The Theory of the Crunch: Holding Difficult Dynamics in Therapy

Preston: [00:00:00] The therapist goes, "It's my job to fix this patient," or, "It's all the patient's fault for not getting better." And that gray area, that nuance that I think the author's encouraging you to look at is that it's, not your problem, it's not my problem, but it is our problem.

Margaret: It's our problem. Yeah. How to be happy.

Hello everyone, and welcome back to How to Be Patient, the podcast where two psychiatrists deal with their own incompetencies even in this episode, together out loud. 

Preston: And sometimes we come to solutions, but most of the time we just have fun. 

Margaret: Today in response to some of your Spotify comments specifically, we are doing another episode within the psychodynamic psychoanalytic realm, which means I am driving.

And we are going to be talking about one of my favorite papers in all of psychotherapy, which is a paper called The Theory of the Crunch by [00:01:00] Paul Libby Russell. We will get more into that paper and it will be, put in the show notes too if you'd like to look into it. But the paper is functionally about when non-suicidal, non-dangerous crisis basically is happening in therapy over and over again, and you feel lost and a little bit on the verge yourself as the therapist.

However, before we get to that, I have our icebreaker for today. Preston, are you ready for our icebreaker that I didn't tell you before? 

Preston: I'm absolutely ready. 

Margaret: So my question is, compared to six months ago, how has your thinking or practice or really any part of being a therapist or the therapeutic part of being a psychiatrist changed, grown, evolved?

Preston: Oh, that is a great icebreaker and I would say that I've, changed the most by loosening up. So [00:02:00] when I first started doing therapy with my patients, I think I was focused on doing so many things at once, like controlling my countenance, looking for good reflective points, trying to find the, the thread in the conversation, what this person's, you know, underlying, insecurities or, issues might be to, help them uncover them.

And it's like a golf swing I guess. You, ever get feedback or I don't know if you golf often, but- ... you get feedback on a golf sp- swing, people will tell you, you know, "Relax your knees, but also straighten your back, and also I need you to keep your eye on the ball, but also look at the arc as you follow through, and also pull with your left arm."

And then you try to do all of them at once and you're like, "Well, well, well, which is it? What do you want me to improve?" 'Cause that's obviously not working. I'm just, I'm swinging and I'm missing. So I was kind of doing that in therapy a little bit. I'm like, "Okay, like, like let me, you know, pat my head and rub my belly and do all the things [00:03:00] at once."

and then I reached this point where I kind of just reacted like a human to things, and that ended up leading me to better doors that I could open to, to be a more effective therapist. The other thing That I've started trying to do is jump to more complex reflections. I'm, I think I'm less afraid to just call out how I think someone feels about something.

So for example, I look very closely at how people act like they are when they say something rather than taking their word as much. So people will always say something's good or bad or okay, but I just care way more about how they act when they say it. And then I just make something up, you know?

Like, I might say something like, "Oh, you know, your mom's coming to visit this weekend." "Yeah, she's coming to visit, all right." And I'm like, "You wish, [00:04:00] like, you wish she wasn't coming at all, do you?" Like, I, like something of that is something a therapist person wouldn't have said, you know, probably six months ago, but then I would've been like, "Oh, and what are you doing with your mom?

Okay, cool, And when is she leaving?" And then you ask for all these stupid details about something that doesn't matter, whereas me now I can kind of get to the creme, the, the- ... core essence, which is how you feel about your mom coming, and then also guessing and naming that you're not happy she's coming 'cause it's not very often the patient's gonna be like, "I hate my mom" openly.

Margaret: Right, 

Preston: right. I'm gonna lead with that. It's easier for me to agree with it. Yeah. So I'd say tho- those are probably the two ways that I've improved. I've loosened up and I'm less afraid to just take a stab and call out bullshit. 

Margaret: Yeah. Yeah. And what do you think has like... Is there any particular influence or just time?

Like, what do you think has led to those two developments? 

Preston: I think it's feedback. Like, and not like explicit feedback I've gotten, but [00:05:00] seeing what is more effective at getting people to open up and helping them feel better over the course of the session. Because you can- Mm-hmm ... I mean, you know this too, you can definitely feel when a session is kind of going in circles.

Mm-hmm. And you're stuck in small talk or you're, or there's something being hidden in the room that's not being addressed. 

Margaret: Yeah. 

Preston: So I guess, you know, every therapy session has an elephant in the room, and my feedback is noticing that I'm finding more elephants. 

Margaret: Yeah. Yeah, like these elephants are...

I'm just, I'm locking them in. They're here. 

Preston: Yeah. 

Margaret: Acknowledge me, as that one meme says. 

Preston: Yeah. Yeah, exactly. I'm like, this... How do I know it's working? Look, like look at my wall. See all the elephants on there? Yeah. Yeah. I hunted those down. 

Margaret: I hunted them. Why are we killing them? 

Preston: Well, I mean, I guess you don't have to kill the elephant, but we hunt for it.

Say no to 

Margaret: the elephant. 

Preston: Yeah. The, there, there are pictures of elephants, not 

Margaret: of their heads. Amazing. Okay. Yeah. So loosening up and deepening [00:06:00] in some way. 

Preston: Yeah. Yeah, I guess. Sidestepping small talk, I guess. 

Margaret: Yeah. Yeah. 

Preston: What about you? 

Margaret: I would say mine has changed- I think I've been working in a residential setting that it, like in the last couple weeks, that is a DBT-based residential.

And so I think locking back in on skills and less of the like I don't remember them, but more of like trying to practice speaking the language every single day in these residentials of like, of DBT. so I think it takes-- I think most models, including pharmacologic, including like imaging or, you know, quote unquote neuroscientific approaches depending on whatever part of that we're talking about.

I think any lens, to really understand it, you kind of have to suspend your disbelief or the other systems that you know are part of this and let yourself be kind of [00:07:00] immersed into that particular lens if you want to be able to meaningfully use it. By that I mean I think it's easy, and like we see patients this happens for, where you'll be like, "Have you ever heard of DBT?"

