Freud Enters the Chat: Psychodynamic Therapy

Margaret: [00:00:00] We're gonna do five minutes of you trying to get to know this character, and then we will do formulation on five minutes for fun. 

Preston: Well, is this Sarah, Jess, Jessica Parker's character for Chance. Okay. I, nothing about sex in the City. I'll just Fiction. 

Margaret: That's good, that's good. How to be,

Preston, how are you feeling today? 

Preston: I, I'm good. I'm just a mere passenger in this one. I'm, I'm, I'm post-call. I'm, I'm a little bit sluggish, but Margaret promised that she would be the captain of the shit. Today 

Margaret: I am the captain today and today we are doing our first ever episode on psychodynamic psychoanalytic approaches to therapy, which listeners Preston did ask if we could do this earlier in season one.

And I flat out just go, no, 

Preston: I need more time. She was like, it's too broad. We don't know enough, and 

Margaret: there's so much, I mean, I'm going to limit myself to only being able to have three [00:01:00] caveats. Like I can only take something back and say sort of three times this episode and Okay. I'll be, I'll be counting those if I go above three.

Yeah. If I go above three, like editor, we need like a buzzer, like some sound in there. Um, but so today we are going to do an, not a historical overview, but an overview of some of the core concepts that I was first taught when I started out in psychodynamic and then also core concepts I've learned over the last few years doing a psychoanalytic fellowship.

So I will say I'm not in candidacy, I'm not fully trained. This doesn't count. This is me giving my, this is me giving my credentials. This is not a caveat. Yeah. Um, but I just finished it a couple weeks ago, my first year of training in psychoanalytic, thinking at one of the psychoanalytic institutes. Um. So we will be talking about kind of core concepts and then myths, misconceptions.

And then at the halfway [00:02:00] point, I have made up a case that I'm gonna have Preston interview me as a patient, as a fictional character, um, who he does not know, who that fictional character is. And then we're gonna, in real time try and formulate together and I will give you some guidance on thinking about formulating from a dynamic perspective.

Preston: I'm ready to formulate. You're ready. This engine's primed. You're ready. Formula one

Margaret: ravioli. Um, so however, we will still do an icebreaker, which is not in form with how psycho analytic sessions are run. Mm-hmm. But I wanted to first start by asking you what are some like ideas, beliefs, kind of misconceptions that. You've, you yourself, or we, both of us have held about psychoanalysis or psychodynamic therapy?

I have a lot of my own that I held. Okay. Yeah. 

Preston: Well, it's time. So I, I don't think I'm, I'm [00:03:00] afraid of the, um, scrutiny of psychoanalytic peers the way you are. 'cause I'm not in training at a psychoanalytic institute, so there's, there's no row of corduroy that's raising an eyebrow at me when I say these things.

So, so I, I think it's, the concept of it is cool. Like, like, what's it called? A chase lounge. Laying back, imagining you, you know, reliving your childhood while someone kind of guides you along. I've just been having trouble seeing it through a scientific lens, which is how I like to conceptualize a lot of things.

So I remember I was, I, there's this Wikipedia page I love, it's called like the, essentially the anthology of pseudoscience and like. Right there is psychodynamic psychoanalytic therapy as you are scrolling through, and it, it lives right next to, you know, like astrology and phenology and, and everything else because it's, I, it's this method of interpreting things that's really just conjecture built upon conjecture, built [00:04:00] upon conjecture, built upon conjecture.

And I think that mm-hmm. While it can be a fun exercise, sometimes people just kind of chin stroke themselves into a maelstrom and it turns into nothing. 

Margaret: So that, so, okay, so you're, you're cooking, this is gonna be an episode. 

Preston: Yeah. Yeah. So it's like, no, I like it. I think it's cool and, and I, I appreciate the optics of it, but then also I'm like, this gets a little bit too fuzzy, way too fast.

So that like the only real benefit of therapy. Is the relationship mm-hmm. Between the therapist and, and, uh, the patient. So however you achieve that relationship is, is I think, the most important thing. So, so those are all kind of like the things I have against. Yeah. Psychodynamic therapy on the other half.

I think it's really cool. Like I, it, I think it's fun to think about it. I, I like when, when people talk about their psychodynamic formulations, I think it sounds intelligent. It's poetic, [00:05:00] graceful, even the way they describe the human mind. And I kind of aspire to be like that too. So, so I'm, I'm like a hater, but maybe it's just because I'm outside of the club.

Margaret: See, that's insight into, into some of it. But, so critique wise, I think the, certainly the history kind of you're saying of what is the evidence basis for this? Can you prove or disprove it? Um, like. Does it feel kind of just like it's made up out of nowhere and in some ways mm-hmm. It does feel like that even to me sometimes.

Not all the time, but uh, and then the kind of other side of you saying there's something about the narrative element of it mm-hmm. That seems like it has maybe a lot of depth or like a broader view of people than maybe other ways of formulating a psychiatric patient's experience Might be. 

Preston: Yeah. Like it's like you can get stuck on the rules of is it falsifiable or not, but then mm-hmm.

You don't wanna put [00:06:00] yourself in this box. You wanna think abstractly and appreciate that. There are really cool, um, tools that come out of this way of thinking, not, not to derail the conversation, but have you ever heard of Russell's Teapot? No. What I'm talking about? 

Margaret: No, I don't. 

Preston: Okay. So. The, the idea with like a lot of these like scientific theories is that something is like falsifiable, meaning that like you can formulate a null hypothesis, right?

And then by disproving that you move a little bit closer to the truth. So, right. It's not circular. Yeah. The null hypothesis is like, aliens don't exist. Right. And then you discover evidence of extraterrestrial life on Mars. Now we're a little bit closer to aliens existing, so that would be a falsifiable hypothesis where one piece of evidence can shatter the whole thing, you know?

Margaret: Mm-hmm. 

Preston: But Russell's teapot is basically the conjecture that there's a teapot that exists somewhere on the other side of Mercury uhhuh, and you could never prove that it's not there. Right. But my hypothesis is that it exists. And so that's like a not falsifiable [00:07:00] hypothesis. 

Margaret: Right. 

Preston: But it, but it doesn't mean like there could be a teapot on the other side of me career.

Yeah. We don't know. Or not, so while something is not falsifiable, it. Doesn't kind of fall through the channels of scientific scrutiny or, or it's not compatible with the scientific method, but it still remains agnostic to us as to whether or not it's true. So I'm, I, I dunno. I think about pea with, with psyched theory, 

Margaret: we're falling really, we're gonna be in really in our foils this episode.

I can feel it and I'm like, the part of me that, like did quiz bowl and debate in high school is kind of like amped up. I get gonna, I'm gonna get, don't be mean to pressed in comments on this episode and I could feel it. Mm-hmm. Do you think Yes, I think that's fair and I, I actually have the same frustration.

There were certain points, especially in the my year fellowship there, that it would be like, we would be talking about something and I'd be like, actually where the hell did this come from? Like, actually we're all just talking about this as if this is a thing, but like, [00:08:00] where is any data? Like, couldn't I just say this?

Like, couldn't I say this in just a different way and. That could be equally true based on the no evidence. Like instead of a teapot, there's a coffee, there's an espresso machine. Yeah. 

Preston: Yeah. I challenge your teapot theory and there's an espresso machine machine that you also never prove, isn't there? Fuck yeah.

Well, well it's a smeg food processor now, bitch. Deal with that. 

Margaret: So I think, I think these are valid complaints. I think one of the things we're not gonna go into a ton of detail today is like an actual review of the literature that's emerged over the last, like 25 years. A lot of it led by Jonathan Shedler, um, who, who is kind of the, he's like this sort of beloved and also like rogue character in my reading of.

Um, two thousands plus, uh, psychoanalysis, because he's a maverick 

Preston: and pop psychoanalysis. He 

Margaret: he is a maverick. Yeah. Well, he is not doing pop psychoanalysis. He's the one [00:09:00] who's just like, we need to have some data. And also the data that they compare psychoanalysis against is like, not fair. Um, he brings up, he's, he has a number of books, lots of papers that he brings up.

