. I love psychiatry. And when I'm burnt out from just being overloaded in other places, it's like that cost is too much for right now. 

Preston: So I, I can't moonlight at my program. Um, it's because I'm a military resident.

Actually. We do have moonlighting though. And, and that's one thing I've noticed from the outside is that a lot of our civilian, um, co-residents that do moonlight say it's more burnout inducing than their regular rotations. Just, it's an interesting phenomenon because they are getting paid better money than they would've otherwise, like doing their 

Margaret: clinical work.

At first it's split at first. It's awesome. Yeah. And then I think I had an attending once say that like at some point the cost becomes too much. Like once you're an attending and like, it becomes just like [00:06:00] not as worth it. And I'm not there obviously yet for attending wise, but I think like I've, I've been just like going at it real hard for two years, for two and a half years, and I'm just like, girl, you gotta chill.

Um, but yeah, that's my crossroads. It's clinical kind of ethical because it's like if that burnout is increasing, do I, how does that get taken out on my other patients who I see during the week? Um, yeah. Then just like life balance. But what about you? What is your, what's your crossroads? 

Preston: Well, yesterday, um, I wasn't sure if I wanted to wear the black shoes with the black belt or the burgundy shoes with the burgundy belt.

So we talked about this a little bit in our, are 

Margaret: you fucking with me right now? 

Preston: No, I'm serious. 

Margaret: Oh, this is your crossroads. Okay. 

Preston: Yeah. Every morning. What do I choose from my outfit? I, well, I mean, I purposely do this a little bit. Like, I think if Margaret gives like a deep answer to the icebreaker, I purposely give like a facetious answer, 

Margaret: then give a deep answer.

Preston: Okay. Um, 

Margaret: I wanna know your deep answer. 

Preston: [00:07:00] Yeah. I guess my crossroads coming up is gonna what fellowship I pick. 

Margaret: Mm-hmm. 

Preston: I like, I like, that's actually probably what's like, wearing on my mind pretty much every day. Like, I'm in the middle of interviewing right now. Fortunately, like all the programs I've interviewed with have been really great.

Um, like I'm enjoying like learning about everyone and it actually makes the decision harder because 

Margaret: mm-hmm. 

Preston: You can't. Have all of them. You can't go to all of them. You can't live in all the ci the cities at once. 

Margaret: So you're like, I only have one rose in my hand. Only only 

Preston: one can be chosen. So I, I guess I'm, it's actually, I haven't crossed this crossroads, like Margaret's already given away her shifts.

This will be probably the next few months where I actually will have to like, kind of confirm my decision. But confronting it is actually forcing me to like turn inward and think about what I actually want my life to look like, whether it's like the climate that I'm living in, the, like opportunities I have.

And it's, it's easier to fantasize. Like I love the coastal cities that [00:08:00] I have family in the Northeast, so I've been like picturing being close to them. But I also like, through content creation, I, and I'm in 

Margaret: the 

Preston: northeast. Yeah. Yeah. And Margaret in the Northeast, 

Margaret: we do podcast in person. We do a studio. 

Preston: But Rob's in la 

Margaret: but 

Preston: Rob's not, I Rob's entire production company in la Yeah.

Everyone's in la 

Margaret: Jason's in la 

Preston: Yeah. Like I, I can't simultaneously do. Fellowship fellow in California and Boston, like, it's impossible. 

Margaret: Mm-hmm. 

Preston: So, yeah. And then so I'm just kind of saying like, well what does Preston want? And I wish I could give you better answers because like, I dunno, right now I want good training.

I want to fulfill my career going forward. I also wanna get to be able to keep doing this podcast. I also wanna be able to work out outside, you know, 

Margaret: crucial. 

Preston: I want a big enough space for not happening in Boston too. Yeah. 

Margaret: Not happening in Boston. 

Preston: Yeah. It's hard. 

Margaret: Yeah. Well, you're in the crossroads, so you're, you're true to your question.

Preston: Mm-hmm. Yeah, that's probably why I was thinking about it. So the, the reason why, um, we're [00:09:00] discussing Crossroads right now is because that's one of the fundamental cruxes of like, kind of the con conundrum of freedom within existential therapy. And, um, to kind of rehash, um, some of these axioms of like, or like existential problems that we face.

There's, um, death or the inevitability of death. There's the problem of, of being free and therefore needing to make decisions, problem of isolation, and the problem of meaninglessness. So this one will be kind of focused on freedom itself. We're gonna take a quick break and when we come back, we are gonna get into more of the nuances about existential dread, how you talk about freedom with your patients.

Mm-hmm. How you pull them back outta the pit of despair and also the alternative theories to those things. We're actually gonna start out with the alternative theories. Oh, okay. When we come back from this break.

Okay. And welcome back freely of your own will. I hope you've come back to join us. [00:10:00] 

Margaret: Maybe you're walking, you're getting your steps in. Shout out to those people in the comments. Maybe you're driving. 

Preston: And, and here's the thing. If, if you are walking right now, you chose to walk and you also chose to listen to this podcast using presumably your free will, and now this episode isn't about.

Whether or not we have free will, we could probably argue about that at Infantum, but it's really about what are the implications of doing therapy with someone with the presumptions about freedom that we have. So before the break, I talked about how there's this kind of existential postulate that we all have free will.

We are, we're freely making our own decisions at any point, which is almost kind of like the assumption of like true agency at all times. But there's a lot of people that would disagree with that, right? Margaret? And I feel like even by me saying that, you can probably think of some counterclaims to that.

What, what comes to mind? 

Margaret: Um, I think, I don't know if it's totally a counterclaim. Obviously there are people on the total end of the spectrum that think that there is no such thing as free will and is more like biologic determinism. [00:11:00] Um, I also think of some of the theology classes i, theology slash philosophy classes I took in college and.

There's this part where there, there's this, um, I'm forgetting the name of it, but it's like this document, I think from the late 1990s that was like what the Lutheran Church and the Catholic church agreed on. And it was a number of things. And one of them was like, when it comes to free will, what can be said of man?

And it's like he doesn't not have, it was like what? They didn't word it like that, but it was like, um, we're not gonna say zero and we're not gonna say a hundred, and that's what we can agree on. And so I feel like I think about that where it's like people's freedom can be limited based on life circumstances and it's also a freedom to what question?

Like I might have a lot of freedom to choose what type of coffee I have in the morning, but not internal or external freedom to choose a different life path that is not available to me monetarily from like a class perspective, from a gender perspective, depending on [00:12:00] what time in human history you live, da, da, da, da.

So sure that's. I think maybe limita besides the opposite, I would say arguments from limitations on freedom. Mm-hmm. 

Preston: Externally. Mm-hmm. So, yeah. So he doesn't not have it. Um, and I think one thing you're, you're kind of bringing up is the kind of social, cultural, political factors that drive human behavior and, and limit their freedom.