And they'll be like, "Oh, I did it before and it didn't work." And it's like there were three groups on an inpatient unit, that is not DBT. Like it is the concepts of DBT, but it's the same thing as being like, "Oh, I read four Julia Child recipes and now I know I don't need to go to French cooking school because I got it."

It's like, "No, you don't." And so-- And I think as therapists it's like, will I be a DBT therapist? No. But do I want to, in this particular part of my training where it's like available, really learn and deepen into it? Yes. And so I think that's been like fun for me as a person and as a psychiatrist to actually be in a setting where they're really specifically practicing one thing in terms of like a skills-based therapy.

And it's-- it-- I think even for my private practice patients, it's like [00:08:00] utilizing skills, and I like to still, even if I'm doing more dynamic work, I still like to come up with things for in between sessions that the patients might try to do to bring something back or kind of deepen the work that we do in session.

I think skills are just like a really great way to do-- to frame that and make it tangible. So I would say I'm trying to be more skillful, as they would-- as Marsha Linehan- 

Preston: Mm-hmm ... 

Margaret: as our, my DBT friends would say. 

Preston: So you're entering the DBT 

Margaret: dojo- 

Preston: Exactly ... and fully committing. Yeah, that's meaningful.

I think like the best way to get good at something is not to try to bounce a bunch of different skill sets at once. It's just to- Mm-hmm ... to lock in on one. 

Margaret: Yeah. Yeah. 

Preston: What, what part of DBT, what pillar of DBT do you find you're the best at skill-wise? 

Margaret: I don't know because they're so, so like all interwoven.

I would say I have like a fair amount of experience with mindfulness, and I think-- so I think the mindfulness ones kind of [00:09:00] come naturally to me now because like the first mindfulness class I took was as like a sophomore in college. So it-- And there's like a lot in contemplative prayer and stuff in Catholicism that is- Mm-hmm

is in a lot of ways s- coherent with mindfulness. So I would say that. I think like many people, the like interpersonal effectiveness skills and emotion regulation, like You need those skills when things are tough. And so I would say I don't like having to practice the tough skills because they're like, "Hey, things are feeling bad.

Let's do it." 

Preston: I feel like such a hypocrite teaching interpersonal effectiveness skills 

Margaret: because- 

Preston: Like the dime game. You ever play the dime game with your patients? Yeah, we 

Margaret: talked about it on this podcast. 

Preston: yeah, exactly. I'm like, "You need to do this," and I'm gonna-- I know I'm gonna walk away and the next day absolutely not even apply it to myself.

Not on purpose. I'm trying. It's just really hard. Yeah. 

Margaret: Yeah. Well, I feel like [00:10:00] also as therapists, like the things that skills do similarly that they do to patients is like skills give you something with like handles on it to take with you versus just being-- it, it can be easy to be kind of abstract and make it so it won't re- you won't be reminded of it in day-to-day life.

But with a skill, it's like you start to see very clearly where you're not doing a skill, where you could. Mm-hmm. And it's like, oh, dang. But that's, I mean, that's good though. It evokes humility and makes us more empathetic. 

Preston: Yeah, it really does. Keeps us grounded. 

Margaret: Speaking of needing empathy and remaining grounded, we are gonna get into this paper and talk a little bit more about some of the concepts in it that I think even if you are not-- even if you are mainly prescribing, but just wanna prescribe psychotherapeutically and understand the relationship with your patient a little bit better, I think this paper is great for analysts, dynamic therapists, and the rest.

And so we will talk about that right when we get back.[00:11:00] 

Preston, the first thing I wanna ask you, so this is one of my favorite papers, and listeners, it is an analytic paper. In some ways it's dynamic. Most of you won't care about that distinction. But Preston, my first question for you is just like, how was reading this paper? 'Cause it's dynamic and analytic papers are very narrative and kind of philosophic, and I know you read a lot of the existential work before, Mm-hmm

so you have some comfort with that kind of writing. But like, what was it like for you to read this paper? Again, this is The Theory of the Crunch by Paul Liby Russell, and it's kind of about borderline personality disorder and dealing with patients that are sort of, quote unquote, "difficult" or present with some difficult feelings that maybe get evoked in the clinical setting.

Preston: Yeah, I liked the paper. I read it twice, so I was like between patients. I perused it yesterday, and I enjoyed the prose, and I liked listening to the ideas, but it's dense. Yeah. And I find myself, like, [00:12:00] kind of glossing over a paragraph and then realizing I didn't really track on anything that was said.

Margaret: Yeah. 

Preston: And then I went back again today and I looked more meaningfully at, like, how the, the ideas link together. I think the thesis of the paper, which I'm sure you'll get at, that, you know, the psychopathology of borderline patients is driven by this crunch- in, in two, two areas, the, like, repetitive compulsion and, the holding area.

I, j- I found myself seeing all the same concepts that are, being named differently in the paper, which, I appreciated and it kinda helped me relate to it. So overall, I thought it was also, Empathetic to the provider or the therapist, which I think not all literature is. Sometimes it's like the patient is this [00:13:00] way and the patient is blameless and you need to do everything you can to support the patient and if you don't then you're biased and it's cultural bias or you're terrible, blah, blah, blah.

But they, I think did a good job or the author did a good job of kind of balancing that responsibility between the parties so I appreciated that. 

Margaret: Yeah. I think he does a really great job and I-- one thing I read about this-- 'cause this paper was given to me my PGY3, and then I read it again my fourth year for the psychoanalytic fellowship and then I read it again before like planning this episode and Paul Libby Russell was like Boston/New England-based as a psychiatrist and a professor and apparently like much of his writings like in- I think including this paper weren't published until after he had died, and died relatively young.

But people had the papers 'cause he would write these out and then like it was like he would Xerox them and bring them over to his mentees in like the College of Social Work or whatever and give them to him and they ended up eventually publishing a collection [00:14:00] and it says it, it said in one of these like writings about him like it's had a big impact on the New England psychoanalytic community and I think that's true.

Like most people I know out here in Boston like in this world at all like know this paper and recommend it and I think it is like a beautifully written paper that has remained Really readable and helpful, and I think kind in a lot of ways like you're saying. so I just thought that was a fun fact about how this paper came to be.