Extremely good examples on this. Mm-hmm. If we ever can get him on, we will have him on. Um, but basically that, let's say that there, there is an emerging evidence body over the last 20 years for this type of therapy, but also in particular cases. So I'm gonna tell you a couple of my conceptions, whether they're misconceptions or not, I probably won't know in my lifetime that I had like starting residency especially, so mm-hmm.

Mine were like. Obviously Penis Envy. That's, that's even the name of this en episode obviously. That's like, I was like, what the hell? What the hell is this? Why, what the hell, why? Like, why would there be penis envy and [00:10:00] not like womb envy? Why is that? Although that is a theory that was then later hypothesized, but never picked up.

Um, what the Helly Yeah. And then there are many valid critiques of like how psychodynamic and psychoanalytic thinking was part of and promulgated the belief that like different expressions of sexuality are pathological and regressive. Mm-hmm. And a response like there's a ton of like denial of racism and other kind of oppression.

That the psychoanalytic world did not pick up on, especially in like the seventies, eighties, nineties, that other schools have thought moved quicker on. Um, so I came in just being kind of like angry my psychodynamic class and was like, and what the fuck is, we'd be reading Freud and I'd be like, 

Preston: so, so it's like being gay is, is a sickness and you don't have insight into it.

Margaret: Yeah. Well it would be like there's something that developmentally paused you is like what they would [00:11:00] have claimed, basically. I see. Okay. Yeah, I mean there's many writings on this that are extremely damning and that I think the world of modern psychoanalysis is still dealing with. 

Preston: The like. Yes. I mean, it's tough when, when your basis of evidence is.

I just came up with it in my head this morning. Okay. Not 

Margaret: too much though. Not too much on it. Not too much on it because, um, the other wor thought worlds of therapy haven't dealt with this either and neither have our medication prescribed it. Like the DSM hasn't dealt with this very well either. So get 

Preston: out.

Yeah, that's true. Okay. Get out there. Okay. Stop the dog pile. Preston. 

Margaret: I feel like now psychoanalysis is like my sibling where I'm like, I can bully it, but if you say something about it, 

Preston: that's fair. Um, that's, that's how I feel about the US when you're repeating Countries make fun of us, you know, I'll criticize our military spending, but like, okay, Italy, like you can't, you don't get to say anything right now.

Yeah. 

Margaret: Um, okay, so those are some [00:12:00] of our myths. I think before we talk about some core concepts of modern. Psychodynamic psychoanalytic also pulling apart what that means. 'cause those are two separate things. Mm-hmm. Um, what tr let's both go with, what training do you have so far? Like what exposure have you had to the ideas of Freud and then the ev evolution of psychodynamic thinking or any supervision?

Um, kind of what have you had so far? 

Preston: Mm-hmm. So supervision Zero. My only psychodynamic experience has been reading a couple papers about it and then listening to maybe one or two podcasts. Yeah. And talking with Margaret that, that's like literally the extent of it. So I, I know some of like the Freudian stages of development, I've read a couple of Freud's like formulations.

Mm-hmm. And that's like about it. Most of my training is in either motivational interviewing or cognitive behavioral therapy and then like some chopped up, um, applications of DBT. That's [00:13:00] basically what I've been taught. 

Margaret: And what will your third year be like? Do you know, like in terms of therapy, didactics, supervision, like how many cases you're supposed to hold?

Preston: Um, so we, we have about a total of like probably nine or 10 cases that move around depending on like what patients stay on or, or not. And then I don't think we, we have, um, any formal didactics on therapy during our third year. So any, any like education we get is kind of self-directed at that point. 

Margaret: And I don't think you're like, I don't think that's abnormal in psychiatry residencies at this point.

I think I'm on the east coast, which is the place that has the most of it. And then. As you know, you know, but did a fellowship at the Psychoanalytic Institute in Boston for a year. Mm-hmm. And then also have been connected, like my program has done something that are like psychoanalytic dinners once a month where like faculty at the Psychoanalytic Institute have people over to their house for dinner and [00:14:00] discuss a case, um, with like residents in different programs throughout Boston.

So I went to that my first couple years. And then we have a psychodynamic case conference, um, that starts during our second year through fourth year. That's like every Wednesday. And residents present and formulate their case. And then I have had weekly dynamic supervision, so for the last three years I guess.

Yeah. And then some. So your psycho psychogenic 

Preston: training really trumps mine, or, or I guess I, like, I mind pals in comparisons. Like all these criticisms I have just for context are based off of essentially no experience with it. 

Margaret: Yeah, I mean, again, I think like I chose coming to the program I went to for residency from a biologic.

I mean, it was still a pretty biologic program on the scale of things, but because I was interested in, in therapy mm-hmm. Um, my other background is, you know, but just to give kind of insight to people is CBT you have to do in psychiatry residency. And then I did two years of [00:15:00] ACT training for OCD, um, or acceptance and commitment therapy.

So I say that just to give our listeners a kind of where are we coming from, what have we trained in so far? And then I've been seeing patients weekly for dynamic for like three years now, I guess. Um, so I say that not to compare ours, but just to compare that to people who have been practicing for 30 years and have been like evolved with the field.

This counts as one of my caveats, this one does. Um, just to say I'm still very much at the beginning of my. Training in, in psychoanalytic and psychodynamic 

Preston: and I haven't even started. 

Margaret: Well, and we're here, you know, 

Preston: you're at the threshold. 

Margaret: So I wanted to start, you know, actually getting into the meat of the topic by talking about psycho.

And so there's psychotherapy, right? And under psychotherapy falls all of the different types of therapy that people might [00:16:00] refer to practice as psychiatrists or you know, people might have heard of. So DBT Act, CBT, behavioral therapies, expressive therapy, psychodynamics, psychoanalytic, relational family therapy, couples therapy.

All of these fall under the psychotherapy umbrella. Within psychotherapy, there's then like the psychodynamic psychoanalytic type of therapy in that category. There is psychodynamic psychotherapy and psycho psycho analy. And then like psychoanalysis. There is some spectrum between, some people would argue, but for, for our sake, I'm gonna leave it here.

Preston: Yeah. And then the C-B-T-D-B-T-C-P-C is all over on this behavioral branch. 

Margaret: Mm-hmm. Mm-hmm. 

Preston: So we're, we're like on two different branches of a tree. Right. Right. Which we can, and now, now we're venturing over to the psychodynamics psychoanalytic branch. 

Margaret: Correct. And the reason that they're so separated has, has a lot of, well, we won't go into that, but the history of, that's actually really [00:17:00] interesting because basically psychoanalytic institutes weren't in academic settings.

Like they were their own standalone things. And they also only accepted MDs up until like the, like late eighties. Like basically you had to be an MD to be trained in psychoanalysis. Um, and so people who were in other modes of training to provide psychotherapy. Basically everyone else, because we don't even really think of MDs doing therapy anymore.

Mm-hmm. We're not allowed in those institutes. And they are training in the evolution of, you know, from behaviorists through kind of like Carl Rogers, then CBT, then the modern like DBT Act. And everything is super impacted by this historical academic and like literally place divide. And this, I should say, was in the US in like the UK and like the rest of Europe.

There wasn't this like division and Freud was actually against this, that like, only MDs can do psychoanalysis. So I think that's fascinating because you'll, you'll [00:18:00] see that there's like kind of evolution and ideas happening in the culture that impact both the schools in a like specific way. Um, and how they respond to the change in culture is, is quite different.

Um, but to get back to this point on the branch, so if you had to guess, Preston, what would you say is the difference between psychodynamic psychotherapy and psychoanalysis? 

Preston: Um, so just going off of the words, psychodynamic to me kind of suggests that there's some like evolution in like the therapy with like the behaviors as, as you go.

And psychoanalysis seems like you kind of look at someone and then you do all the analysis yourself, I guess. So I, I picture you kind of rolling together in psychodynamic. Mm-hmm. And whereas psychoanalysis, it's almost like you're, look, you're peering through a one way mirror and you make your determination on that person, but they can't look back at you.

