Teaching About the Dynamic Mind: Then and Now with Jonathan Shedler, PhD (San Francisco)

We bring our patterns with us wherever we go into every relationship and we necessarily and inevitably bring them into the therapy relationship or the psychoanalytic relationship because that's a relationship too. It's not a matter of choice. It simply happens. It happens everywhere. The therapist doesn't do anything to make it happen. This is the human condition. We bring our patterns and the thing that makes psychotherapy, the thing that makes psychotherapy, psychotherapy, and not just another relationship, is that we do something different and what we do that's different is instead of just repeating, you know, our same old, same old patterns with a new person, we create the conditions where it becomes possible to notice the patterns, to recognize them. To put words to them and understand them and discuss them. And out of that experience and that understanding, comes the freedom to do things differently, to not have to repeat the same patterns. And I was like a point, you know, well, is that true for everyone? Does everybody need therapy? Well, everybody repeats, early, you know, repeats their, you know, their characteristic patterns. For some people, those patterns allow you to live a, you know, satisfying and rewarding life, you know, with pleasure and connection and meaning and intimacy. So if that's the case, you know, yeah, you're still repeating, you know, early patterns that were acquired early on, but that's what it means to be human. However, you know, some people are living out patterns that cause distress or limitation that get in the way of living the life they could lead. And that's what we work with in psychotherapy and psychoanalysis. Welcome to the IPA podcast psychoanalysis on and off the couch. This podcast consists of conversations with psychoanalysts from around the world, who share with us their clinical and psychoanalytic work with individuals, both on and off the couch. What we mean by off the couch is that they share with us their community involvement in many different venues, apart from their consultations. They describe their work in hospitals, in community clinics, in refugee centers, in classrooms, indeed in war zones. We also have conversations with psychoanalysts who are focusing their work on the couch, and they are continuing to refine both our familiar and novel understandings of the dynamic. Mind as it presents itself in the analytic situation. Please visit our website, IPA off the couch.org, where you can subscribe, where you can see the recommended readings provided by our guests, and you can also leave a comment. I hope you enjoy these conversations and find them thoughtful and meaningful. And I appreciate your listener. Thank you. Welcome to today's podcast. I'm Harvey Schwartz, and my guest today is Dr. Jonathan Shedler. Dr. Shedler is best known for the jargon-free manner in which he discusses foundational dynamic concepts. And that's what we spend our time today discussing a paper he wrote on the topic, and that was called, that was then this is now an introduction to contemporary psychodynamic psychotherapy. And he takes foundational concepts, defenses, unconscious mental life, the mind and conflict, and foundationally, then and now, how through the affective experience in the office between the two parties. The person can discover how they are being so influenced by factors unknown to them from their past. And he has clinical examples that demonstrate this, including a very charming example he gives when he tried to start his analysis. And as you'll hear, he didn't show up for the appointment and he uses that to demonstrate some of the points we're trying to make. Jonathan is an author consultant psychoanalyst, well known teacher. He's written the efficacy of psychodynamic psychotherapy, which really established this work as an evidence-based treatment. He is the co-author of psychodynamic diagnostic manual. He is a clinical professor of psychiatry at UCSF and a training and supervising analyst at the San Francisco Center for Psycho Analysis. As you will hear Jonathan brings two special traits to this work. One is a passion about it, which becomes immediately clear and also a clarity of thinking. And the engagement with both of those is really special. And I hope you find it as I did. Here's my conversation with Dr. Jonathan Shedler. Jonathan, welcome to the podcast. It's a pleasure to have you on board. Jonathan, my understanding of your work is that there are three themes that you are very involved in. And the first and most important one is your appreciation. And I would indeed say your talent in writing about the dynamic mind and dynamic therapy in a jargon-free manner. It is not something everybody can do. And it's something as we will discuss, you feel is really vital for the future of our field. That's theme one. Theme two related to that is the importance you feel to communicate to the larger mental health community of which we are just a small fraction. To communicate to them a number of things. First of all, through your jargon-free writing, what it is we do actually not what they misunderstand us to do. Be how most therapies nowadays, in fact, are derivative of the dynamic mind and how we understand it, though they use different language and we will get to this in your paper. And the third thing is that our efficacy, though not as popularized as some therapies, is indeed as powerful, if not more so, than the more widely known therapies. The way you've characterized it is, I think, has a nice succinct way about it. You've said, we need to appreciate who we think we are and who they think we are. Important thing to keep in mind. And the third theme that I see you as upholding is to be sort of a sentinel, a watchman over our field, to warn us when we get sort of too self-involved and to esoteric that we miss the heart of the matter and we miss communicating the heart of the matter. Now, you have focused on these three things in numbers of things you've written and there's one chapter in particular that we're going to spend time on today that I think really wonderfully accomplishes that. It is available on a link on the show notes. It is available for free to