And so I guess the first concept I want us to cover-- So one thing I wanna note is that, like, there are a lot of concepts in this paper that are not necessarily, like, capitalized or bolded, but are kind of like concept words within psychodynamic and psychoanalytic therapy. And so-- and sometimes they mean things that are different than what they mean in, like, common terms in psychiatry, a few of which that are most notable are kind of in terms of object relations and the idea of, like, the depressed state in development, and [00:15:00] then as well as, like, borderline, the original name for it was regarding an idea of being borderline psychotic, which wasn't just clinical presentation, but was also thought of how analysts thought about development.

So I won't go too into that right now, but I just wanna note for people who do try-- read the paper, I think it's still readable without knowing those things, but there may be some parts that are confusing because they use words in different ways. Does that check out, Preston? 

Preston: Yeah. Yeah. So, the words I'm thinking of are, like, introjection versus internalization or identification.

Margaret: Yeah, those are all so pretty complex- 

Preston: Yeah ... 

Margaret: concepts within psychoanalysis. 

Preston: Yeah. And so I, I-- Like, when I came across those, I-- I'm like, "I know what introjection, internalization mean," but I wanted to make sure that I could, like, look them up in the context- Mm-hmm ... of, like, psychoanalysis. 

Margaret: And what did you find?

Preston: So, interestingly, it, kinda seems like it, it lives on this stepwise spectrum from almost, like, no identity to, like, a fully secure, developed identity, [00:16:00] and I think that's kinda how he describes it, too, that on one end you have, like, pure introjection, which he describes as almost a subconscious absorption of another's identity without any awareness, you know, in the name subconscious.

So I don't know. I was picturing, I think it's, like, April from Parks and Rec. She, like, dates these boyfriends, and then she's like, "Yeah, I was dating this cowboy, and then I completely became a cowboy during that era in my life." I was like, "Oh, that's like introjection." like, you just take on someone's personality and don't even realize it.

But then there's identification, which is, like, you have parts of your own self, but then you take parts of other selves to mold it into yourself. And then there's, you know, obviously a complete stable ego. So I was picturing your ego as, like, a circle. It's like going from being completely contained to completely open and suggestible.

Margaret: Yeah. And I think one that is important is the idea-- and where it [00:17:00] becomes less of a line or a spectrum in these concepts, but more of This dynamic thing, for lack of a better term, that happens moment to moment in relationships. So you could be internalizing someone, or you could be totally, like, projecting or introjecting, and then the next moment you could be doing projective identification.

But it is fu- fundamentally, right, these relational concepts of how does my... You

know, to go back to that one concept of I-thou versus I-it, right? how do I relate to another person? How do my emotions relate to their emotions, their identity, all of the interpersonal kind of grapplings of that, and rage, and love, and joy, and sexuality, and all of it. so yeah, there's so much we could say about all of those because I going through, the fellowship on it, it was like you would think you had grasped it, and then it would be like you would read another paper and you're like, "I have no longer grasped it anymore."

Yeah. Which is okay. It's like, it's one way to think about things. I [00:18:00] wanna go, I wanna just say, like, let's start by basing on this. The thing that we are talking about here in the paper is he's reflecting on ideas around borderline personality disorder and the ways of relating to self and others.

And the starting point of this paper that he starts with is the idea of patients where people are hesitant to accept them into their clinic because of crises that have happened in the past because, like, things that he lists are like they fired three other therapists and there's intermittent, like, self-harm or substance use or things like that, and that people are like, "No, I won't accept them into my clinic.

I don't have capacity for them," whether that's true or not. And this paper is written from a place of how do we understand the difficulties that can happen in the therapeutic space between someone that may have personality kind of dynamics, which include borderline personality disorder, they also include, like, narcissistic, [00:19:00] histrionic, all these other dependent.

How do we understand what's happening when we are in the crunch, of which one flavor is the crunch or kind of the symptoms or parameters or ways of relating that arise between the therapist and the patient with borderline personality disorder? 

Preston: Mm-hmm. So, so these parameters that you're talking about, these are, like, the different avenues through which you can relate to someone with a personality disorder?

Margaret: So the parameters, like, the way he talks about it is one of the ways he defines it is referencing someone else, which is parameters in psychodynamic or analytic therapy are, like, ways of doing the therapy over and above the, quote, "usual frame" to continue the relationship, which then eventually will need to be analyzed and removed.

So for example, I can imagine that there, as you get further and further into practice as, like, a therapist or even as just a prescriber, there's your usual way that Preston does things, and while it may change a little bit patient to patient, there's [00:20:00] sort of a usual range and a way you go about things.

And then you may have a patient who for whatever reason relates to how you do medicine that is successful for other patients in that it is not working or successful or acceptable to them. And for that patient, you can unconsciously or reactively, like, change things and maybe in a way that's not healthy or is part of this, repetition compulsion.

Or you may say, "I am thoughtfully and under supervision being a little bit more flexible here than I would recommend for all of my patients because I think it can get this patient eventually to the kind of care and relationship that is therapeutic." And so the parameters thing is used a little differently by him in different parts of this paper, I think.

But ultimately, I think about it as, like, parameters are the ways of relating, are both the way the patient relates- Mm-hmm ... and how you flex it. So I think it, there is some- 

Preston: Okay ... 

Margaret: flexibility in the term. One of the ways he uses it [00:21:00] is also the patient's patchwork holding operation to make do around something prior that is, is like the way they learned how they had to relate to other people.

Th- 

Preston: that's the one that I saw where it's, he lists like masochism, narcissism- Yep. 

Margaret: Yeah ... 

Preston: like guilt. Like these are, the parameters are just the, the temporary fixes that they've- Yeah ... they've learned to function without truly being able to relate to another human. 

Margaret: Exactly. 

Preston: Okay. 

Margaret: And so one of the things that he talks about in this paper at the beginning is kind of like what are the s- clinical situations he's talking about?

And I found it interesting in that He talked about the thing that arises in the therapist in these, which is like a feeling that you yourself are on the edge of your sanity, uncanniness, feeling helpless, feeling the patient is doing this on purpose, feeling that there is some better therapist out there who could do this differently and better.

and that process, that [00:22:00] disorientation, is what makes some patients so difficult and what he's trying to help us with this theory of the crunch. 