That's how I would see it. 

Margaret: Yeah. So that's wrong. 

Preston: [00:19:00] Like, 

Margaret: so, so if we think about, so some people will refer to psychodynamic psychotherapy as psychoanalytic psychotherapy, and that, that is different than psychoanalysis. Psychoanalysis is in many ways the classical model that is very determined by form, um, of you're going.

Three to five times a week, there is more of an emphasis on the blankness of the clinician. So that transference and counter transference and that interpretation, um mm-hmm. What's happening in the room can be the center of what you're doing. And there is more of the kind of classic, like you're gonna be on the couch and face away and there's going to Yes.

Preston: So I said the metaphor for a one-way mirror, and you just said flat wrong, but it seems like what you're describing right now is a one-way mirror. 

Margaret: Well, but dynamic. So it's not the difference in the approach, it's the difference in like the frequency and dynamic can still beat the [00:20:00] blank slate. So like dynamic is basically like, we aren't gonna have as strict of rules around.

How often we're meeting, like if you ask like classical analysts, if they can do psychoanalysis and only see you once every two weeks, they'll say that's not psychoanalysis because it's not enough frequency for the relationship to form in the room. 

Preston: Mm-hmm. Where there can be kind of, it's not true psychoanalysis.

Margaret: Well, I mean to be very fair to them, like there is something specific that happens that if you only see each other like once a month, or if you only see each other every other week and even once a week, not for most patients, but for some things that you're working on with people, there's a term that analysts use that's like you get crusted over that basically like.

If you're gone from someone for too long, then it's hard to contact the emotional thing that you've been repressing and having defenses against. And then you have to work all session again to get back to the point, I'm sure you've experienced this as a therapist mm-hmm. Where it's like you get to something and you feel like you get to a [00:21:00] breakthrough in the session with someone and then you regress.

Yeah. And then the next session it's like, where did it go? And maybe you get there eventually again a few weeks later. But so again, I don't, I don't practice like four times a week with people. I, I'm not saying I'm a psychoanalytic person, but I have come around to some of the, like the form maybe Right.

In certain clinical situations, which we can talk about. Mm-hmm. So basically dynamic and psychoanalytic could all be evolved from the line of thinking of psychoanalysis. 

Preston: Like Pokemon. 

Margaret: Yes. Yeah. So difference there. Just to summarize. More rigid for psychoanalysis, you're going three to five times a week.

There are some people who will be like, maybe you don't have to, but mostly psychoanalysis is like three to five times a week. Mm-hmm. More of the like, I'm not disclosing to you, I'm pulled back. Some modern psychoanalysis, they don't think you need to do the couch, but it's this frequency and like we're not doing other stuff with it.

Like we're not res also [00:22:00] incorporating DBT skills. We're not also incorporating like 

Preston: mm-hmm. It's distilled in its purest form. 

Margaret: Yeah. Yeah. 

Preston: Okay. 

Margaret: So I think that re we're supposed to all as psychiatrists have dynamic patients at some point during our residency. I think that's part of the A-C-G-M-E requirements still.

I mean, I, 

Preston: I don't 

Margaret: know. I'm sorry. I'm sorry. I'm like a slam you after 

Preston: call. Well, well, the thing is like, yeah, I'm, I'm sure we have like two or three like afternoon didactic sessions where someone's come to talk to us about psychodynamic and then we've technically had the opportunity to incorporate that into our Got it.

You know, therapy interactions. So we've thus checked the box on psychodynamic education. Yeah. But it, I think it's different than like coming back and purposely trying to do a psychodynamic approach with the patient with supervision every week. So before we dive into the rest of what psychoanalysis is and, and show more of Preston's ignorance, we're gonna take it quickly.

Margaret: I'm so sorry. I did not mean to 

Preston: trying, I'm not taking, [00:23:00] I'm trying to, I'm not taking any offense to this because like Okay. I don't take pride in my knowledge of psychoanalysis. Okay. Like, Preston's ego is not built off of the pillars of how expert he is at Chase Lounge interpretations. So, okay. 

Margaret: Not 

Preston: too much.

I have at it, you know, not too 

Margaret: much on it.

Hey, Preston, what does the sound remind you of? Oh, 

Preston: God. It, it makes me think about being on call. It's the pager. 

Margaret: Okay. Well, it's not my pager, but it is equally stressful as the timer I use for studying. 

Preston: Oh, we got a Pomodoro queen over here. 

Margaret: Do you know what has made studying less stressful though? 

Preston: What 

Margaret: Now You Know Psych, you familiar?

Preston: Am I familiar? I, I use Now You Know Psych for my in-training exams are, are we talking about the same thing? That excellent resource that has thousands of questions with associated flashcards, organized content in a user-friendly way. 

Margaret: You use it for pride. I'm using it for the board exams. But yes, we are talking about the same resource.

We, 

Preston: we can use it for both ao 

Margaret: Ready to take your [00:24:00] exam prep to the next level? Go to nowyouknowpsych.com and enter the code. Be patient at checkout for 20% off. That's nowyouknowpsych.com.

So I'm gonna ask you a question then I'm gonna not ask you prodding questions anymore. Welcome back listeners. Um, if you had to define what happened, not in psychoanalysis, but let's just say psychodynamic therapy for now, and talk about the theory, which as we've said can be shared in psychodynamic and psychoanalysis, even if the form changes, um, what would you describe from what you know, if you had to guess?

Mm-hmm. Like how is psychodynamic therapy different than like CBT? 

Preston: This is one I think I do have some, um, insight into. So, CBT is really a way to control someone's behaviors. This, it's in the core of the word and the analogy I like to use with this is like. House, you, you, your mind is [00:25:00] your home. And CBT teaches you skills about how to fix things around your house.

Like maybe the windows are broken or there's like a hole in the wall that's been affecting you. You have a maladaptive way of coping with it. And then we teach you some carpentry skills to go and fix it. But psychodynamic theory goes into the basement. I would say there are aspects of unconscious drives or motives or concerns that control your behavior the same way conscious things do.

And psychodynamic theory is a way to uncover what some of those unconscious things are. Prob, which most likely came up through your childhood. And then curious about how those, your behavior now.

Why do you have termites in your basement that's affecting these like weight bearing beams? Mm-hmm. Huh. Like that's curious. Like how did these get in here? Yeah. Why is this part rusted? Why does this foundation look like this? And then you're like, oh, my whole [00:26:00] house is slanted because the foundation was built weird.

And like I've learned my whole life that I have to, you know, set cups a certain way or do all this other stuff. But I never really understood that this all because it was built on this one thing. 

Margaret: Mm-hmm. Mm-hmm. So 

Preston: I see psychodynamic therapy as a lot of it is investigation of the childhood and then seeing how that has influenced certain ideas we have about ourself that kind of guide unconscious behavior today.

Margaret: Yes. Yeah. Yeah. No, I think that's a great metaphor. I think kind 

Preston: of do that great metaphor. Bingo. She didn't say wrong with the heart thing. Not back to you Margaret. 

Margaret: I think that's a great metaphor of kind. Some of the core differences of these approaches. I also think that's, you know, it's part of the strength and the weakness of this, of the psychodynamic psychoanalytic approach is if someone comes to you in the emergency department or in an inpatient unit where you're gonna see 'em for 10 days.

Like probably being like [00:27:00] there are psycho analytic people that disagree with this, but, um, probably for the most part, teaching them concrete coping skills and just like, what are we even talking about doing? Like psycho ed might be more effective and appropriate than trying to do depth work in a. A 10 day stay in an inpatient 

Preston: unit.

Yeah. Well, I'll ask these patients like, what, what was your childhood like? And they're like, I don't even remember it. Like, okay, well we've got 72 hours for you to start remembering it, and we've got another 72 to analyze it. So like lot baby, we have three 

Margaret: business days, not including holidays to solve it.