everybody. I would recommend it not only to the listeners, but to your colleagues and your students. And the name of the paper is that was then this is now an introduction to contemporary psychodynamic psychotherapy. And before I turn the mic over to you for your elaboration on this, I want to pick on that phrase that was then this is now because we use it in our title. And as you point out in the paper, it refers to two things. The first is the then refers to how we used to talk to our colleagues or they're saying not talk to our colleagues versus the now when it's an imperative that we do talk to our colleagues. But another point you make in the chapter is that the the we all live in our now and the beauty and the gift of psychoanalytic engagement. Is to help people appreciate how much of the then in our lives is living in the now. And that's also captured in the chapter and in your work. So now let me invite you to elaborate on any or all of those. Yeah, the the title that was then this is now was meant as a double entendre and one meaning of it is most people who are not psychoanalytically trained have an understanding of what psychoanalysts or psychoanalytic therapy is. You know that that's really based on stereotypes and caricatures and misinformation that literally date to the horse and buggy era literally. And this is how almost every college educated person is introduced to psychoanalysis. If you pick up a psychoanalytic if you pick up an introduction. psychology textbook that someone would read in Psych 101. What you find is misinformation, right? The stereotypes and caricatures from the horse and buggy era are coming from the textbooks. So people read them, they think they're getting information from an authoritative source. You know what they're getting is, you know, number one, about 120 years out of date and number two, a fundamental misunderstanding, even even over the thinking of 120 years ago. So that's one meaning. You know, the other meaning, I mean, there've been people outside of the field don't understand. There've been sea changes in psychoanalytic theory and practice, you know, over the past decades, over the past, you know, more than half a century. And you know, no one outside of our own echo chambers understands that. You know, the second meaning is so much of our work really is about helping the person to, we through our own development, we develop to use, to use not jargon. We develop certain, you know, templates of how to function and what we expect of the other other people and and how we see the world. And you know, those templates are out of date. They were formed in early childhood. So that people tend, you know, the things that bring people to our offices for help is that people tend to live in ways and respond, you know, in ways that are based on past experiences and not based on what's happening in the present. We say the past over shadows or colors are understanding and are functioning in the present. And that's essentially what this kind of psychotherapy is about. It's about helping people to kind of loosen the bonds of those past experiences so they can live more fully and freely in the present. So that's my, that's my unpacking of the title. And what's important to emphasize and you do in your writing is it's not just an intellectualized understanding of the past. It's not like, oh, yeah, I'm relating to you like my father, it's an actual experience that the way effectively they are living in the moment and most hopefully demonstrated in the office in the transfer that they're able to see the distinction between the now and the then. And you're very clear about this in the paper. Yeah, and that's where we write that this is actually a pretty good example. This is where we lose people who are interested in our way of working, but are coming as beginners when we say it has to be, you know, it has to be experienced in the transference. Right, here's the issue. You and I are so used to talking that way. It's just part of our normal vocabulary. How we speak to each other? Nobody outside our own, you know, our own pretty closed communities actually knows what that means. So if you say, you know, so if you say, I could say, you know, good psychotherapy, psychoanalytic or any other kind is not an intellectual understanding. It's actually a lived experience and something changes from that experience. Right, that gets us a little closer to right now people listening as they, oh, what does that mean? A lived experience in the therapy. Now we can talk about it when we use what I would call shorthand, you know, the transference that we used to speaking to each other. People who are not analytically trained don't follow us. And actually, what's even worse than that when I was a psychiatry professor and I was an out an attending, basically an attending doctor in an outpatient psychiatry clinic, all of the psych, all of the psychiatry residents I taught had encountered the term transference and thought they knew what it meant. And they all didn't know what it means. So, you know, there's two kinds of people out there. People who don't even know what the word, I mean, just, you know, Greek to them. And people who think they know what the word means and actually get it wrong. And that's what we're up against. That's the challenge of psychoanalytic communication, I think. Well, let me ask you just to jump to the most difficult question is if someone hasn't had that experience of seeing the past contaminate the present. What what can one do except use words to approximate it? No? Well, yeah, but, but, but that's a word that's, you know, that's a word that's jargon. It's not plain English. Unless you studied psychoanalysis, you wouldn't be able to connect the word to experience. So, one thing that I work, you know, very hard to do and in part, I learned this through, you know, repeated efforts at teaching this, you know, not to not to psychoanalysis or candidates, but, you know, to graduate students, psychology doctoral students or or psychiatry residents, you know, sort of repeated failures to connect and trying to figure out, you know, where we were going wrong. You know, so, I mean, what I would say if I were talking to someone who's not in the field is we all acquire certain, you