Preston: Yeah, the, the uncanniness of the problem presented for you, I think is the sentence I saw. And then I- o- one thing I liked about it, I think I earmarked this, is that the crunch in a nutshell is that the patient makes the therapist feel the uncanniness of the unsolved problem between them.

and he says this is why it's such gut-tearing work. And then, he talks-- he continues on and says, "If the therapist, if he is going to be helpful to the patient, the therapist's resolution of the gray area within himself has to be genuine. He cannot lay trips on the patient. He cannot resort defensively to some bits of the theory to an interpretation or putting it back on the patient, but it's your problem."

Margaret: Yes. 

Preston: So that's something I see all the time, I think in like my colleagues or even in anyone when they're regarding these patients is they [00:23:00] externalize it back onto the patient. Mm-hmm. But it's your problem. Mm-hmm. or we internalize it. how often is it- I'm just a trainee. Yeah, the therapist goes, "It's my job to fix this patient," or, "It's all the patient's fault for not getting better."

And th- that gray area, that nuance that I think the author's encouraging you to look at is that it's not your problem, it's not my problem, but it is our problem. It's our problem. Yeah. 

Margaret: Yeah, I think that I-- and I think that instinct is so easy to go to, right? 

Preston: It makes you feel better. 

Margaret: It does make you feel better.

Like why wouldn't you go 

Preston: for it? 

Margaret: And like also when we have all these conversations arou- and like are learning to be therapists or clinicians of any kind, how do you know-- Like there's not one answer that's like, and this is what you do every time there's a patient who is making you feel their situation and their problem has been-- you're so empathetic with it or involved in it that you feel unworthy or that they're trying-- [00:24:00] that they hate you, or that you don't know where y- like kind of where you are emotionally or like what's happening.

like it's almost like you find yourself, and this is where part of it that we won't get into comes into like projective identification, is that a lot of projective identification is the idea that like the way someone relates to you in therapy makes you act in ways that are very much like not like you.

And it's not that it absolves the therapist of like doing things, but if I come in and I sit down and I just start yelling at you, and you start yelling back at me, and you never yell at someone, I had some role in why you were yelling, correct? 

Preston: Mm-hmm. 

Margaret: So that, that's kind of the idea. But that can be very confusing for the therapist, especially early in the career.

So I just think the, like, desire to remove yourself in many ways as a therapist, like, we can have so much compassion for that without then saying, "And that's the right move to do 100 times out of 100 times that it might come up." 

Preston: Yeah. 

Margaret: And we love to [00:25:00] intellectualize. Like, in some ways, like, how do you become a psychiatrist besides loving to intellectualize feelings?

Preston: No, absolutely. Like, I'm only feeling sad because they're externalizing onto me, and clearly the patient had no desire to get better in the first place. 

Margaret: Yeah. 

Preston: Boom, now I feel better and I can go home, but we actually haven't done anything to address the uncanny problem. 

Margaret: Yeah. Yeah. And so this is, like, I think one of the things he doesn't-- that he's kind about in this paper is not to say that this doesn't take emotional work and a lot-- like, it takes a lot of involvement.

And I think that framing in this paper that, like, the therapist has to really contend with themselves well and, like, kind of be, I think in that, in my mind, is, like, well-rested and, like, resourced enough that you can take in this kind of complex cognitive and emotional task of trying to sort of feel your way through this conflict over and over again better and better each time.

Like, that takes-- But, like, to recognize that as the task, I think is [00:26:00] compassionate in that it's something that is difficult, right? 

Preston: Mm-hmm. 

Margaret: Whereas I think sometimes it's like, "Why can't I just, like, not be impacted by this? Like, why is this impacting me?" And It's because it's very difficult 

Preston: It takes a lot of energy to be compassionate.

Margaret: Yeah, it does. It takes a lot of thought, especially when it's like, as he's describing here. So one, one of the other, important parts of this that you mentioned a little bit early, earlier is the idea that when we're working with patients like this, one of the things that they are battling, and that is the problem that then we come to engage in and share, is the idea of a failure of containment.

And so he quotes, you know, classic Donald Winnicott's 1965 paper of the holding environment, which was the idea that, like, early in development, at some point there was a failure in that environment and in attachment and responsiveness to be able to supply [00:27:00] to the child, like, a way of working through their emotions with them.

So, like, the concept here is that you have a two-year-old who's, like, crying and angry, and maybe the parent screams at the two-year-old and doesn't understand that they're, like, a two-year-old and are-- this is appropriate, or, like, ignores their crying until they just stop crying. And so that is the containment of kind of these strong-- I mean, we've all seen this, right?

Like it's this containment. Mm-hmm. You can think of it even with, like, a three-month-old. Like, the parent or caregiver comes in and, like, attends to their needs and, like, your one-year-old can, like, bop you on the nose and you're not gonna, like, bop them back. Like, you take in their anger and their impulses, and you hold it.

And over time, that kind, like, regulated holding teaches them and contains them to how to internalize their own emotions. And so when that's missing, then these patchwork kind of parameters or ways of dealing with emotion start to be the thing that gets people [00:28:00] through- Mm-hmm ... these environments that didn't provide them with what they needed, and then the problems come, and they come to us when those ways of dealing with things are not the most effective and cause problems.

So, like, let's say you're a kid who learned, like, parent is gonna have really big emotions, so you're gonna isolate and avoid when there's big emotions to try to keep the peace. That will come into the therapy, as I'm sure you've experienced as a therapist, right? And then- 

Preston: Yeah ... 

Margaret: that patient being able to be angry and express themselves and inconvenience you a little bit is their-- the work to be done.

And so this idea of containment is one of the things that I think takes a lot of work, and it's also the most central, as this paper says, in working with patients with borderline personality disorder. And it-- When you think about the symptoms of borderline personality disorder in DSM, like, this sense of lack of self and, like, volatility in relationships, like, this idea makes sense as to why this has to happen in the therapy.