Um, so, 

Preston: and also you're under emergency detention and can't leave. And I'm the reason also we started 

Margaret: Depakote. Um, also you're in withdrawal, but it's gonna be awesome. So one of the, um, texts that I'm gonna refer to is, um, the, there's an evidence-based, psychodynamic therapy is a textbook from, I [00:28:00] believe, post COVID 2022.

It'll be in our show notes, but the author goes through different major figures in different schools of thought within psychoanalysis and psychodynamic theory over the last a hundred years. And it's like, what do they say it is? Because it's hard to actually define like. Who does this treat? Why does it work?

How does it work? And when do you know you're done? Mm-hmm. Um, so he quoted Glen Gabbard, who people in the psychodynamic world will be familiar with. Glen Gabbard. I, I have a book 

Preston: on my shelf. 

Margaret: His, 

Preston: his speak is a woman. Gabbard just sounds like a woman's name. Glen Gabbard, I don't know, maybe, maybe I have inverse penis Envy.

Margaret: Well have the pelvic floor therapist back on, um, 

Preston: pelvic floor. Pelvic floor envy 

Margaret: you. Okay. So quoting Glen, um, define psychodynamic psychotherapy as quote, a therapy that involves careful attention to the therapist, patient interaction with thoughtfully timed [00:29:00] interpretation of transference and resistance, embedded in a sophisticated appreciation of the therapist contribution to the two person field.

It's actually by Gunderson and Gabbard, who Gunderson shout out to people who are working with BPD and DB and not DBT, but he's a, he's a big deal in the BPD world. Um, so just to go back to that, I'm gonna read that again 'cause I actually feel like it's getting at some of the core elements we're about to talk about.

Okay. So 

Preston: can you do it but slower? 

Margaret: A therapy that involves careful attention to the therapist patient interaction or dynamic dyads to that relational center with thoughtfully timed interpretation. So we're not just like looking at you and analyzing and saying, you are using this defense and this defense carefully timed of transference.

So what the patient to oversimplify puts onto you and into the relationship and resistance. So what are we trying to not see? What's under the house, kind of as you're saying in your metaphor? Mm-hmm. Embedded in sophist. Why is 

Preston: the basement door locked? [00:30:00] 

Margaret: Where are the termites? Yeah. Embedded in a sophisticated appreciation of the therapist contribution to the two person field.

So the countertransference in our own biases that we bring into the room and into the relationship, which is one of the themes of psychoanalytic thought over the last like century since Freud is. You know, he has a lot of problematic parts of him. Say it, you know, he has a lot of problematic parts of him say it.

But also we take so much for granted of how we talk about therapy now, even when we're not, when we're talking about like CBT, when we're talking about like pop psychology that is in the water. Because Freud was actually quite radical. No one thought what Freud really thought, at least at that time, where he was in medicine.

Certainly there are things that we've missed because we've refused to see other groups of people who have wisdom. But Freud was quite radical. And so the idea that like for example, trauma might impact people over the long term [00:31:00] and cause differences in how they emotionally relate to things and feel, and somatic symptoms show up wasn't, it's something we just like think now, but much as everyone hates Big Daddy, Freud.

There is a lot of thought. He was the 

Preston: first person to, to formulate that as a concept. 

Margaret: Yeah. And then famously gave it up because everyone was like, men would never, I'm not kidding. Do you know that? Really? Yes. No. He was like, all of these girls and women are traumatized because I think there's been a lot of sexual abuse that has happened to them in their families and like presented this as like a paper to like this like fancy board.

Mm-hmm. Basically in Europe. And they all, like a lot of his patients were these fancy people in Viennas. Like children. Yeah. Or relate really. Like they're related to them. And they were like, no, this can't be true. And then he was like, you're right. They're making it up like that. Like he, he worked with people with his, like, with hysteric patients, so like mm-hmm.

Women and was 

Preston: like, [00:32:00] they're being traumatized by their families. And then all the oligarchs are like these families, the aristocrats us and had to come from somewhere like. That's impossible. Go back to the drawing board. Oh yeah, you're right. Yeah. 

Margaret: Yeah. 

Preston: It's all just made up. You guys are perfect. 

Margaret: Yeah. How could I be so dumb?

But like, if you like read FUD deeply, like he, it's interesting 'cause his theory and what gets approved and how it changes over time versus his like actual clinical approaches are not the same. Like he's actually a much kinder and like gentler clinician than some of his theory writing makes him sound like, he's like, yeah, theory's cool, but you kinda, you know, you can't just like use a hammer for everything.

Preston: Yeah. You have to be thoughtfully timed with the hammer. Yes, exactly. Gently stroke their cheek with it. 

Margaret: Do you know that they used to do this? The, like, the first, the first, like what they thought was working in like psychoanalytic therapy with Freud was they would place their fingers on the person's like forehead and be like, call to mine the memory.[00:33:00] 

And they thought, I'm not kidding. And they eventually realized like, that's actually not what's, what's making this work or happen. Um, so maybe they just didn't 

Preston: use two hands. 

Margaret: Yeah. Just needed to mind 

Preston: a memory to explode. 

Margaret: Um, so I wanna go into a little more detail around transference and interpretation.

Mm-hmm. So if you had to define transference for people listening who are not sure what that is, how would you try with curiosity to define? 

Preston: Okay. It's, it's how, so it's, it's how the, the patient takes ideas about relationships or people in their life and settles them onto the therapist. So transference is where, is where you start to see the therapist similar to other people in your life.

Margaret: Mm-hmm. Mm-hmm. And, 

Preston: and you, you basically could, in theory, you don't know anything about who this therapist is. They're just kind of sitting there to reflect things [00:34:00] onto you. So you're not creating a true formulation of what this person is, but you're projecting some of your other relationships onto them.

So, for example, you know, someone may, like an older woman may remind you of your mother, and then you start to, to talk to your therapist in a way that you would talk with your mother or something. Mm-hmm. For example, about being an example of transference. 

Margaret: Yeah. Like if she's like a couple minutes late, it's like, you don't care about me and my, like, there's something in you that you may be, you know, not conscious of that is like, 

Preston: yeah, 

Margaret: I bet this means this more than someone who didn't have that experience.

Preston: Yeah. And then you make assumptions that your therapist may think similar to that other person, right? That, that you're projecting onto, onto them, right? 

Margaret: Yes. Yeah. So. You know, and there's coherence. If we take a step back as we'd like to do on this podcast, and we think about, like the episode we did on attachment and John Bowlby's idea of like internal working models of attachment, right?

There's been an integration in the last few decades of attachment like studies and [00:35:00] psychoanalytic thinking. Um, but we can see that there is this, um, similarity so that they, even though all these schools are separate and like, no, we don't, we have the truth. You don't, there is still this kind of like, you can think about it as, as in childhood, in attachment you would say you learn a certain way of getting safety, getting your needs met, and then you project that onto how you're gonna interact in the world.

And we might call that transference or call it something different in psychodynamics. 

Preston: Yeah. I, I found like with a lot of these therapies, it feels like just using different lenses to observe the same phenomenon. Mm-hmm. You know how in like. In physics class when you had to calculate a ball rolling down a hill and they're like, do it using Newtonian mechanics.

And then they're like, do it again with kinetic energy. And you're like, whoa. Mm-hmm. These two different seemingly totally different models managed to get you to predict the ball in the same place. Yeah. I think that's kind of like what a lot of these different, like therapy theories are. And we've, we have a different lexicon and different names for it, but it's, it's all the same [00:36:00] flower petals and stems and mm-hmm.

Whatever else we're observing. 

Margaret: Yeah. But I mean, similar to that analogy is that different lenses might give us more accurate, different lenses give us different information and different ways to hypothesize causes and 

Preston: treatment. Mm-hmm. And different people interpret differently in different lenses. 

Margaret: I, I guess what I'm saying is, uh, we probably need all of them.