Which, um, I guess to even like push that even more to the extreme is kind of the philosophy that all human behavior is like resultant of its environment. Mm-hmm. Like we are like on that extreme of the spectrum. Like we are ultimately resultants of all of our circumstances, both biological and like nurturance social that have brought us to this point.

And if you approach therapy in that way, there are a lot of positives to it. No. And, and, and, and like I'm sounding like, uh, kind of facetious here, but there is a, like almost a dogma in medicine, um, to approach a lot of, [00:13:00] um, patient care like this, that. Um, you know, people are products of their, uh, social environment.

And I, and I think it's a great way to look at population data, but it can be challenging looking at the individual. 

Margaret: I, I do think that's a new kind of trend in medicine. Like, I, I think 20 years ago or 30 years ago, there was maybe more of this, like, people have total autonomy and choice in your patients who are sick are just, they're just not taking your medicines 'cause they're not compliant.

Preston: There's moral failures, right? Yeah, yeah. 

Margaret: But yeah, I agree with you that there is more of that, that way. Now the other way. 

Preston: Yeah, exactly. And, and I think like, this way of thinking is almost an, an antidote to that. So if you could tell a patient, actually, you know, a lot of your upbringing did this to you. A lot of your biology is why you're feeling these things.

This, the depression, the psychosis, that's really validating to someone who's, for the last several decades has been told it's actually all just because you suck and you're, and you've, you're, you're, you're morally derelict. You're spiritually weak and this is why you're the infirm [00:14:00] ultimately, you know.

And then you're like, actually there's other factors at play. It's not all your fault. Like this is very validating, healing and it diffuses a lot of shame around it. And then think it provides much needed compassion. Yeah. That we just kind of, uh, bereft at the time. 

Margaret: It reminds me of what we talked about last week with like the dialectics of like, you are doing the best you can and there's other things impacting you that are making it hard.

And probably where we're going with this is if we have the like second path part of this is, and there are other things that we can have more choice in and try differently. So I'm just, I'm liking that this is going, we have the like concrete clinical DVT, we have this episode and then like soon I think in a couple episodes we have Dr.

Felling on to talk more DBT. So I just, I'm liking how this works together. All 

Preston: it's all coming together. Yeah. And it's funny 'cause this, we're coming from independent places, but we're we're driving the same way. Yeah. So I, I mean, you're, you're throwing out the punchline already of a lot of this episode, which is the [00:15:00] dialectic, you know, I was gonna start with like, you know, behavioralists environmentalists only, and then like the Freedom Agency people, and then someday you'll meet in the middle at DBT.

Um, but, you know, Margaret's seen the light because she's already at DBT 200 and we, we have a DBT therapist coming up, so, so we can power through this. But, um, when, when we're looking at the, like, the positives of that, like one, it provides compassion to, to say you're a product of your environment, but also it helps you find the actual levers that you need to get someone healthy.

Because it doesn't do much good to tell someone with schizophrenia that if they just will themselves hard enough, they're gonna break out of their psychosis. You need medication for psychosis, for psychosis, point blank. You know what I mean? Yeah. And, and I don't think it's helpful to like, view people as like, everyone has free will and agency and yada yada.

And if you just, if you just turn hard enough, if you 

Margaret: just 

Preston: knock it off, stop, you know? 

Margaret: If you just visualize, if you manifest it enough, your dopamine receptors will return to the [00:16:00] naturalistic state. Do not take that of context, 

Preston: Jason. Um, 

Margaret: Jason. So it reminds me of like, this is 'cause we're, I'm on one because they, not literally, but because people were like, we like your little rambles that you guys do.

Mm-hmm. It's just, it's making me think about like, what I see on like, wellness TikTok that doesn't talk about this, but it's like the, like, listen, it comes down to calories in calories out and you're going to the gym or not. And I don't totally disagree with some of those things. Listen, okay. I might be haze informed, but like, um, but it's just interesting to me that if we step into existentialism, it actually gives us a frame to discuss what happens on, about health on the internet.

Preston: Mm-hmm. Yeah. It, it, I find it's gives me a good frame to talk about a lot of things. 

Margaret: Mm-hmm. You 

Preston: know, almost like existing is ever present. 

Margaret: Almost like, it, 

Preston: almost as if 

Margaret: almost like these are eternal themes. 

Preston: So while we have positives to, to telling people their products in the environment, there's always drawbacks, which you, you've probably thought of intuitively.

Um, one [00:17:00] from the start is, is that it can actually reinforce almost like therapeutic nihilism, um, which is what Irvin Yam describes. And I think, um, he sees us as, uh, one of the main drawbacks of some of like Freud's approaches, um, which is essentially that if I'm determined to be like this by my biology or by like my drive to always be, um, pursuing sex, I guess is Freud would, would, uh, frame it then nothing I do matters.

Mm-hmm. Right? If, if I'm a product of my environment, then I don't have power. So, so who cares? And then that in turn encourages an external locus of control. So since nothing I do matters, I'm not responsible, I'm product of my environment. 

Margaret: Mm-hmm. 

Preston: Everyone else must fix me. It's up to you. The doctor to prescribe the right medicines, to advocate for the right policies, to put the right social change in place.

And then ev then all the pieces will fall. 

Margaret: Right. And it's a, it, it promotes kind of like a negative spiral when you think of [00:18:00] around it that it's like, and if I'm not getting better, it's because either I can't ever get better and no one can help me. So I mm-hmm. Suicide makes sense in some ways in that like, nihilistic approach and or mm-hmm.

And or it isolates you by thinking the doctor doesn't care about me. They're making things up. The therapist doesn't care about me. No one cares about me enough to actually help me. Even though they could, they're just not, which is a fundamentally sort of antisocial position. Mm-hmm. Um, both of which those are not particularly healing.

Uh, 

Preston: no 

Margaret: paths to go down. 

Preston: Th they aren't. And um, I think it's really interesting you brought up that it has to do with, um, other people not caring enough about me. Like that's the reason why I'm failing is 'cause other people don't care. Um, and. We'll kind of get into this, this concept of responsibility and, and how the existentialists kind of hypothesize where that leads to kind of pathology and, and, um, um, mal adaptation.

So obviously there's a dialectic here. And so, so if we kind of come back to saying, [00:19:00] okay, well on the other end of the spectrum you do have free will and agency, what, what does that look like and how, how do we approach it? So I, I wanna start out with like a couple postulates from existentialism, which, which the first one is that if we are truly free to make our own choices, we must make decisions, right?

If like, that's the, the ultimate consequence, and then following making decisions, you have to take responsibility for those decisions. Those three things sit in line. And the reason why I'm hammering on all those is that's because that's where a lot of the squirming and like frustration comes from. So the, the responsibility comes with consequences.

And a lot of patients may have, um, or I shouldn't even say patients here, 'cause this is just individuals, like this is every person, honestly. Mm-hmm. We fear consequences. And those consequences [00:20:00] are tied to responsibility. Those, that responsibility is tied decisions. So as you walk back up, then you're like, okay, actually if I give away my freedom, then I won't have to deal with consequences.