Preston: Do you-- I, and I guess synonymously I see the lack of [00:29:00] containment as just a lack of regulation or lack of, like, restabilizing or, you know, containing the emotion Do you think that it's in larger contribution that it's harder to develop a stable sense of self when you can't regulate? Or that the dysregulation comes from not forming a stable sense of self?

Obviously, they're intertwined, but I guess I'm kinda getting like a chicken and egg argument here. 

Margaret: I'm not sure. What do you think? 

Preston: I think that the lack of regulation impedes your ability to form a sense of self. And I would g- guess that because very early on you have no concept of self, but you do have to have a concept of regulation.

And so y- your ability to regulate your emotions as you enter new environments and you enter new opportunities to relate to other people, that your ability to regulate is absolutely [00:30:00] necessary for you to form an ego. And if you don't have that, then the ego lags behind, and then in turn contributes to more dysregulation.

Margaret: Yeah. Yeah. It's almost like, it makes me think of even just, like, biological development, that it's, like, in utero, like, you don't, like, the fetus doesn't ha- like, developing fetus doesn't have its own total body. Like, it's not feeding itself. It's, like, coming fully from, like- Mm-hmm ... the mother's body, and then eventually it's outside of the body and being, like, fed via formula in modern day, but formula or breast milk, right?

And then eventually it totally learns to eat of its own and then feeds itself as you grow up. And I think that's, like, a very good analogy for This process that includes the building of the self that you're saying. That, like, that there's, not some, like, cognitive developed form of the self yet, and you kind of, like, slowly build it by taking from parents and family environment.

And then eventually you go off on [00:31:00] your own and you build it from other things too. But if there's so much dysregulation and you're sort of not metaphorically being fed by being regulated, you don't have the capacity to start. You don't build that in the same way, at the very least. 

Preston: I mean, like, how, do we build who we are?

We, look at values and actions and parts of ourself that largely, I'm sure, stimulate certain emotions. This, makes me feel happy. This makes me feel content. this helps me relax. So, so we look for those signals in your life. Am, am I a soccer player? Am I gonna join band? Do I care about relig- like, all these things give us signals back to us as to how we wanna form ourself.

But if overlaying all that is just this crazy noise that's like you're in crisis all the time, this is terrible, this is great, this is terrible, this is great. Like, the, the signal-to-noise ratio is off. You can't find those signals of yourself under all the, [00:32:00] the failure of containment. 

Margaret: There's this famous quote by Winnicott that everyone likes to say all the time in child psych, and it's, "There's no such thing as a baby."

And what he means by that is, like, there's no baby's self outside of the family dynamic and the parent, caregiver, whatever. Like, the, self- Mm-hmm ... kind of like you're saying, is so what, is that not built up yet? And so I think that's a great quote, one. But two, it's just to say, like, human beings and our development is deeply relational, and with- Mm-hmm

I, like, we're incoherent without relationship, and our development reflects that. And so the one other part I wanna say about this that he goes on to say, which I thought was well written, was, "Now, one cannot simply supply in the treatment relationship the parenting that was absent when the patient was a child.

The reason for this is that the patient is not now a child." 

Preston: You can't just be the mom. 

Margaret: And a large part of what is now wrong represents what the patient himself has structuralized, [00:33:00] or these parameters or ways of relating that ha- came to save the patient, but now are kind of codified or at least deeply grown in.

And then he goes on to say, "The thing that seems to me useful about the concept of containment is that it begins to get at a common element that is missing, both in the a- patient's actual past and in the present as it is internally and externally structured by him. It is the actual successful containment in a relationship with a therapist that is the agency by which the capacity to contain is structuralized within."

When I think about this, I think about another concept in psychodynamic therapy that I think works well. You could use other lenses of therapy to say it, but The idea in intersubjective and interpersonal psychotherapy is, like, the corrective experience and that you have to get a lot of reps of a different type of response in relating for it to stick.

Preston: So by the, the, by the corrective experience, you mean that simply by just being [00:34:00] a healthy object or stable object to relate to- 

Margaret: Mm-hmm ... 

Preston: you just have to give it time for that to- 

Margaret: Yes ... 

Preston: to simply 

Margaret: correct In the therapeutic relationship. Yes. Yeah. 

Preston: Yeah. 

Margaret: Which is easier said than done. Like, if someone comes in and looks at you kinda like they're pissed at you every single time, you get why that's not happening just out in the world, right?

Preston: Mm-hmm. 

Margaret: Like, if they look and they're like, "What are you looking at?" And it's like, as a therapist, your job is to know, like, "Okay, that's gonna trigger this in me. Did I get enough sleep? Let me know this is happening. Let me not just respond- 

Preston: Mm-hmm ... 

Margaret: how that might draw out in other people. Let me do something a little bit weird, I guess."

You know? Like, a little bit strange and maybe not impulsive to change what's happening and to s- Mm-hmm ... to struggle it out with them, as he says. and 

Preston: that could be six months into court-mandated therapy before- Yep. ... they're finally not lashing out at you the second they come into the session. Yeah. Or another hard one, too, is I think if the patient's, [00:35:00] I guess parameter or if they're used to eliciting affect from other people as a way of kind of mediating the failure of containment, that you have to hold onto it.

So they'll comment on your appearance. I think that's hard, too. 

Margaret: Mm-hmm. 

Preston: Like, I don't have the mustache now, but I would have patients say, "Oh, it's..." Like, "Did you lose a bet? Why are you, why does your face look like that?" And I'm like, "This is the start of the, session." Like damn. You know? And most of the time you can take it on the chin or the upper lip, wherever you wanna put it.

But when you're tired, like you said- ... if you don't have, if you haven't supported your please skills, it's so easy to be like- Yeah. ... all right, like we hooping. Like let's hoop. What's happening? 

Margaret: Yeah. Yeah. 

Preston: it sucks. yeah, so like you have to learn... The corrective experience is so much easier said than done, being like yeah, the, you know, these antisocial patients are gonna come in, they're gonna supply you with conflict, and you just be that [00:36:00] stable relationship that contains it for them, even if they're just insulting your appearance, insulting your intelligence, just degrading you in every way that they can.