Like, we probably need the mr, like, not all of them for every patient, but like, I. It is our own to, because we're in the psychoanalytic episode, it is our own fantasy that any one system, I think at this point in the history of mental health, is going to get us to wellness for everyone. Mm-hmm. And so similar to the like physics class, like you would like to know all of the different equations and ways of making sense of this so that you can put it together and know the most possible about the ball rolling down the hill.

Preston: Mm-hmm. Yeah. So MRI, CT [00:37:00] EKG analysis, x-ray, there's, there's no single one that's 

Margaret: the best. Right. Right. And the other thing I, I think one of the other parts of transference is just think to, to touch on a couple like common ones people might hear, so there's idealize, idealizing, transference. So this can happen sometimes in, this can happen in any patient, but.

I think one of the ways we think about it is like when someone has borderline personality disorder and we talk about a split, idealizing would be one side of it, and then the devaluing is on the other side of it. Mm-hmm. Um, in psychoanalysis, it doesn't have to come with devaluing. It can come as like this way of admiring someone and using that as something that's helpful so you can trust and do the process of therapy that is scary and anxiety provoking because you're uncovering stuff.

But it can also be something that can be used as a sort of defensive [00:38:00] maneuver to not actually get to know someone or not. Mm-hmm. Like if it happens in, not therapy, but like in a relationship. Right. You won't actually know the person if you won't ever take them off the, like they're this God authority replacement mother figure.

Mm-hmm. Um, that's a common one. There's some others, but I feel like there's, you know. There e even primary care doctors. There's this, the, have you read the paper? The, like caring for the hateful patient? 

Preston: No. 

Margaret: Okay. It was in like, I was it in jama. Anyway, it doesn't matter. But all of us have experienced this where we walk into a room and we feel one way and like every time we walk into a room that day with a bunch of different sorts of people, we still felt similar.

And then suddenly something feels like tilted off its axis and how this person's interacting with us and we don't know what's going on. Um, and it feels like we haven't even said anything yet. And already there's something being put into us or, you know, projected into us. Mm-hmm. [00:39:00] Um, and then my other question for you before we play our, before we play our, I'm gonna be your dynamic patient and then we're gonna make a formulation together, which I'll prompt you through, um, is interpretation.

What do would you explain if a patient said, I went home and I read a WebMD article about psychodynamic therapy, and it said, you're gonna interpret things, what would you say that means? 

Preston: Because it means, um, I'm going to apply inductive reasoning and form hypotheses about the relationships between past experiences you may have and current drives or, or for behaviors 

Margaret: that you, um, 

Preston: deal with today.

So interpretation could be like, I think that you put men on a pedestal [00:40:00] because. You put your dad on a pedestal because he was the only one around after your mother left. And that it was really traumatic for you to see your dad as a fallible person, because then it almost seems like maybe your world would've collapsed.

So now you've kind of taken that, um, idea of men and translated onto other men. Mm-hmm. But because of that, you don't see the flaws in your partner and end up in a lot of traumatic relationships. Mm-hmm. Mm-hmm. Uh, or get too deep. Yeah. So I, I basically, I see something from your past. I form a hypothesis about how maybe affects your present, and then I share that with you.

And then we both say, do we agree or disagree with this? Right. That's how I'd say interpretation goes. Yeah. 

Margaret: I think the idea that being a hypothesis is helpful and is the way most modern psychoanalysts and dynamic theorists, therapists like mm-hmm. Would present it. I think the other thing to think about, and there are people who are quite.

Rigid around, and maybe this [00:41:00] makes sense for 'em, but like very rigid around what interpretation is and that it's only verbal and it's only when you're really directly pushing against in a certain way. But I think a majority of modern kind of psychoanalytic thought is that interpretation can also be like, can be, there are levels to what the response can be.

So an interpretation could be me saying directly, like what you just said, or it could be me holding into inside myself, like working with this person, like what they just said about a relationship and then noticing what's rising in me as they say it. And then in knowing them in the relationship diad saying what part of this is like in the neighborhood is a phrase that people will use sometimes in dynamic work.

Like what is a part that will push them a little bit to take a step and, and look at and question and maybe bring to consciousness something they're not aware of. Mm-hmm. But that isn't so much that it [00:42:00] steals the revelation from them is another phrase people will use. Mm. Um, so it could be, you know, to one kind of side of the spectrum could be saying explicitly like what you just said.

Right. But it could also be something like, instead of like, let's say like her, the way her before her mom, this patient's mom left, like the way they responded to her was like to shut down their emotions and tell them they didn't wanna hear about them. So maybe the interpretation would be something gentler in saying like, I wonder, we've talked about how it's hard, you've had a history of people not listening or like mm-hmm.

This, this person, whatever. I can feel you wanting to move on from that topic. Or like, I want us, I'm wondering if we should stay even more with this emo whatever. Like mm-hmm. That kind of thing. Or maybe 

Preston: she says. Preston, I think you're perfect. Something I get a lot and have to deal with. Um, and, and then I reply, huh?

[00:43:00] Just, just like how you thought your dad was perfect in your recent relationship. 

Margaret: So that, interesting. That would be, again, on this side of interpretation, that's like extremely direct and kind of concrete. Oh, that, 

Preston: that's super direct. I, I guess, yes. Oh, okay. Shoot. 

Margaret: So that would be super direct. Um, like in that example you might, an interpretation could still be, I wonder like it could be that you show up on purpose two minutes late to the next appointment.

It wouldn't be necessarily that, but like, it could, even, the middle of the spectrum might be like, I wonder why I get the sense that it's really important to you that like you see so much good in me, but I wonder if it's hard for you to think about the things that may not be very good in me as your therapist.

'cause like that could be scary. Mm. You don't have to connect it to the Yeah. The dad stuff. But you in your mind can be like, the pattern, I think if as repeating is this dad stuff? 

Preston: Yeah. I, I, so like, I wonder why you want me to [00:44:00] be so perfect as your therapist or something. Yeah. Mm-hmm. Okay. Interesting.

Mm-hmm. That's a little nudge 

Margaret: that, yeah. So it can be anything from like very subtle to just like how you respond, like with your body language in the room, all the way to a more direct, like mm-hmm. I think that they're ready to hear this because it's kind of like when you go to a primary care doctor and they're like, you need to get out there and be running more like that.

Your blood pressure is high or something. Mm-hmm. How many people actually change their behavior because of that? 

Preston: Yeah. 

Margaret: Like it kind of is like it has to come from the inside and you have to write it. 

Preston: Well, uh, what, and there is a name for this too, right? It's called like therapeutic reactants or something, which is where if you bring up an idea I'm gonna face at you.

Sorry. Oh, really? 

Margaret: I, yeah. I, I thought that was just, you're 

Preston: responding to your drink. I, I, so you can correct me on this one too. Um, no, no. 

Margaret: I'm not gonna correct you. I didn't mean to make as mean of a face that I did. I've actually not heard that term. 

Preston: Oh, okay. I think it's, so basically when you bring up something too strong and [00:45:00] too stark mm-hmm.

That people are gonna resist it just because of how radical the idea is, even if it is like true or accurate to them. So, so like if I push too hard, people's natural responses to kind of pull away. Mm-hmm. And that's something we see a lot in, like, see, like I see it in consult liaison, weirdly enough when we have these, you know, alcohol use disorder patients who are dying of cirrhosis and then the internal medicine team is like, what if we just.

Convince them a little bit more how much they're gonna die if they drink, continue to drink. And you're like, you're right. Yeah, let's keep digging. That's gonna on side. And then they kind of push, they're gonna love that. You more into denial. Yeah, exactly. 

Margaret: Yeah. Yeah. Well, and I think that if we, one of an another view of psychodynamic thinking is that what's happening is a quote, corrective emotional experience like that, that is the work of therapy.

And in some ways you could probably apply that to different modalities of therapy and maybe is related to why the [00:46:00] Therapeutic alliance is like the biggest predictor of success. Mm-hmm. Of therapy or symptom reduction. But in that, right, you could have two people come in with, on the surface the exact same story, but one of them internalized their story as like, I'm not allowed to feel sadness.