know, patterns, you know, relationship patterns, right? Ways, you know, ways of experiencing and functioning in relationships. It's not good. It's not bad. It's not a diagnosis. It's not pathological. It's, it's the human condition. We acquire patterns through our earliest attachments. And in one way or another, we tend to repeat and recreate those patterns throughout our lives because they're there from the very beginning. The patterns are generally as invisible to us as water to a fish, right? And the way that I try to communicate this is, we bring our patterns with us wherever we go into every relationship. And we necessarily and inevitably bring them into the therapy relationship or the psychoanalytic relationship because that's a relationship to it's not a matter of choice. It, it simply happens. This, right, this is the human condition. We bring our patterns and the thing that makes psychotherapy, the thing that makes psychotherapy, psychotherapy and not just another relationship is that we do something different. And what we do that's different is instead of just repeating, you know, our same old, same old patterns with a new person, we create the conditions where it becomes possible to notice the patterns, to recognize them, to put words to them and, you know, understand them and discuss them, right? And out of that, out of that experience and that understanding, it comes the freedom to do things differently, to not have to repeat the same patterns. I mean, does everybody need therapy? Well, everybody repeats, you know, repeats their, you know, their characteristic patterns. So if that's the case, well, yeah, you're still repeating, you know, early patterns that were acquired, acquired early on, but that's what it means to be human. As usual, very clearly said, let's, let's work up to that because in your paper, you have foundations and you, you demonstrate the various foundations of how the dynamic mind works. So let's go through them. The first one you've list, which you've been referring to is, it's called the unconscious mental life. So let me just read a piece and then I'll ask your thoughts about you right. We do not fully know our own hearts and minds. And many important things take place outside of awareness. This observation is no longer controversial to anyone, even the most hard-nosed empiricist, research and cognitive science has shown repeatedly that much thinking and feeling goes on outside of conscious awareness. Usually cognitive scientists do not use the word unconscious, but refer instead to implicit mental processes or procedural memory and so on. The terminology is not important. What matters is the concept the crucial, at crucial memory perceptual, judgmental, affective and motivational processes are not consciously accessible. Psychoanalytic discussions of unconscious mental life do, however, emphasize something that cognitive scientists tend not to emphasize. And this is your key point, you write. It is not just that we do not fully know our own minds, but there are things we seem not to want to know. There are things that are threatening or dissonant or make us feel vulnerable in some way, so we tend to look away. And then you say in a bit down the page what you just said, which is most psychological difficulties or once adaptive solutions to life's challenges, they may have been costly solutions, but there were solutions nevertheless. Difficulties arise when circumstance change and old solutions no longer work will become self-defeating, but we continue to apply them anyway. I think you want to head to that? You agree with it? Yeah, it sounds like something I would write myself a bit of a chance. Yeah, but that's the really the issue that we're talking about that we acquire certain patterns and those patterns generally are the best we can do under the early circumstances where they were created. And of course, a small child doesn't have the mental or emotional resources that we hope an adult would have. So the child's range of solutions to challenges and to interpersonal difficulties and how to maintain a relationship, sometimes with relationship with primary caregivers, parents who are sometimes very difficult. The child's solutions are a much more limited range of possible solutions than what's open to an adult with the maturity that comes with adulthood. So the issue is a new solutions are possible, but the person doesn't know that and not only do they not know that no solutions are possible, they also don't realize how much of their functioning is based on an old solution to something else in another time and in other place. And that's part of what I meant to get at with the title. That was then this is now that when treatment goes well, the patient comes to recognize not an intellectual or cognitive way, but as lived experience. Oh, I'm bringing all kinds of patterns, thoughts, feelings that really may not apply here. Let me ask you though about that one sentence that I think is so important and it's not just that we do not fully know our own minds, but there are things we seem not to want to know, which takes it out of it's just we don't know about it, but it actually describes a dynamic process of keeping a distance from it. Do you want to flesh that out a little bit? Yeah. So this is really this is really a big difference between what we could call the cognitive unconscious. It's a bit of a pet peeve with me, with me, you know, analyst sometimes say the unconscious. And when you put that article, the in front of it, I think it becomes a barrier to understanding because it actually it right, it treats it as if it's a thing, it's a thing that's known that's understood. We can talk about it. The unconscious does that this the unconscious does that right that there's no place. Coat to me called the unconscious. It's a shorthand right there's many, many different kinds of unconscious processes meaning by unconscious right things that either aren't you know, accessible or aren't accessible without some work. And there's different levels of consciousness. Some things are fundamentally biologically not going to be available to consciousness. You know, some things are so one of the areas of of things that happen outside of awareness that we focus on in particular are things