Margaret: Right. 

Preston: Just say, just being soft. 

Margaret: Yeah. and still responsive and still hopeful. 

Preston: Mm-hmm. 

Margaret: That, and like reflective in some ways of like the reality of like, that kinda hurt my feelings. But like- 

Preston: Mm-hmm ... 

Margaret: if this was going to be fixed for people who come to the clinic for this kind of treatment, if this was gonna be fixed by people around them just being healthy people, that would've worked already.

Like, there would've been people somewhere along the line that they would've met that they would've been like, wow. This kind of regular responses to me will normalize things out. And it's like it has... I think the other thing, especially with borderline personality disorder, is like it is relational in so many ways.

I think across the board we sort of agree with that. Like, there's other components that make it happen, but like Linehan says like an invalidating environment match to the child's like traits. And so it has to h- I do think [00:37:00] it has to happen in relationship, and that, and it doesn't just happen through insight, which I think is the frustrating part for us who as people who are, tend to be intellectualizers.

or for people who, as psychiatrists where we're like just doing the medication and seeing people once every like four to six weeks, but then this stuff comes up in our relationship too, and it's like- 

Preston: Mm-hmm ... 

Margaret: well, knock it off. I only see you every six weeks. Why is this still, why are you doing this still?

It's like insight alone is not enough. 

Preston: What do you mean? Insight on which, on the provider's part or the therapist's part? 

Margaret: No, insight on the patient's part. Like us being like, "I'm noticing that you..." Like, if someone came in f- and it was their second visit, and they greeted you the exact same way, like angrily, right?

Or not greeted, maybe greet is the wrong word. But like, they're like, "Well, I see that you shaved. That wasn't a good look." If you just immediately bluntly turn to them, most of the time it won't get us on the right path to just be like, [00:38:00] "It's really rude that you say that to me." Right? Like, that's not gonna do much.

Preston: So me, me calling it out to the patient would be granting them insight that- It 

Margaret: would be trying to give them insight. 

Preston: Yeah. 

Margaret: Would it... it's kind of not metabolizable in that form by the patient in that moment. If it was, they wouldn't be in our office, and it would've changed. 

Preston: I mean- I would say the patient has insight into the, that what they're saying is hurtful or critical.

Margaret: Mm-hmm. 

Preston: And they lack the insight in that this continuous trait that they have is probably why they don't have a stable relationship in their life. 

Margaret: Yes. 

Preston: So it's like I, maybe I'm like targeting this, this comment you s- you said, but it did kinda made me wanna think more about like- 

the layers of insight that we have.

Margaret: Right. So- You could, word this differently that like basically there's a part in the paper where he says it has to be felt through and struggled through within the [00:39:00] relational capacity to be real, and that the patient himself within the process over, being done over and over again, getting more and more of these reps, has to within the process themselves discover it happening.

Mm-hmm. And you can like help along the way, right? We can name certain things, but the point is not to give an interpretation and say, "See, we're in that same thing you do again," because that is not the patient building an ability to do that. And so I guess like just to, to your point, like you c- we could rename insight in a different way and say like that would be like experiential insight.

Mm-hmm ... the point of this being though is that often I think we all want to be like Say the thing that will make them finally unlock all the stuff, and then everything will be clear and we'll go from there and, like, whatever. And it can't be... I don't think it can be cognitively known in many of these cases.

It has to be felt. 

Preston: I agree. You could, like the, what, like the Oracle of Delphi. I feel [00:40:00] like you could go to the Oracle of Delphi and say, "I want to know what is absolutely wrong with me and what I can do to fix it." And I get she-- I bet you for most people, she could just spit it right out and be like, "Ah, screw you.

It's probably wrong." Like- 

Margaret: That's probably not it. Yeah. 

Preston: Yeah. E- even if it is 100% accurate, like the, the truth doesn't matter if it's being told to you as long as you haven't experienced it or emotionally believed it. 

Margaret: Well, and this is part of why other analytic writing uses the idea of being able to attach and, like, breastfeed as the what is happening in therapy.

I know. Don't be... L- listen, this is a natural process. It is not literally, but metaphorically, it's like, can I-- are you giving me something that I can metabolize? 

Preston: Mm-hmm. 

Margaret: And I think why these cases are so hard is we continue to try to give something that can't be metabolized, and then also it makes us feel really hard feelings, and we have to work really hard to contain it often.

Preston: Yeah, it's like herding [00:41:00] porcupines without oven mitts. 

Margaret: Yeah. It's I don't know. We've all experienced this where maybe you interpret too far with a patient, and you're like- Mm-hmm ... "This is what you're feeling." And they're like... And you could be right. Like, they could come back to you two months later and be like, "You were right, but I just, like, was pissed to hear you say that and not in a good way."

Preston: Mm-hmm. 

Margaret: And we've done something where we've-- another phrase that is used by, from a different paper in psychodynamic therapy is being in the neighborhood, and that the patient has to be in the neighborhood of what you're saying in terms of their awareness to actually, like, use it. Mm-hmm. I think that's also part of this slow work with these patients.

Preston: Yeah. that makes me think about one of the aspects of, existential psychotherapy when you're trying to confront death with patients. So most patients are not gonna be in the neighborhood of their death denial and their- fear of death. So it's almost, like, never helpful to directly talk about it because [00:42:00] it's always gonna be, like, too much.

Margaret: Yeah. 

Preston: And, like, Ir- Irvin Yalom talks about how it's, like, easier-- the easiest way to, like, address or directly talk about death with patients is when they have either had a near-death experience or are already, like, diagnosed with a terminal illness or have... Are, like, no longer able to deny death based on their life circumstances, then they're close enough to the neighborhood to talk about it.

But otherwise- Mm-hmm ... even if all these things in their life are being influenced by their fear of death or their death denial- it's so many layers buried that trying to jump to it, saying like, "Oh, this is all just because you're afraid to die, and you think that if you can just live on in the, the minds of other people after you go, you might secretly live forever."

They'd be like, "No, I don't give a shit." Like, "Fuck you." Like, "I'm- Yeah ... I don't give a shit none of this has anything to do with this." Yeah. Yeah. I'm cold as ice away from that, even if it is right and probably the best way to summarize what this person's doing. 