And the other one internalized it as I'm not allowed to show anything but anger. Right. And the way you respond to those people with the same story, even from the same family, would be very different. And it's not just resistance, it's also like maybe one of those people like never got to speak so you speaking that out before them is actually worsening their feeling of disempowerment.

That is like the core reason of why they're coming to therapy in the first place rather than needing to know the exact kind. Or like you, I think about like people who really res rely on like over rationalization or intellectualizing their feelings. That would be give me, giving an [00:47:00] interpretation to someone like that would be the exact wrong move because I'm actually enacting with them this avoidance of their emotions.

Preston: Yeah, my, that's what my therapist did to me. 

Margaret: Oh, what? 

Preston: No, because, so I love, um, in intellectualizing things and I love analysis and I'm like making my own formulations about myself. And she's like, Preston, why don't you just feel what's in your body right now? And I'm like, no. And she's like, what do you, do you feel hot?

Do you feel cold? Like, what do you, what, what do you feel? Let's just talk about like the somatic sensations that you experienced. And so like, she would often try, like, I think she would get like frustrated with like how much I had to interpret everything and would just kind of force me to just like return to stillness.

Margaret: Yeah. 

Preston: So I, yeah, I was, I thought that was a good move on her part. And, and then I tried to incorporate it too. 'cause I'm like, oh, I think I also, you know, project my own, I guess preferred pathways of analysis onto [00:48:00] my patients. And I, and I've been learning over this last year. Different ways you have to show up for people.

Yeah. And, and interestingly, so I'm, yeah. I'm one who loves to, to analyze and form, form these hypotheses. And I realize that so many people that come to therapy, especially in underserved places like San Antonio or South Texas where they're kind of, they're therapy naive, I guess I'll say. Mm-hmm. The first like few months or sessions.

It's really just being someone who can be an empathetic listener. 

Margaret: Yeah. And, 

Preston: and people are so deprived of that in their life that the best way to show up for them is just to be like, wow, that sucks. Yes. So it doesn't seem psychoanalytic to just kind of be offering supportive psychotherapy intentionally, but Right.

I've observed that this the only, the thing with that this person needs right now before they can even go into criticizing or, or forming an analyses. 

Margaret: Yeah. So that brings, you know, one other point we're gonna make a couple other points then we're gonna do. [00:49:00] Our practice. I'm gonna kind of blitz through these, but that brings up something which is, there's Glen Gabbard.

Hass also been part of a series of like, he like the Basics of Therapy. That's a series of books I think a lot of residencies have that are like each of them are this big. They won on CBT that he didn't write, but he was like the editor for a lot of these. And they have like short-term psychodynamic therapy, long-term psychodynamic therapy are the two separate ones in it.

And one of the things that's an important concept is the spectrum. It actually was originated by Le Borsky in 1984 of thinking about the like different ways of approaching that is the supportive to expressive, or you could say instead of expressive like analytic kind of depth work spectrum. It's not that psychoanalysis doesn't ever do supportive or that supportive, never does depth and analysis, but that when you're thinking of like a patient who you really cannot, like let's say they're in [00:50:00] crisis, like they're on a short-term unit.

They've recently had like self-harm or suicide attempt or something like that. This is not the time to like, to push them into depth and be like, we have to talk about that trauma, that whatever. We've to talk about this like pattern of relating because it is de state. It's like doing construction on the house.

It's like, okay, we're gonna go in and we're gonna take out that core pillar that's falling away. Things are gonna be bad for not bad, but they're 

Preston: gonna be, yeah, we're gonna fumigating so 

Margaret: you better move out. You better move out. Right? Like, we don't take away a defense without enough support and kind of strength in there to help rebuild something in some ways.

Mm-hmm. Um, so that's just to say that like they aren't opposites. They just like. Supportive therapy. Right. Lives mainly over here. And true psychoanalysis lives mainly over here. But like let's say you're doing psychoanalysis with someone for three years and then like their spouse dies, like a psychoanalyst is probably going to like lean away from as much depth work or [00:51:00] pushing as much and go more towards supportive during the times when their patients are more in crisis.

Mm-hmm. Does that make sense? Yeah. So we are going to take a break. When we come back, we're going to do a five to eight minute mini session and then we'll formula. 

Preston: We're gonna 

Margaret: role play 

Preston: Yeehaw. Okay. I'm gonna go get my acting chops ready.

Margaret: Okay. We are back for our favorite section to do and sometimes the best section in the podcast and maybe sometimes also the weirdest what we are going to practice, what we just learned. Preston, how are you feeling? 

Preston: Um, you know, I'm always ready for some real life application. 

Margaret: Okay. Are you ready for your fictional vignette?

Preston: Yeah. Let, let's go, let's go test this baby out on the racetrack. 

Margaret: Okay. So in your psychodynamic clinic, you have your patient presents [00:52:00] who is going to be your psychodynamic patient for this year. Okay. You'll see once her once weekly. 

Preston: I'm, I'm a Psychodynamic Incorporated patient comes in? Mm-hmm. Okay.

Margaret: You're a big psycho. Big Fre. Um, so she is a 34-year-old white woman, domiciled, uh, living in a large urban area. Um, she works as a. Columnist for a newspaper in the large city. And the column is her writing about her love. Did you 

Preston: prewrite this? Yeah. Or Oh, wow. I nailed it. 

Margaret: What? No, no, keep going. It's not exactly exactly where 

Preston: I was, just when I was describing my classic psychodynamic patient.

Oh yeah, 

Margaret: keep going. She is presenting to you for therapy after a year of an on, again, off again relationship with a man that she calls Mr. Big. She, you haven't watched Sex in the City. Okay. Um, she describes a lot of anxiety [00:53:00] about work and then about, but more so about this relationship. Her psychiatric history otherwise is she's never seen a therapist, she's never seen a psychiatrist before.

Her family sort of didn't believe in psychotherapy or anything like that. They're seeing shrinks quote, um, from her. She describes you as a shrink as well. Uh hmm. But she is presenting now at the, um, recommendation from two of her friends to talk about the emotions she's having in this romantic relationship.

Um, and mainly she says she just wants to get rid of all the anxiety she has about said relationship. So no acute safety concerns, no kind of significant medical history concerns. She is a pack a day smoker. Um, but otherwise relatively well functioning, bright, well dressed, very well dressed and presenting to, seems a little bit, uh, maybe mildly anxious.

Also kind of makes a number of jokes and again, refers to you as a shrink throughout. So we are going to [00:54:00] do, I'm gonna set my timer. We're gonna do five minutes of you trying to get to know this character and then we will do a formulation on five minutes for fun. 

Preston: Okay, well, is this Sarah Jessica? Jessica Parker's character?

Yeah. 

Margaret: Okay. I don't nothing 

Preston: about sex in the city. I'll just fix it. That's good. That's good. Okay. Well, welcome. Wanna have a seat? 

Margaret: You want me to sit on this chair? Like, do I look away from you? Choice? Can I here? Uh, I prefer if you didn't. Okay. What brings you to therapy? Well, my friend told me I should go because of this relationship that I'm in.

That's not really a relationship, but it's sort of a relationship. But I, I, she says I'm, I just, I'm, I am pretty anxious all the time. Hmm. So your friend said you? Yeah, she said her shrink had helped her feel better and that I needed to do something. 'cause I kept keep talking to 'em about every day over [00:55:00] cosmos.

Preston: Gotcha. And, and is, is that something that you want to feel better? 

Margaret: I mean, I would certainly like to talk, stop talking about big all the time. Who's big? Big is my. Not boyfriend. I mean, he is the guy I've been seeing for a like year. And we see each other every week. We see each other a couple times a week and we mainly see each other when we're out and then go home together.

And sometimes we've gone on dates, but it's never really progressed more into like a full relationship. Like I've never had a key to his place. I haven't met, like his family hasn't met mine. He like ditches, my friends and I, and recently I realized he was still dating other people at the same time as dating me, just, which is [00:56:00] shitty, but we can just have fun.