Mm-hmm. In the same way. And that's, that's how a lot of people can actually try to avoid responsibility. So like one of the things that, um, Irvin Yam talks about in ex Existentials psychotherapy is this concept of responsibility of avoidance. Mm-hmm. And how there's like a payoff to avoiding responsibility, but it has its own issues.

And there's, there's kind of like two flavors of that. So one of them is through, um, framing things as compulsions. And the other is through kind of the frame as the, the innocent victim. Mm-hmm. Almost. You, you kind of are already like describing that, that innocent victim, um, which is someone who's, um, scorned, they're frustrated by the world, they're wronged by everyone else, and, and they're helpless.

There's nothing they could have done. Whereas the other person says, I have to do [00:21:00] this. You know, he, he talked back to me in the store. I have to punch him. 

Margaret: Mm-hmm. 

Preston: I don't have a choice. I, you know, I gotta, I gotta say what's up. 

Margaret: Yeah. And I'm just thinking about this because I think the countertransference in cases like this that comes up is always really interesting.

Um, but yeah, this kind of like abandonment of any autonomy, whatever, we wanna argue the amount that it is, but the abandonment of any choice that you might have in your life mm-hmm. And, and kind of collapsing into it. Even, even if it's for a very good reason, like Right. Like. There is in the kind of chronic trauma or abuse literature, this sort of the learned helplessness, but also what that actually looks like and kind of chronic depression.

And at the same time, does it help someone to, to collude in them feeling like they have no power over their life? 

Preston: Mm-hmm. Yeah. It, it ultimately, [00:22:00] um, reinforces it, which, which can feel good in the moment, but can be like counterproductive in the long term. Um, and I know like in during the death episode, I kind of mentioned, um, loosely that like a lot of these other existential problems relate back to death and the responsibility or the choices, uh, relates to it in the sense that, you know, um, the ultimate consequence of making decisions is that there are less decisions that you can make.

Margaret: Mm-hmm. 

Preston: If I do something, I can't do those other things. And every decision you makes. Brings you closer to the last decision that you'll ever make. 

Margaret: Hmm. 

Preston: So I guess as, as he heiddeger puts it, um, death is the last opportunity. 

Margaret: Yeah. You know? 

Preston: Yeah. So, so, and, and then we can look at a more, at a more meta stage, right?

Like, if I pick a career, if I choose to be a nurse, I can't be a businessman. I mean, obviously you can change paths, but like each thing I do, I narrow my potential a little bit and, and it's a reminder [00:23:00] that my time is limited. So a lot of this can be actually in some ways linked to death, anxiety that people are afraid of, like that ultimate finality of things.

And in order to avoid the consequences and preserve the illusion of as many choices as possible, they don't make a decision. 

Margaret: Yeah. It's almost this sense of like, it's, it's a sort of like nearsighted or Peter pan syndrome esque kind of thing of if I never cut anything off. Then I can always be this sort of like limitless stem cell.

And then things start to get cut off as you move year after year into not choosing. 

Preston: And there's an irony in that because another one of these, um, the postulates is that it's impossible to not make a decision. So like, you kind of, I guess you're getting into the realm of meta decisions here, making decisions about making decisions, but ultimately choosing to [00:24:00] not decide or choosing to wait.

Those are all active decisions. 

Margaret: Mm-hmm. 

Preston: And I think, um, we can delude ourselves into thinking that we're not actually like doing those things. Like, we're like, we're almost like coaxing ourselves into making a decision while not actually like thinking that we're making a decision. I, I responded to a therapy video on TikTok the other day where I, this person was making a joke, but they're like, how come therapists aren't telling people to go OB mode?

I'm actually convinced therapy's fake because if therapists really cared, they'd be telling me to go beast mode. 

Margaret: Now it was Go Beast mode, which I did. I did take it as a compliment that before you respond to that video, you sent a text to me that was like, I feel like you could do something with this.

And then I was like, I don't know. And then you were like, well, I'll do something with it. And I was like, I appreciate your confidence in me. They Boyer venturing outside of my usual content, but I appre I couldn't have done it better than your Beast Mode video. 

Preston: Oh, thank you. Yeah, she's, Margaret's just not certified in beast mode therapy yet.

Um, 

Margaret: I'm triple certified bitch. 

Preston: Yeah. [00:25:00] Sorry, sorry, I wasn't familiar with your game. Um, ultimately though, um, like people, they want to go to the therapist and then be told, like, choose to have the therapist tell 'em to go beast mode, right? 

Margaret: Yeah. 

Preston: Um, but that's still a decision. It's a decision to say, I hope I want all the advice to come from my therapist and 

Margaret: Right.

Preston: Or, or from anyone else. And, and the problem with that is. The person who's making the decision has the responsibility. So if the therapist tells me to go beast mode, it was the therapist's idea all along. So this is the therapist's responsibility. So if I don't commit to it, 

Margaret: it's still an abdication of responsibility.

Preston: Correct? Yeah, 

Margaret: yeah. 

Preston: Ask soliciting advice. It, it's, it's, you, you said it perfectly. Is it abdication of responsibility? It's way to externalize it. The, um, in the book, they actually, um, Dr. Allen brings up a great example, which was he, he was trying to help a patient, um, with their substance use habit. And he said at one point, I wish you could just [00:26:00] give me the plan to stop using heroin so that if it didn't commit to it, it wasn't my idea.

Margaret: Mm-hmm. 

Preston: He, like, he, I think he had a moment therapy where he like said that out loud and he was like, wow, let's sit with that. You know, like, what a profound revelation. But that patient was actually doing a great job of identifying. There are true, uh, like distress around responsibility and commitment.

Mm-hmm. You know? Yeah. They, because they had, at that point, they had made the decision to get better. They knew they wanted to stop using the substances. 

Margaret: Mm-hmm. 

Preston: But it was the, the responsibility of that decision that they didn't wanna own. And by avoiding that responsibility, they said out loud, I hope the therapist would take that responsibility over.

Margaret: I do think that this is like one of the things that, like health TikTok or like on the, like quote unquote fe feminine side, like the, like skinny talk stuff that happens. I do feel like one of the things that it's speaking to in the culture that people want is like everyone, I now I've talked about like the over sense of control, but it's also speaking to this like [00:27:00] latent part that therapy speak in like the 2010s and, and 2020s now doesn't get to, which is like pushing people to own something of their experience.

And I do think like there's something on like the internet and maybe honestly even, this is not a politics podcast, but like. Maybe even in some of the political side of things, that is people are yearning a little bit to be told that they can take control and change their life, which is tale is old as time, but it's particularly potent lately.

Preston: Yeah, and and it's interesting because people and both wanna be told they have agency and also be told they don't have responsibility. 

Margaret: Yeah. 

Preston: You know, me 

Margaret: too girls. Me 

Preston: too girl. Because it, the implication of a lot of this is that if you have the responsibility and agency to change now 

Margaret: mm-hmm. 

Preston: That means you always have the responsibility or always have the agency to do that.