Margaret: Yeah. Which, like, if we think about it from, like, a broad understanding of, like, psychological [00:43:00] development, it is...

You-- Some people can call it defenses, and sometimes that's, I think, right. But it's also, like, very healthy, similar to having, like, a functional physiologic immune system- 

Preston: Mm-hmm ... 

Margaret: for our brains to not just be like, "I accept someone else's truth." Because it'd be like, you'd be just doing whatever if we immediately just were like, "I accept what someone else is saying to me as the truth, and my mind is now changed."

Like, your life would be kind of very directionless 'cause you'd just be every which way thrown in the wind, right? So it-- And I think he does a good job in this paper, as well as kind of talking about some of, like, these ways of relating on their own, done a few times, not fixed, not compulsive, not all the time, not disrupting function, could be seen as healthy.

Like, having defenses and having some narcissism and some ego and some this, that, and the other, and some dependence is not inherently unhealthy. But- Correct ... when they become super fixed, and they get in our way, and they make our life harder to live [00:44:00] Then we gotta work on it, unfortunately. 

Preston: Yeah. and to, so what I was saying too, death denial is a good thing.

Like, it's not unhealthy to suppress the idea that you're gonna die someday and not think about it all day, every day. Because if you fully accept it or fully end up thinking about it, it can consume you. so it's, okay to bury it a little bit. it's just when that, fear is transformed in a way that's controlling your life.

yeah, but all, all these things are helpful. The... I think it takes a little bit of healthy narcissism to, to get up on a stage and perform for people. Like, you have to kinda use some of that grandiosity. You know, like, "I'm the shit. I can do this. I'm the best one here for the job." Like, those are all narcissistic traits, but they're good in the moment.

I have a, I have my first, like, improv show on Saturday. I'm kinda, like, trying to channel some of my [00:45:00] inner narcissism. Say, like, "Yeah, I'm funny." I'm that girl. "I don't care what people think of me," you know? My fellow kids. "I'm on stage. They're not. Yeah, it's gonna be fun. I'm gonna act a fool. Who cares?" Like, all, like, all those things, like, help you, like, live throughout your life.

Margaret: Mm-hmm. yeah. There's, like, time and place for them. When it just becomes an issue when it's like, "And this coping mechanism is here, and this defense- Mm-hmm ... is here, like, all the time." 

Preston: Oh, dude, did you ever watch Marty Supreme? 

Margaret: No. 

Preston: That... We could do... Maybe that'll be, a, an episode we do next week. 

Marty Supreme, it's just a great case study of a severely pathologic narcissist just wreaking havoc for two hours, and then finally at the very end of the movie accepting responsibility for one thing But in the movie, his confidence makes him a good ping pong player. [00:46:00] His grandiosity helps him be a good ping pong player, so, so people see this one aspect of him.

And also every other part of his life is falling apart because of these narcissistic traits. 

Margaret: Yeah. Well, to fix. I wanna say one more thing, which is just one of the end parts that he talks about related to containment, and I think is just like a very beautiful way of putting it, which is, "What it is that needs to be contained varies with the patient just as it varies with the very young child.

At one moment it might need to be held, another it might be to be given space for movement, and another it might be to set limits, and another very simply to be there. There are times when hospitalization is containment for a borderline patient. There are other times where containment is the therapist's trust that the patient will n- negotiate an extremely difficult situation time on his own."

Which I just think is beautiful and I think is like- Mm-hmm ... it is why the work is difficult in the same way that parenting is difficult, which is what someone needs and how to respond and be attuned requires attention [00:47:00] always and ideally kind of like a, a humility of an acceptance of the mystery of never fully knowing another person- Mm-hmm

in front of you and trying to adjust and stay kind of agile in your thinking and how you attune to s- someone as the therapist, which takes a lot of energy and thoughtfulness. 

Preston: Yeah. Trust, trust being the most valuable thing to help someone with their containment. I do find it interesting that like the containment temporarily can be the hospitalization, but that is a, a substitute for other forms of containment.

So The patient doesn't ha- doesn't-- even though they're physically contained to being in the hospital, they don't actually have to contain themselves at all while they're in there. Mm-hmm. Yeah. so th-th-- I don't know, that, like... I read that, and it resonated with me in the sense that, you know, I understand why people decompensate when they're in these inpatient settings because it's like they have [00:48:00] externalized sources of containment, and it's-- You really get better when the containment comes from inside through the relationship with the therapist or their trust in you.

Margaret: Well, you can imagine also, like, to put a sharper, finer point on it, like, there could be a patient maybe in this kind of setting with borderline personality disorder, whatever, who could one year that you're working together view your denying them wanting to go inpatient as you denying them a significant need that they are not ready to have denied and talked about, and that is fracturing to the relationship.

Preston: Mm-hmm. 

Margaret: And then there could be a year later where it is viewed as a belief in them, like they're saying to not hospitalize, and that if you did hospitalize, that would be a fracture of the relationship once there's more trust established and maybe progress and the feeling of like, "I don't wanna go back there."

And so I think that, like, the meaning of the things that we do, of the interventions we do-- This is one of the things I find, like, fascinating [00:49:00] about it is like it's never just increasing someone's dose of Prozac. It's also like what does it mean that you are responding to someone having distress in front of you as like we need to chemically alter you?

Sometimes it can be that's help, sometimes it can be you don't have space, no one has space for my sadness 

Preston: Mm-hmm. you don't trust that I'll be able to handle this- 

Margaret: Yeah ... 

Preston: in the future It can be 

Margaret: that meaning, too. I 

Preston: think one of, one of my best, cases in residency was when I trusted a patient enough to take them off of their antipsychotics.

Margaret: Mm-hmm. 

Preston: That they could regulate without that. So I think there's a l- a lot of value in it going the other way, that I think I can, you know, humanize you and I'm not going to try to put a chemical patch on every single, like, piece of behavior that comes out of you. 

Margaret: Yeah. Yeah. And I think it, like, it means something different for each patient [00:50:00] each time you-- a- and it can mean something different each time you see them, which makes it, like, very difficult to discern and why we probably do get it wrong often.