Mm-hmm. Are you having fun?

I mean, the sex is good. So you, you have this sexual relationship with someone that 

Preston: has, hasn't blossomed romantically in any way. 

Margaret: I mean, I don't think I've ever felt for someone what I feel for him, but, so I'm kind of stuck. 

Preston: What's different about him? 

Margaret: There's just something like intoxicating about him.

Like the, the first time we met, even the first time we met, it was like exciting and he like implied, he thought I was a prostitute and I feel like that's, I mean, damn, that's like the first day and I feel like that's still how he doesn't make me feel like a prostitute, but like mm-hmm. He's ashamed of my column I write and like downplays it and [00:57:00] doesn't bring me around any of his like finance friends or any of his like high New York City society people that he used to be around all the time and is still around sometimes with his ex-wife.

Preston: Hmm. So the way he's denigrating to you is, that's the intoxicating part. I mean, he's 

Margaret: not denigrating to me. 

Preston: I guess he called you a prostitute and it was, I mean, he was joking. 

Margaret: He was joking. I mean, you got you. I mean, come on. Have a sense of humor. 

Preston: You, you're right. I can take things quite literally. 

Margaret: So what was your childhood like?

Um, you know, the usual mom? I don't know. Well, I mean, I was, oh man, 35, 34. Now, I was raised in the seventies. Um, my dad was always at work. My mom was secret, you know, had a lot of, let's say she had a lot of Valium and a lot of drinks. Uh, [00:58:00] no cigarettes though, which I still wish you wouldn't. Some shrinks let their patients smoke in the, in the office.

You know that, right? I'm aware. Um, so she was checked out, never saw my dad really had a brother. He was kind of around, he is fine. Nothing for you to psychoanalyze me about. 

Preston: Hmm. So everything was, was normal and perfect. 

Margaret: Well, no, but it wasn't anything big like that. You're gonna take and write in your notes that you're not even writing notes.

Why aren't you writing notes? 

Preston: Yeah. I, I noticed you're, you're pretty concerned about how I interpret 

Margaret: you. I, yeah. I mean, isn't your job just like, judge what's wrong with me so you can fix it? Mm, I don't think so. I, 

Preston: I think my job is just to help you feel better. 

Margaret: Good job. 

Preston: Really. 

Margaret: Yeah. I feel like I was trying to like.

Uh, like [00:59:00] get you off center. I was playing my character, not perfectly, but I was sure. You're doing 

Preston: a good job. Yeah, I was like, dang, she's turned up the heat a little bit, you know. 

Margaret: Well there's an episode where she sees a shrink or she's a psychiatrist and like that she's not having it. She's like funnier than I am with that, but yeah.

Um, okay, so obviously this is a very short, that was my third caveat of the episode. 'cause there was one I didn't mention in there, but this is very short. But I think talking about some of these core things that we've mentioned for what makes psychodynamic therapy different outside the form than other form, like other types of therapy.

So let's start with this kind of like in the chief complaint way. What would you say she's coming to therapy for? Like what's your sense of her? 

Preston: She's coming so. She's having relationship distress. Mm-hmm. And or, or relationship dissatisfaction, [01:00:00] I guess. And I think a lot of that is, is a mismatch in desire between her and this partner.

Margaret: Mm-hmm. 

Preston: But, um, I guess where I didn't go with it, like if I wanted to say more behavioral lens would be like, what makes you anxious? Like mm-hmm. Oh, but when you find out that he's seeing other people, okay, how do we, how do we bottle that anxiety? Or how do we dissipate it? Mm-hmm. You know, how do we cope with it?

I, I think ours was rather just continuing to excavate. 

Margaret: Mm-hmm. Mm-hmm. 

Preston: How do we untangle this knot between you and big and why it's so distressing to you? Mm-hmm. 

Margaret: Yeah. 

Preston: Like the, I think you did a great job kind of showcasing that. She's like, oh, it's just sex and we can have fun. Yet also, I'm extremely distressed by it, and I'm frustrated that it's not progressing.

Like, oh, that's, that's like a huge mismatch. Mm-hmm. Mm-hmm. Since, and so I tried to like kind of push on that maybe too early, where I was like, doesn't seem like you're having fun mm-hmm. With this person. It seems like it's driving you to see me. 

Margaret: Yeah. 

Preston: So [01:01:00] that, that's kind of more, 

Margaret: yeah. 

Preston: The, this kind of almost like Socratic meandering, um, right.

Curiosity 

Margaret: and maybe you already get a flavor in some ways. What would you say the flavor of her defenses are? So like in those moments? Mm. 

Preston: Um, so there's definitely 

Margaret: a use of humor Yeah. As like a way of pushing off. So a nega not, not an adaptive use of humor. 

Preston: And then she would shift, uh, she would shift the focus to me.

Mm-hmm. So if I would kind of ask a question about something that she had resistance towards, she would then make a comment about, um. How I'm not letting her smoke or how I'm not behaving in a way that she would expect or something like that, so mm-hmm. 

Margaret: Kind of devaluing you. 

Preston: Yeah. 

Margaret: What if you, if you let yourself kind of extrapolate on this, let's say you learn over the sessions that she's doing that to you in this first session, which is one thing, but that it continues to happen whenever you get close to something [01:02:00] vulnerable or feeling connected or maybe you like are on call for a few weeks in a row and can't do sessions, then she comes back and she's even more this way.

Mm-hmm. Let's say you notice a pattern there. If you let your, yourself as the therapist feel that, how might you imagine what that is like outside the room when she's interacting with this big character Mr. Big character? Like is there a way that something that happens between you may be part of what happens there that is keeping her stuck?

Like she's, she's experiencing 

Preston: transference where she devalues big. That's like a part of the ban of their relationship. So when we're getting at this part where maybe she feels devalued in the relationship, that it's a projection onto me or onto big or something. Is that, was that what you're getting at?

I'm, I'm a little confused by the question. 

Margaret: No, that's okay. A little bit. Um, I think what one of the things I was doing [01:03:00] that you would've noticed if I kept doing it and had multiple sessions, right, is when you get close to something that may make her be perceived as weak or emotional or dependent, she strikes out kind of.

Masochistically towards you of mm-hmm. You're not devaluing you like she's devaluing you. Yes. But like that particular timing. And so she's coming in and saying, I have anxiety about this relationship. It's driving me up a wall. It's just sex. I don't know what I want. Who, who even knows, whatever. Right. And with you, whenever you try to get close and know her and be with her in her emotions, she strikes out.

And so maybe in that relationship, there's a way in which she's contributing to this relationship being like this back and forth, kind of like mm-hmm. 

Preston: So it's not just that he won't like progress it. She's not letting herself be vulnerable. 

Margaret: Right. And even if that would be, like, if she was [01:04:00] vulnerable, he would end it.

Either of those like that she's not. Mm-hmm. The anxiety and the kind of fear of being, let's say if we're looking at like the parents, she described being too much. Mm-hmm. Because no one's present. Prevents her from getting closure and safety, either by breaking up and pursuing other options or by actually being close enough to have like a satisfying intimacy.

Mm-hmm. So that would be a way that what's happening outside, you can learn from what's happening inside the room with what's happening for the problem you present. Yeah. So 

Preston: I, I'd say, okay, you can't, you lash out anytime you start to get vulnerable with me in the room. Mm-hmm. So I imagine that probably happens with your other relationships.

Margaret: Right. So I remember that thing I said about interpretation. Mm-hmm. Of like, where do we go, how direct, and not stealing their revelations. Mm-hmm. So maybe a way you would say it, like let's say you're 10 sessions and it keeps happening, right? Mm-hmm. Maybe the way you would say it would be like, [01:05:00] sometimes I notice as we get closer to talking about something that's hard to talk about and painful.

I, I feel like you put distance between us by making a joke or by questioning something about me. And I'm wondering if you notice that ever. And then letting her 

Preston: just simply bring my observation to her attention. 

Margaret: Yeah. 