And with that [00:28:00] comes accepting that to some degree, the reason why you're here at this station in life is also like your fault. And that like, I think broaching this, this concept of responsibility, the patient requires a lot of stabilization first, because otherwise it's like. You know, hey man, like it feels like you're just telling me it's all my fault again.

And then we're right back to the beginning of the podcast with, you know, kind of the tales all this time. The moral failure situation, which 

Margaret: right, 

Preston: is maybe not the intent of it, but like you have to be in the right place to have someone say, you know, this is, this is on you. 

Margaret: Yeah. I feel like you to say 

Preston: it in the right way, 

Margaret: the element and, and this probably can be connected in some ways to like death anxiety, but like the inherent uncertainty that we, you can do as much therapy as you want, you can do as much studying of the current neuroscience as you want.

And where we are in the year 2026 is that we can't know why with like a hundred percent this is why you got here [00:29:00] and whose fault, who pulled the levers, who didn't like we can only guess and like have compassion and then try to work with what we have. And that sucks. Yeah. Because that is like, technically you can never know if it was your fault that your life ended this way, or if it was that person's fault or that your brain biology's fault.

There are certain things we can know, right? But like the fact that we can't solve this big life question of like, why am I here and why is it like this is, you know, the question of generations. 

Preston: Yeah. And, and you have to accept that You can't know. You have to own that. You can't know. 

Margaret: Yeah. In the, in theology we call this the Odyssey, like T-H-E-O-D-I-C-Y, which is the study of the question of why suffering exists.

Preston: Mm-hmm. 

Margaret: And I think that the uncertainty and that part of that is in this as well, when we're like fighting this out clinically in therapy is like, well, why the fuck does this [00:30:00] happen? Like, 

Preston: I, I find the Odyssey is really fascinating. Um, that could be a whole nother like side episode or a Patreon segment.

Um. 

Margaret: We won't figure out suffering in the 

Preston: paycheck. You can't know why. Yes. It's one of our hobbies, you know, for 

Margaret: $8 a month you, you two, we've become evil at this point. 

Preston: The problem of evil will be your bitch after 

Margaret: us. Do you hate suffering? Yeah, we're gonna go bemo. 

Preston: So 

Margaret: sorry Preston, 

Preston: we're, we're talking. No, no apology needed.

We're we're talking a lot about how we're free. Right. But by implication of all individuals being free, it means that other people make all their own decisions. And regardless of whether or not they take responsibility for them, you cannot take responsibility for them, if that makes sense. So, um, that's just like kind of one other postulate we're, and then in a little bit we're gonna kind of get to the sources of pathology and distress for the patient, but I'm kind of like [00:31:00] teasing that a little bit.

The final thing that I wanted to, to kind of bring up. Which is, I guess, a way to bring in this dialectic of being a product of your environment versus not, is kind of the concept of, um, taking ownership for your both voluntary and involuntary, um, phenomenon, I guess is how I'll put it. Mm-hmm. So, um, Irvin, I don't know why I say his name, so familiarly, Dr.

Yalom in this, in the book, he kinda describes his passage where earlier he's going, snor 

Margaret: my, discuss this 

Preston: the big y you know, so he's going snorkeling and I went, snorkeling Costa Rica. It's, it's a really beautiful scene. You, you're down there, you're seeing all the different colors of fish, like the beautiful coral.

There's crabs moving around the, um, there's sea urchins kind of like waving back and forth in the water. Like the, the beams of sunlight are coming down and, and you're, you're struck with this profound feeling. You think, wow, like how [00:32:00] beautiful, how serene that I get to be here. And it's a strong emotion for you, but if you take a second think, you may be the only one who's perceiving that for a lot of those fish.

It's a terrifying environment. They're like, some of those small fish are running from the large fish. You know, the, I don't even know if the urchins are comprehending where they are. They're, they, they're just, they just are, you know, most of them are just like shooting sperm out into the water or filtering for food or doing whatever else.

And, and, and the point is that the phenomenon that you're observing, the it, it's indifferent. It's not that you're discovering it's serene, it's that you are perceiving everything to be serene and you have ownership of that perception of it. Because I could also be like, Ugh, I'm wet. This is gross. My feet are cold.

I don't care about where my 

Margaret: crazy, the earth socks. 

Preston: Yeah. I Where's the cuddle blanket? When I needed it. Oh, when I need 

Margaret: [00:33:00] her, 

Preston: when I needed it most. And the snorkeling thing. So, so, uh, I guess the point of this like little sidebar is that the emotions you feel you have to take ownership of them and that, that it's ultimately your perception of it, whether it be voluntary or not.

And, and I guess the, the, the other analogy I'd use for that is like, if you're responsible for a dog, even if you didn't voluntarily tell your dog to go poop in someone else's yard, you're still responsible for that dog ultimately, uh, the, the dog in you in a way, when you go beast mode, um, 

Margaret: all 

Preston: circle back.

That's, yeah. That's another like postulate that we have to take into. Yeah. Like you're, you're, you're responsible for, for it all. You're responsible for your anger. It may be involuntary, but you're still responsible for it. And so the, the way that they kind of navigate this dialectic is by saying that the involuntary phenomenon is the coefficient of adversity, but mm-hmm.

Still, ultimately, like you [00:34:00] are finding ways to deal with that coefficient of adversity. 

Margaret: Right. And this is like, tell you how we kind of started talking about some of this. Like, you know, it's, it's hard to actually quantify this in real life, but like it, if you talk about, you know, someone giving a hundred dollars to charity and they are a millionaire versus someone giving a hundred dollars to charity.

And Yes, for, for my former or current Catholics or Christians, this is a Bible parable, uh, giving a hundred dollars and they have $300 to their name. Like, there's a different type of capacity. And like I think about people who've been through different traumatizing situations, let's say have they have PTSD.

Their ability to go to their friend's birthday in a group setting when they are trauma. And their PTSD happened in like a group setting, like that singular choice is they have a limited capacity based on their trauma and their internal experiences compared to someone who does not have that trauma. [00:35:00] And so I feel like what this also gets at, or this like adversity coefficient, is somewhat unknowable for person to person.

Mm-hmm. And at the same time, we can probably generally agree that there are things that, there are experiences or other things that like limit people's that change, that adversity coefficient that may limit their theoretical freedom to act or not act. 

Preston: Yeah. I'm snapping. Um, for all that except for the theoretical freedom stays the same.

It's just that no one is making the same decision period. So two or two or three different friends choose to go to a party. Um, they all. We'll never know this, but there are, are all feeling different magnitudes of anxiety and, and therefore the person who's like, oh, it was easy for me. I just chose to go to the party.

Well, you're not experiencing what I'm experiencing. 

Margaret: Mm-hmm. 

Preston: You know, um, there's a, there's an old [00:36:00] joke. It took me forever to like, understand this joke. Okay. So, so basically there's, there's a doctor and a soldier in a foxhole and, uh, it's during World War ii and, and they're talking and the doctor goes, or sorry, the soldier goes, I'm here because, um, I became a soldier and I fear, I feel no fear.