And then we're like, "I'm tired and I have 80 more patients," and blah, blah, blah, blah, blah, "I'm in the emergency department, I haven't slept." so empathy for that part, too. But those are my thoughts on this paper. I don't know if you have any other points that you wanted to make or touch on or that you were like, "This stuck out to me as well."

Preston: not particularly. I think we really covered the, holding environment. I think I found the, kind of the, the repetition compulsion to be pretty interesting. 

Margaret: Mm-hmm. 

Preston: In that the-- like, not only are these, like, parameters the things that we use to kind of get through the day, but that they, each one of them almost, like, ramps up on its own, and- What 

Margaret: do you mean? 

Preston: I think they described it almost as like a st- a spiral staircase that you- 

Margaret: Yeah ... 

Preston: you [00:51:00] come back to the same thing over and over again, and- Yeah ... you're like, "How is this, like, crisis increasing?" And it's like, well, the pressure has to keep building. Yeah. 

Margaret: I don't know that it's about the pressure building as much as the like, "We talked about this last time.

Why are they doing it again?" And that it's like the spiral staircase idea in development is that it feels like you're hitting the same place, but you're actually improving and getting a better view, I think is the word he used, as you go up. Mm-hmm. Oh, I see ... so I don't know how much it's, like, pressure increasing as much as it's like one time around the circle isn't gonna fix it, but you're not moving anywhere.

It's like, well, last time you would've maybe like s- you're struggling with someone who copes with self-harm. Like, "I self-harmed again, Doc." And it's like, yeah, but, like, six months ago you would've self-harmed and drank and done this other thing. And like, yeah, it's not perfect and we're here again, but, like, look at how it's different than how it was at the beginning even though we're in the same spot in some ways.

But I do like the spiral staircase. It's used a lot in spiritual development too as a [00:52:00] con-concept of like You're in this, like, vast abyss of, like, whatever the thing is and you're like, "Ah, nothing's changed. I still do the same stupid shit I did when I was 16." Like, it's like, no, you do it in a- Just 

Preston: with more money and more responsibility.

Margaret: No. Like, you do it in a new, somewhat better way now. 

Preston: it's more expensive at least. 

Margaret: Yeah. 

Preston: this is really more of a, of an aside. so I saw this was published in, like, 2006. I'm sure he wrote it long before that The... I guess, is this just, is there anything of psychoanalytic importance in doing this, or is this, like, a vestige of the 20th century, referring to patients as, like, the borderline or, like, the hysteric or the, what was it?

The neurotic. Like, I notice there's, like, a lot of use of, like, of nouns, or, like, having the patient be- [00:53:00] being their illness. And maybe it's just, like, how they spoke back then and has no, no meaning. But I was just curious if you had any thoughts on that. 

Margaret: Yeah. I mean, I think it's how they spoke-- I think it's how most of medicine spoke that back then.

Like, that's why we get so many trainings now that are, like, person-centered instead of, like... the one they always say in, like, med school training is, like, "Don't call it, like, that stroke patient in whatever," or, like, stroke in, like, whatever, like stroke in room 54, right? That it's like we were-- Medicine in general, including therapy, I think was doing that.

so I think it's, I think it's just an artifact of the, the language of the time. I don't know many people who would ar- like argue or-- Like, the modern papers from the last, like, 10 years don't write it like that. They also now do more person-centered. does 

Preston: it impede their ability to communicate psychoanalytically by, by- No

seeing patients with, with borderline traits? 

Margaret: Yeah. 

Preston: Yeah. 

Margaret: Borderline, yeah. 

Preston: I was reading this, it was, like, a [00:54:00] book on, like, 100 ways people have died in the Grand Canyon. It was written in the '80s. It was like, "This person drove their car off, but they were a known depressive." And I was like, "Damn, I hadn't heard that one before."

Really? Known depressive. Yeah. 

Margaret: Yeah, they-- That's-- They be talking that way. 

Preston: Mm-hmm. You are your depression- 

Margaret: We've changed it ... and nothing else. so yeah. Well, I hope you guys enjoyed this paper or whatever. I do think if you have time to give it a read if you can find it, I'm gonna, like, write down the name of it and stuff in the show notes.

I think it's a great paper. I think it's a paper that can also, like, to speak of spiral dynamics, like, come back to it again and again. Because you have to repeat this learning with yourself, with patients that you're like, you find your n- new exciting weak areas in your own practice

and you're like, "Damn it. I'm in the morass again." Like, "What's happening?" 

Preston: Yeah. Some- someone wise I knew once said that when you're growing, it [00:55:00] hurts. That's how you know because it literally feels like your arms and legs are being pulled. that's a sign that you're improving. If it's comfortable, you're not-- your product, you're not growing.

Yeah. Yeah. Okay. Well, I think that'll kind of wrap it up for today. I'm glad that we were able to talk about this paper. I think it's fun to, to put my psychoanalytic hat on, even if it's as a co-pilot. Thanks again everyone who's been watching the show and commenting on Spotify. I- from our Psychiatric Roots in Greek Mythology podcast, which was, a fun change of pace for us to do, somebody, said, or this is KH06, "Y'all never fail at making time fly on my regular long drives whenever an episode arrives.

I appreciate you," and a nail being painted with nail polish emoji. Thank you, diva. And then we have Thomason, who is [00:56:00] requesting us to do an episode on sleep disorders- Nice ... which I think would be a, a fun topic in the future. Yeah. So if you want to, listen to more of our podcasts, we are on Spotify and Apple Podcasts.

You can find, full videos on YouTube as well as on Spotify. I'm on my socials at itspresro on YouTube, and I'm just presro on TikTok. Margaret is @badar everyday on Substack, TikTok, Instagram. You can also just contact us directly on our Instagram page @howtobepatient. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan.

Our executive producers are me, Preston Roche, Margaret Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To learn more about our program disclaimer and ethics policy, submission verification, licensing terms, and our HIPAA release terms, go to howtobepatientpod.com or reach out to us at howtobepatient@human-content.com with any questions or concerns.

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