Preston: Yeah. Rather than any of the interpretation that goes with it. Right. 

Margaret: Right. And maybe she'll be like, I don't know why I do that and close you off again, but, 

Preston: and then I'm like, so you just did it again?

Margaret: No, no. You don't say that. There you go again. You're like, we're gonna get an MRI show you. Um, and then I guess one last thing that I think is so important and why supervision and having continual, like every week psychodynamic training. What was happening in you when you were pretending to be this character psychiatrist?

Like [01:06:00] mm-hmm. What was your counter transference? Hmm. This is what Gabbard was saying, and this is the relational perspective of we create the inner subjective field is the term that that is often used. So this thing between us is the therapy, but that we both actually contribute to it in different ways, but we both contribute to it versus being Freud's.

Kind of like I'm a scientist of the microscope on a person and analyzing them. 

Preston: Yeah. I don't, I don't know what my countertransference is to think more about that. 

Margaret: Mm-hmm. 

Preston: So I, I guess almost the, like a lot of the relationships I have with mentors or people in academia, weirdly enough that are like critical of me and my competence 

Margaret: mm-hmm.

Is, 

Preston: was kind of what's coming up. Yeah. And so by, by criticizing how capable I am, that kind of called back some of that. So I, so I felt the need to reaffirm how capable I was as a therapist and kind of felt less able to, to show my own vulnerability, you know. 

Margaret: That's great. That [01:07:00] is, yeah, that's perfect. 

Preston: Okay, cool.

Margaret: That's a super, I mean you could have said anything there, but that is like a super duper common, like especially for us as like early trainees. I, this person is saying I'm not capable. And so the kind of feeling of like it touches on something about me that is one is not capable and two is worried about worthiness and not being capable, which are two separate things.

Uh, and then all the things that we do as therapists and trainees to avoid contacting that already painful spot, especially if there's prior experience of like, this part of you is bad and needs to be othered and shamed from other experiences. So I think that's great and that's where our, I say this jokingly, but where our evil can hurt patients is if we don't have contact and like the ability to slow down with like understanding what's happening in the room and what it draws from us, that is not them.

Then that is how we get into enactments, where we accidentally redo their [01:08:00] trauma. Boundaries are crossed, we don't like the relationship flows up and we never undo what is some called in one paper the crunch. Um, which is that the dynamic gets into the room and you guys recreate something they've had before emotionally.

Preston: Yikes. 

Margaret: And then it's like, oh, and that's not just what the therapist brings, it's what you both bring. But it's such a core skill in psychoanalysis and psychodynamic therapy. But I think should be a core skill, not just like, oh, reflect about medicine, but like taking a minute, being like, what did I feel before I went in the room?

And then what did the patient touch on in me that maybe I don't wanna see but activated me in some way, or mm-hmm. Drew something different that I feel uncomfortable and how do I actually just like allow that to be there in me as well? 

Preston: Mm-hmm. Yeah. Interesting. 

Margaret: So we just covered all of Yeah. We could have 1000 more episodes about this.

Um. But we will end, we will end here for today. Any final thoughts from you [01:09:00] on the experience of that? 

Preston: No, I, I enjoyed it. Um, I, I think I, I stick to what I, I said earlier about the falsifiable and like scientific scrutiny, but it, it is, I think a really helpful process to think through and, and I think if we just kind of table the need for the scientific method for a second and realize that we're just kind of philosophers trying to analyze our own thoughts, this is, it's a really refreshing way to, um, measure the human experience.

Yeah. 

Margaret: I mean, well, my, my counter question to you would be our, our medication. Like there's sort of a fantasy of certainty of provability with the medications as well. 

Preston: Yeah. 

Margaret: So, 

Preston: and, and I, on top of that. We sometimes fail to acknowledge that our medications are therapeutic objects in and of themselves that exist between the doctor and the patient.

And that the [01:10:00] capsule of the medicine in a lot of ways represents or is a metaphor for the relationship between the doctor and the patient outside of everything that the medicine does. So, 

Margaret: um, in our show notes, we will have a couple of these texts and papers, uh, cited that I mentioned, and let us know if you want us to do more sort of psychodynamic psychoanalytic podcast episodes.

There's so much we could talk about. Um, we'll do a Neurobio episode next. Yeah. To balance our lenses. 

Preston: And then we can, we can psychoanalyze the, the neurobiology. 

Margaret: Yeah. I'm like, so why do you like that certainty so much? 

Preston: I'm just gonna lead into Yeah, yeah. Sure. 

Margaret: Didn't you ask last, our last episode? Um, didn't you ask like, do you believe in free will?

Preston: Yeah, exactly. And then we were just like going down a whole rabbit hole in determinism. Yeah. So if you like that, let us know. I'm sure [01:11:00] we can find other guests or people to, to include in our, in our psychoanalytic role playing, 

Margaret: hold on. I'm sorry. We have to do one question 'cause I did put a, a poll up.

We'll do one question. Okay. From the, from the audience. That is my bad. Sorry. Someone asked, is there a new perspective insight you've gained training in cycle at analytic dynamic therapy compared to prior? Yes. To obviously the entire episode we just did. Mm-hmm. I think it was new to me based on my prior conceptions and misconceptions, I think.

One of the biggest things I took away from the fellowship year in particular was, I don't know the importance of having kind of mystery at the center of the work that you're doing and understanding more about like what my own feelings bring into the space of the therapy that we're doing and how that can both be used positively and can be a liability, and that it's like this [01:12:00] constant paying attention and practicing that makes these therapeutic relationships really come alive.

So that's my answer to that question. I know you haven't, you haven't had as much, but 

Preston: Yeah, I think the, the little bit of engagement I had with psychodynamic therapy is, it's been interesting to reflect on how these. Paradigms or concepts apply to my own relationships. Mm-hmm. So, uh, for example, like something called like object constancy or like the ability to, to handle the dialectic of emotions towards a person has been something I reflect on a lot.

Like, okay, how am I labeling this person as like a single good person or a single bad person? How, how can I kind of see them as both or, or I find myself, actually my biggest revelation is not, not necessarily how do I feel about this person, but what is our dyad? And so that kind of actually helps me take a [01:13:00] third step outside of the room and like look in on our relationship from the window, so to speak.

So I would say that's probably the biggest revelation I have is just being able to zoom out a little bit more and reflect on the dyad rather than just like, what is, how do I feel about you? Mm-hmm. Well, 

Margaret: mm-hmm. 

Preston: How do I feel about, how do I feel about you? Like that's, that's the real question. Where is 

Margaret: my tweed jacket when I need it?

Preston: Exactly. Uhhuh, where's 

Margaret: your, your fedora housing come out. Okay. Thank you guys for asking us questions. Also on there, there were others we will get to at another time. Okay, Preston, now you can do the outro. 

Preston: Do you want You want me to roll it? Roll it. Okay, 

Margaret: brother. So 

Preston: if you wanna come chat with us in the Human Content Podcast family, we're gonna be on Instagram and TikTok at Human Content Pods.

We also, um, are available for questioning at bad Art every day, and it's pre for questioning. Yes. Any of your inquiries will be fielded promptly within two business days or two weeks. Who, who knows? Depends on two hours much you have after call. If you want to see the full videos, they're [01:14:00] gonna be on my YouTube edit.

It's prerow. And you can also see that the video version on Spotify, which I watch sometimes, shout out to all of our listeners who leave the kind feedback and awesome reviews. Uh, someone posted on their story last week that we were part of their morning commute, and I forgot your name, but thank you so much.

Uh, if we're on your morning commute today, uh, I'm gonna remember your name for next time and we'll shout you out. 

Margaret: Stay tuned. We're your hosts, 

Preston: Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aaron Corny, Rob Goldman, and S Shahnti Brooke, our editor and engineers.

Jason Portizo. Our music is Bio Mayor Ben V. To learn more about our program, disclaimer and ethics policy, submission verification, licensing terms, and our HIPAA release terms, go to our website, how to patient paw.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.[01:15:00] 

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 [01:16:00] background.