And look at you, doctor. You are like, you're, you're cowering. You know, like clearly, you know, you, you're inferior to me and the doctor goes inferior to you. Like it, I imagine if you were feeling anything, what I was feeling, you would've, you would've run away long ago. 

Margaret: Mm-hmm. 

Preston: And at first I was kinda like, what?

But, but honestly, like. Is the soldier making a harder decision? Is he more courageous if he doesn't actually feel fear? Could you argue that the doctor's more courageous if he's scared out of his mind, but still willing to do that thing? 

And 

Preston: now at 

Margaret: different coefficients of diversity, existential ethics of everyday therapy, because this exact shit comes up implicitly and directly every time you're [00:37:00] doing therapy with someone and doing like something as quote unquote, simple as exposure therapy, right?

Preston: Mm-hmm. 

Margaret: Because there's this, there's a, like, there's this thing that's like, oh, I understand and I'm the expert in you're, but you're the person experiencing it that always underneath it is like this. This sort of push pull of, well, how much fear do they actually fear and can you know it and is telling them to push through it or whatever, like.

That we as therapists can never know. This is, this is like a, like existential crash out episodes. Like technically nothing is knowable. 

Preston: You, you can't know the mountains that other people are climbing. It's impossible. Dunno what 

Margaret: other people are going through 

Preston: and they're all different. Yep. Yeah. And it's so funny, like these, these con conversations feel so complex and nuanced and then it comes back to you don't know someone else's life.

What, what my says? 

Margaret: Yeah. 

Preston: So, uh, be nice 

Margaret: everyone, because you dunno what battles they're fighting. 

Preston: Yeah. We're all on different battles, honey. We are gonna take a quick break [00:38:00] and when we come back we're gonna talk about how these, and we've already kind tease them, but how these conundrums actually lead to specific sources of distress for the patient.

And then how you can actually talk to them without just sending them into an existential crash out.

And we are back to talk about how to fix everything. For, but first respons, toran respons to tri trance. So, um, with the responsibility problem, and when talk, we talked about responsibility avoidance. Um, the theories that the pathology, the psychopathology comes from, not necessarily just avoiding responsibility, but actually the misappropriation of responsibility.

So if I take something that is my responsibility and put on someone else that causes distress and pathology, but also if I take someone else's responsibility and put on me, that causes distress. So, [00:39:00] um, like, like that pa that like hypothetical patient you were talking about earlier, who they're mad at their doctor because they're like, no one cares enough to help me.

No one's doing anything to change me all. This is terrible. It makes you like indignant, you're angry and, and you don't actually move anywhere to solving anything. I actually, I have a, I have a personal anecdote about this. So first I'd like to say, Trevor, I love you, but this snowboarding story is great.

So we're going to Japan. The last thing I wanna do is lug my snowboard through the Tokyo subway. It's a terrible experience. I don't recommend it to anyone who's thinking about trying it. I did it one time. I never wanted to do it again. I go, okay, I'm just gonna rent when we get there. Trevor says, actually, I think you should, um, like buy a powder board because we're being doing some backcountry stuff.

We're moving around resorts. It's gonna be really challenging to rent. I don't think it's gonna be possible. Okay, you know, this sounds exciting. I'll, I'll fork over $500. I'll buy the board board. And I go, we show up. [00:40:00] I'm in, I'm in the Tokyo subway with my snowboard and everything 'cause we're going back country and doing all this stuff.

And then Trevor meets me there like we meet at the subway and I'm like, oh, great to see you Trevor. Wait, where's your board? And he goes, oh, I decided I'm gonna rent. And I was like, ah, like, and then, and then like, if this was a show, it's like cut to the next scene and we're packed like sardines during rush hour at like Shinjuku station.

And I'm like hugging the board. I'm sweating on it. I'm trying to keep my luggage from like, driving around. And then Trevor's just like sitting like next to his luggage, just like chilling on his phone. There, there were other issues, like my sim card wasn't working. I'm, I, you know, Japan had me bricked outta my phone and Trevor's, Trevor's like on Instagram reels.

And so 

Margaret: he's like, fuck you dude. 

Preston: Yeah, no, I'm fuming. I'm fuming. And then, and then I thought, wait, like, I'm like, I'm listening to existential therapy on audiobook. And I said, I am not a helpless victim, you know? 'cause at first [00:41:00] I was like, you gave me bad advice. You didn't even tell me we were gonna do this.

Like, I bought this board and then now we're here. And then I was like, wait, we're 

Margaret: board buddies. So funny. 

Preston: Yeah. Yeah. And then I, I, I, I had, I had to go back through it and I said, wait a second. I didn't do a lot of planning for this trip. I've made it very clear. I'm busy in residency. I have a lot of stuff going on, so I'll defer to them to do the trip planning.

I have to take responsibility for that decision. Had I been more involved in the trip, I might've been like more prescient about whether or not it was be feasible for renting, but I had to go off of Trevor's word, right? Trevor's doing all this planning and probably at some point decided it was better to rent actually, and then maybe never relate it to me or forgot about it.

I also have to take responsibility for the fact that I bought the board because I chose, I made the decision to listen to Trevor's advice. Trevor could have said all that stuff, and I could have said, screw you. I'm renting anyways. Right? But I have to take responsibility for that choice. I also have to take responsibility for the fact that I chose to carry my snowboard.

On the subway [00:42:00] station when I could have left it at the, um, like the baggage drop off. And I'm, I'm changing some things about the story, so if, if Trevor, you're hearing this, like I know it's not perfectly factual. 

Margaret: Trevor enemy of the pod, just kidding. Trevor, let me use that gym for free one time in la.

Shout out Trevor. 

Preston: Yeah. Equinox. Yeah. It was awesome. So, so anyways, actually as I'm like recounting all these things and I'm like taking responsibility for each one, I started feeling better. It was so interesting. It was like I was doing therapy on myself in real time. Like all of a sudden as I'm like taking responsibility for each of my decisions, I felt less indignant.

I felt less like a victim and I actually gave me more empathy for Trevor. 

Margaret: Mm-hmm. 

Preston: And, and then all of a sudden, like what could have been like a crash out and like a, a fight waiting to happen, I was kind of like, you know, now we're going forward. You know, and 

Margaret: I love it. 

Preston: I think that's like probably the best hypothetical situation to, to say like, okay, 

Margaret: and great 

Preston: interpersonal effectiveness skills, I'm emotions in the air.

Yeah. How do [00:43:00] we allot responsibility every which way, right? 

Margaret: Mm-hmm. 

Preston: Because like, I, I can't take responsibility for Trevor's decisions and he can't take responsibility for mine. Another one that's really common, um, and I think you'll see this with parents a lot, is wanting or hoping to take responsibility for their kids' decisions.

So the kids' actions, and that causes parents a lot of distress. And it's almost like you have to get them to the point of, of letting go and saying, you're only responsible for what you can do, and you can't make every decision for them. So you, you can kind of see, I guess I won't go into the nuances of that one, but if putting responsibility in the wrong buckets is where the distress comes from, and then you as the therapist help resort them into the right buckets.

Mm-hmm. And almost in just the act of doing that, there's a feeling of catharsis. 

Margaret: Yeah. I was thinking earlier in the episode we were talking about this, that like [00:44:00] exactly what you're saying, that the issue I end up feel like I work with patients on the most is not that they're on either end of this like theoretical spectrum, but that they're things that they're really attached to or fixated to or have had experience being told and socialized to think that they're responsible for.

And then the things that they are, can actually impact and can take responsibility for are like totally being ignored. Um 

Preston: mm-hmm. 

Margaret: Or the like helplessness that they feel and the fact that they can't make x, y, or Z thing happen over here where they're taking a lot of, trying to exert responsibility is then transferred laterally to things that's like, well you, you, you could, you know, I think about like working with families like, well, no, you can't make them your, your kid feel the right feelings or feel not depressed anymore, but like you can help them.

Get to therapy every week or something like mm-hmm. There are things in it. It also reminds me of the Serenity Prayer, which I think has been mentioned, we've mentioned before [00:45:00] in this podcast. Yeah. So like, help me accept the things. Help me accept the things I cannot change, the courage to change the things I can, the wisdom to know the difference, that wisdom to know the difference piece is kicks our assses, this human.

Preston: Yeah. And, and that's where the, like the insights of the therapists come in and actually where your well timed and well thought out reflections can actually have like therapeutic, like potency in them. Like just those observations themselves, helping people direct 'em to their responsibilities. Um, the, the next place, uh, that pathology kind of manifests in this concept of freedom is existential guilt.

Hmm. And I think it's something we all kind of know intuitively, but it's defined here as. Guilt about the gap between who you perceive yourself to be and who you want to be. The feeling of I could be doing more, or that I'm guilty ultimately because I'm wasting my freedom. I [00:46:00] have the capability of doing more than I'm, 

Margaret: yeah.

That, that really gets optimization talk every single time. That's it's kicking their ass, 

Preston: dude. There is an entire, like, industry of bros and Siliconed Valley that are just losing to this question, um, right here. And, and no amount of soil in the world is gonna, is gonna help them. 

Margaret: You hear that Soy boy. 

Preston: But so the, I guess, um, Dr.

Yam like frames this as both a positive and a negative. So existential guilt causes a lot of distress for people. But it can be a positive driver of change because, 'cause also with it comes the knowledge that you could be more Right? That, that, that's hope. It's something that you can kind of harness to help direct people.

And the, the antidote to existential guilt is through using your freedom to make decisions, but you also have to know where [00:47:00] you want to budget that freedom and where you want to spend your decisions, like what direction to, to bring this ship. It's, it can be almost like a, a vacuum and open space. If you're like, I could be more, but I have no idea what more thing I want to be.

Margaret: Mm-hmm. 

Preston: So the antidote to this distress and along with making decisions, is to have a wish. That's, that's the core of it. All that exist, that existentialists, uh, propose. It's have a wish. The wish is. Whatever you want to have in your life. So, um, Dr. Strom, my program, Dr. Shout out. Dr. Strom shout Will, like, talk to us about this a lot.

Where, you know, he's, he's like residents. We always, y'all always struggle between wanting freedom and wanting nurturance. You know, I want all the responsibilities of the attending clocked, but I don't want out. I don't, but I don't want all the liability, you know? Um, I want to be [00:48:00] able to, I want the respon, I want the freedom to not have to sign into didactics, but then I don't do it.

And now, you know, we have to bring back the sign in sheets. Real thing happened at a program. Perfect. For example, 

Margaret: a program nationwide probably issue 

Preston: nationwide problem residents not showing up enough to didactics. 

Margaret: Our curriculum sucks. Girl, you weren't even there. 

Preston: How do you know? 

Margaret: Question me?

Preston: Yeah. So. So he say, so then he'll say to us, I would hope you guys are all solving this issue by applying the wish that you hope to someday be a great psychiatrist. So you give up some of your freedom to sit in those chairs at didactics, pushing you closer to your wish of one day, uh, like being that great doctor that you want be.

Mm-hmm. So the, the wish ultimately, it doesn't necessarily matter exactly what it is, but it has to matter to the patient. It has matter to the individual. 

Margaret: It offers like a directionality, [00:49:00] 

Preston: right? Precisely. And, and like once the wish is there, everything else that kind of starts to fall into place because then your decisions start to make sense.

Because at first you have this kind of, the wishlist person may have decision paralysis because what, what direction do I go in? Every decision I make has an opportunity cost. It cuts down more decisions, it puts me closer to death. But I don't actually know where I want to go. But if I take time to think about that wish, then then.

I can start moving somewhere and that mm-hmm. Gives you catharsis. 

Margaret: It makes me think more generally about, like nihilism as well as, um, some of Victor's Frankel Frankl's work in man's search for meaning that like having the internal ability to have a place you're moving towards, or a value you're moving towards, or a more concrete thing than a value that, that directionality offers.

The sense of [00:50:00] being kind of in a narrative arc and like really being in a narrative arc that you are aiming for something and, and hoping for something and pitching yourself forward rather than sinking into the abyss. 

Preston: It's funny you should say that, um, it also makes me think of the, the book Bullshit Jobs we were Reading.

Margaret: Mm-hmm. 

Preston: Where for, for those who haven't read Bullshit Jobs highly recommended, it's a great book, but. That's actually done. 

Margaret: So this, I listened to it when I was burned out and then I asked Glaucomflecken, our executive producer, shout out Dr. Glaucomflecken. I was like, after seeing some of his insurance stuff, like, have you read the book Bullshit Jobs?

It's not about medicine, but 

Preston: Yeah. Yeah. It's, it's by a, a professor from the London School of Economics, and he talks a lot about how being in a meaningless job is actually like severely psychologically damaging. And I think a lot of that ties into this concept of wish [00:51:00] and the feeling that you, you don't contribute any purpose.

And then there's, there's no inherent wish baked into it. And actually it's the antidote of, it's, it's, it's insulting then you're, you're doing nothing. And I guess when we think about a wishlist patient, we, we think about a patient or an individual who has no wish, but the o there's actually a kind of a foil to that to think about, which is the.

Individual who tries to do everything. So that, that in and of itself can also be, I guess, a sign that someone, um, is having trouble constructing a wish. 

Margaret: Mm-hmm. 

Preston: Because I'm, I'm just gonna keep doing a little bit of everything. I'm keep doing something else. But, but when you're trying to go in every direction, you're also not really going in a direction.

Mm-hmm. 

Margaret: So 

Preston: it can lead you to the same existential dread, existential guilt, and like kind of pit of meaninglessness that we described for the wishlist person. 

Margaret: Yeah. It makes me think of, and this is a different side of TikTok, but the like thought dot or [00:52:00] side of TikTok, which is the like intellectual women in their twenties.

My beloveds, who I think are like probably 90% of my following. Um, and it's how the fig metaphor from Sylvia Plath kicks their ass the same way that optimization, and it's, the idea is, is this part of the bell jar by Sylvia Plath that is like, I imagine my life. I'm gonna misquote it, but it's like I imagine my life branching out in front of me and every hope to be like a poet or a painter or this, that, or da da da da was like a fig on the tree.

And I sat in the middle of the tree and I watched them rotting and falling off and I never could move because I didn't know which one to move towards. And that kicks their ass to which I always now re asked them, what if it's like a bell pepper, where it's like you pick one thing and you pick the bell pepper and then you open the bell pepper and oh my gosh, there's another little bell pepper growing inside the original bell pepper you chose and it's not, you're sitting with your rotted face because mm-hmm.

That metaphor's not hand. If you look at hashtag big [00:53:00] tree metaphor, you are gonna see. Girly pop depression up and down. It's a bad, but like to your point of not choosing 

Preston: and, and, and like we mentioned earlier, it's, it's iron, it's ironic because you are choosing, you're choosing to not choose. Um, so, so there's, there's no avoiding that, that responsibility of wish.

And in a way you have to take responsibility for not having a wish, like you are choosing to, to not contrive or pursue a wish. Um, it took me way too long to realize the spelling of thought daughter side of TikTok. I, my brain to the gay son thought daughter thing. 

Margaret: Well, they switched and I was like, they switched back and forth.

Preston: Okay. Okay. Gotcha. 

Margaret: It's like, that's part of the joke is like, daughter, 

Preston: daughter getting acids kicked by the fig metaphor. I see. 

Margaret: They're, they're both, they're getting their asses kicked them in their 10 milligrams of Lexapro getting their ass kicked. And I love you guys. Okay. I'm one of you. But they're getting their [00:54:00] asses kicked.

Preston: I guess so funny to think about like each problem of existentialism we're going through and how there's like a great case study of a subgroup of people on TikTok that is absolutely getting owned by this problem.

Margaret: Exactly. We love case studies here in this 

Preston: podcast, and I mean even, and for the wishlist crowd, I'm one of you two guys, but I'm the second kind. I'm the kind that can't decide on a wish. I'm playing harmonica, I'm doing ventriloquism. I I'm coffee bro. Question mark. Now he's also doing fashion. Okay. Who asked for that?

Yeah. Don't even mention the marathon training like this. All screams of crisis. This is wishlist behavior that that is being displayed here. I'm just saying, you know, let he who is sin, throw the, and like let he who does not have a wish comment on my wish, you know? [00:55:00] So we're just saying none of us are perfect here.

Margaret: Let let the fake daughters and the wishlist sons congregate in this podcast.

Preston: So we, we've talked about a, a couple anecdotes here. So you can help your patient have a wish, you can give them insights into placing their responsibility in the proper buckets. And then, then kind of the last thing, and this is more I guess like a subtle technique, but is using your language to help reinforce the ideas of agency.

So I've tried this a couple times in therapy. I'm not sure how successful it is, but it's been a fun experiment and it's using the kind of the, I can't button. It's little things like zeroing in on someone's language where, you know, I could tell you right now, I would love to go tonight to your party, but I just, I can't make it.

I've got kids to take, take care of. Oh, and then you could reflect back. You're choosing to take care of your kids instead of coming to the party. It's not harsh. It's not saying that's a decision you're making, but it's, it's [00:56:00] reflecting the same words back to them, but swapping the one word for lack of agency.

With agency. 

Margaret: Yeah. And it's not harsh, but it is, I think in a really good, important way that good therapy does, depending on the setting, like slightly confronting. 

Preston: Mm-hmm. 

Margaret: And, and I don't mean that in a negative connotation, but it's like, like you're saying, taking it from passive to, oh, so you're choosing to do that and maybe they hear that and say, yeah, I'm a good parent.

I'm like choosing this, whatever. Maybe they hear it though and they're like, well, no, I'm not. I mean, I can't, I don't have any other choice but to choose it. Like, this is what I have to do to be a good parent or be a good whatever. I don't get to blah, blah, blah. And then you get to dig into that with that.

Preston: Yeah. Yeah. Exactly. The, the other thing you can do is you can affirm and reinforce choices that the patient makes that aren't even discussed very often patients come to therapy with a decision that they're struggling. Then they may not, maybe don't make a lot of progress on that decision. But you can say other things like you're still choosing to come [00:57:00] every time.

I think that's a powerful thing. You care a lot about getting better and you choose to sit here and do the work with me so you can reveal to the patients the active decisions that they are making. 'cause everyone is making active decisions all the time. And help kind of show them like you do have agency, you've actually already, you've had agency.

See, like, look, look at all the great work you've done. 

Margaret: You've had it the whole time. Surprised. 

Preston: Yeah. And, and the other thing too that you can do, and, and I'm, this is probably one of my favorite parts of therapy, does not happen too often. Um, maybe I wish it happened more often, but, but like, if a patient really gets better and says, I owe so much to you.

Like you, like I'm doing so much better. And it's all because of you. That's the perfect moment as a therapist to say it was actually all you. You made all the choices, you did all the work. I was just here to watch you. And, and it feels good. And it's nice to say when [00:58:00] things are positive, and unfortunately, like some of that can be true.

When it's a negative outcome, the patient stops showing up, they don't get better. Those are also products of the patient's decision. And we almost have this desire as therapists to take responsibility, both for the positive and negative. We wanna take responsibility when our patients get way better because we're so good and smart and insightful, and we did everything.

And we also wanna take responsibility when things don't go well. But like at the beginning of the episode, we are subjecting ourselves to that same pathology of misplacing the responsibility, and then we're dealing with our own existential dread and, and then leading to burnout and other things. 

Margaret: Yeah, it's, I'm just, I'm just lingering on this idea of like, when someone says to you, it's like, thank you for doing this and, or whatever, like, and then saying like, you did it, but also the feeling that that can sometimes be like.

It can make patients feel like they're not, like, I feel like it depends on if a patient, and you're not saying this, this is me abstractly thinking about this. Like, is [00:59:00] this a patient who I know is someone who never takes, you know, they never take the trophy for their accomplishments. And in that case, how much do I focus my response to 'em on them taking the trophy of like, they did this work versus is this a patient who feels like they have to be super self-sufficient and no one ever helps them and they like dah, dah, dah, dah.

And me saying like, you actually did it, but I, or saying something instead, like, I'm really glad we could do this together, might be important. You know what I mean? Which is like not, yeah, I don't say that. I realize as I say that that might be annoying and I am not critiquing your response to it, but it's just making me think of the different types of patients of like, what does it mean when someone says to us.

You did this, which is somewhat out of this topic of this episode, but 

Preston: Well, and, and it's both, obviously. Mm-hmm. So, and it's just what we're choosing to reflect back to the patient. 

Margaret: Yeah. 

Preston: I, if the patient gets better after months of therapy with me, I would [01:00:00] hope I did something. You know, it feels nice to be like it was all you, but maybe like, maybe there was a we in there.

It's just that I choose to reflect back to the patient, like, this is your agency. And like, almost, almost as like a, you have agency and on your way out the door, like it's all you, you can do everything. That's, that's I guess kind of like my approach to that. Um, and then the, the last part and, and we mentioned this maybe a little bit, is the idea of like all of your decisions having payoffs.

So, and this I think, borrows a lot from like, kind of the psychodynamic, um, school of thought, which is that every decision conscious or unconscious has some sort of payoff for you, and that that payoff like has a benefit. So, so it's really operating under this assumption that. No one does something to purely sabotage themselves.

There's some secret payoff somewhere. 

Margaret: Right? 

Preston: And as the therapist who's trying to help the patient to take responsibility, understand their decisions, recognize their freedom and their agency, [01:01:00] you can help them recognize the payoffs for the different things that they're doing. And that can even come in the reflection of, you know, there's, there's obviously a payoff for you by not, um, you know, cleaning your room in the morning or something, even though your mom wants to do it.

There's, there's a payoff to it. Yeah. You know, 'cause, 'cause from the outside he'd be like, why would you not clean your room? You're clearly just sabotaging yourself. You're gonna, you're gonna piss your mom off. You know, you're gonna have a dirty room. Like there's literally no benefit to this. But there's a payoff somewhere in there.

And, and the payoff might be that you get to feel cozy a little bit longer in your cozy earth cuddle blanket. It all comes. I'm just kidding. 

Margaret: Yeah, no, I mean, I, the way I like to pose this to patients is often I'll say something like. I think that what we know from research, but also in general is I think most people have a sense of a certain wisdom and they don't, no one does something for no reason.

I wonder what makes this sometimes the option, even though on the surface it feels like it wouldn't be helping you. Like [01:02:00] sometimes this is the better option of getting out of bed. What do you, if you had to guess, what do you think would make it the better option? 

Preston: And, and you frame it as, I could just be making this all up in my head.

I'm an idiot. I come up with ideas, but I had this idea, I wouldn't go 

Margaret: that far. 

Preston: That, that there might be a payoff to you staying in bed. 

Margaret: Say, just say 

Preston: that might be possible. 

Margaret: I wonder what makes it easier? Because payoff is a connotative word. This is where you, you guys, you have two therapists disagree with each other.

Uh, about like, what I would word it this way. Um, but yes. Yeah, I agree. 

Preston: And then, and the thing is, you know. Like our, our like differences in style may work better with one person or another person. 

Margaret: True. 

Preston: And you have the freedom to decide isn't that beautiful? 

Margaret: We have the freedom to decide. 

Preston: We all can decide.

Um, so this is kind of like the main, most of the content I had for the main part. We're actually gonna transition into the Patreon section. 

Margaret: Are we gonna Blue Skidoo? I we can tune into Patreon. Yeah, 

Preston: we [01:03:00] are. And, and we're gonna tease it a little bit, which is, um, so some people had other different strategies for helping patients realize their freedom, realize their wishes, and like take back agency, one of those therapists is Fritz Pearls.

And he thought you could, what a name. Do it by. Yeah. Eliciting affect affectual, uh, like evocation is essentially what he did. 

Margaret: This is gonna be, 

Preston: and I 

Margaret: don't like this 

Preston: and this exactly how it sounds. It, it, it, it almost looks like nagging the person and like, I'm rage kissing them off. Rage. And then No, no, I'm serious.

It's like I'm gonna rage you and then now that you have affect, let's talk about it and then, and then that affect is gonna tell us everything. So the whole point of gestalt therapy is gonna do everything in the moment. It's really like, it's performative. It's it's banter, it's back and forth. I was gonna try to do Gest gestalt therapy with Margaret, but for the sake of our relationship, you're not gonna raise, we're just, I'm not gonna like rage you on a podcast.

May maybe, yeah. Maybe if he had a super [01:04:00] patriot or 

Margaret: something me that before and he doesn't wanna see 

Preston: Exactly. I'm choosing, I'm choosing to have us, I'm 

Margaret: using my 

Preston: freedom. Watch this video and react to instead. So, so if you did wanna see us, like do the Fritz Pearls thing, um, like come over and check it out on the Patreon.

Um, but outside of that, yeah. We'll, we'll be back soon with the end. 

Margaret: You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy Patient Pod. 

Margaret: So we solve the problem of world suffering. 

Preston: Yeah. Fritz Pearl. 

Margaret: And 

Preston: you'd 

Margaret: use your freedom 

Preston: Smoking a c serious subscribed 

Margaret: Patreon. 

Preston: I'm kidding. Okay. And, and that's okay.

You know, I, I hope, I hope you, you made a good use of that time and it puts you closer to your wish. So, um, that's all we have for today. Stay tuned for when we go into part three of the existential therapy series. That one is gonna be on isolation and it's, it's lonely for us over there, so, so come listen, 

Margaret: it's lonely.

Preston: How's the show? We, we enjoy getting existential [01:05:00] with y'all. Do y'all like getting existential with us? If you want to come chat with us, tell us about it. Um, you can always come to the Human Content Podcast family. You can find us on Instagram at TikTok at Human Content Pods. Here's the How Business Spotify 

Margaret: comments, 

Preston: Instagram, Spotify comments are, that's, that's where we live and die.

Really be in there. You know, 

Margaret: we be in the Spotify comments, as I said last week, I think verbatim. 

Preston: If you don't want to find us in the Spotify comments, I'm at it's pre row on Instagram and YouTube, which is where we also have the podcast episodes and the video. I'm also pre row on TikTok. You can find Margaret at badar every day on Instagram.

TikTok Substack, thank you again to all of the commenters. On Spotify. We're gonna read out some of them right now because you, y'all are the best. So, Lillian, she said I would love more info on the political climate. This is in response to our, um, policy video. It's so overwhelming to keep up, but I also know it's important to stay informed.

I also love the casual conversations and tangents. I know you had [01:06:00] feedback asking for more structure, but devils advocate, en raging, A DHD, are here. I love a buddy trail and I'm just listening to you guys go off script for a bit. Never fails to make me laugh. Thank you, Lillian makes us laugh too. 

Margaret: We love.

Preston: And then, uh, this tension 

Margaret: span. 

Preston: Ryan Hutchinson said, great episode, and thank you for highlighting important conversation. Also, you guys crack me up. I'm outwardly giggling as I do my beach walks in solidarity with Margaret, of course 

Margaret: steps. 

Preston: Chase that wish. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan.

Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aron Korney, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Zo. Our music is Bio Mayor Ben V. To learn more about our program, disclaimer and ethics policies and mission verification, licensing terms, and our HIPAA release terms.

Go to had we patient pod.com or reach out to us at had We patient@humancontent.com with any questions or concerns. Had to be patient is a human content production.[01:07:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:08:00] background.