that you know are potentially accessible to awareness right we could notice we could pay attention to them. We could express them in thoughts or images or words, but we don't know. And it's not just that it's not a cognitive not knowing we just don't know somebody could explain it to us. I mean, there's a reason we don't want to know because there's something there's something threatening, frightening, uncomfortable about it right. So, you know, the historical word of course is we talk about defenses and defensive processes. I think an equally good word would be to refer to it as protections right we all have our protections right so that we can function day to day without undue distress without being overwhelmed by distress but some of those protections are very costly. So when we get into this work and this is where I see a lot of younger therapists and people who are you know not particularly well trained, they never say this they don't think of it this way but they bring a fundamentally a didactic mindset to the therapy situation right they'll talk about skills training right homework, psycho education right that they think of therapy as an educational process right and it's kind of important they don't really think they don't think that that's how they're approaching it right you know but think of the language psycho education there's you know there's especially if it's the kind of therapy that's now widely promoted as evidence-based therapy and it's really a code word for a pre-structured you know a pre-structured scripted therapy that's literally conducted by following an instruction manual right so you have essentially a course you know with a syllabus and a series a lesson plan and a series of assignments right it's a didactic or educational lens to look at to understand therapy and what it leaves out of course is what we call the dynamic unconscious which is it's not just that we're in need of education somebody can just explain it and then we just practice it and it will be all better right there's things we don't want to know about we don't know about ourselves we don't want to know you know that it will you know fight unless unless the therapist is skilled and how to work with this you know that will fight with our last breath you know to not know and of course that's the the art and science of of this kind of work and in treatment is how do we work with somebody to help them right to make it possible for them to notice things and see things and experience things that they automatically habitually reflexively turn away from to help them see that the dangers that they assume are associated with that freedom to think feel and imagine are also derived from their childhood and don't have to limit them now yeah tell them see that you know first of all they're first of all they're not a small child who can't who can't tolerate you know who can't tolerate the overwhelming emotion right now they're an adult with capacities and resources that that child never had what was once intolerable actually might be you know quite tolerable you know they're also not stuck you know it's not like it's not like a three-year-old gets to choose their parents and their life circumstances and their family right this pretty limited choices in childhood right one of the things that the center of psychoanalytic work is you know the recognition that we actually do have agency and we do have choice you know generally much more choice than you know than we realize and you know the work is aimed at supporting and developing the person's sense of agency right so you say in very important ways we're really not as free to live our lives as you know we think we might be we're constrained in many ways so we could say one goal of psychoanalytic treatment is to create or expand freedom freedom of choice where previously you know things were obligatory or automatic you have a wonderful case in a little bit where you talk about the limits of psycho education we'll get to that but the next one of your foundations is the the great phrase the mind and conflict which of course resonates with a well-known book book by that title and you write psychoanalytic therapists were the first to explicitly address the role of inner conflict or contradiction in creating psychological difficulties but it is noteworthy that every therapy tradition addresses conflict in one way or another cognitive therapist may speak of contradictory beliefs or schemas behaviorists may speak of approach avoidance conflict or responsiveness to short term versus as long-term reinforces humanistic therapists may speak of competing value systems, and system oriented therapists may refer to role conflicts. There is universal recognition that in their dissonance is part of the human condition. And then you go on to say that these findings from cognitive science based on rigorously controlled experiments have striking parallels with Freud's descriptions many decades ago of conscious and unconscious mental processes. Far from discrediting core psychoanalytic assumptions, you italicize this part, research on cognitive science and neuroscience has provided an empirical foundation for many of these assumptions. It is also helping psychoanalytic thinkers refine their understanding of mental processes and effective interventions. Yeah, again, I'm sort of so concerned to be about what we talk about in our own psychoanalytic echo chambers and what the rest of the world understands or misunderstands about what we do. And there's kind of a myth out there, and narrative that's taken hold. And the narrative is that psychoanalytic ideas have been debunked, have been superseded. And now we have scientifically based evidence-based treatments that are based on science. Now it turns out if you actually can read the primary sources and know how research is done, it turns out actually the science doesn't support those claims. The new treatments are not quite as based on sciences. Some would like to believe that the myth is, that core psychoanalytic ideas have been debunked. We have to distinguish, first of all, what was psychoanalysis in 1890, just how it's usually presented in textbooks and what psychoanalysis now, and we have to distinguish between the core foundational principles, and 10, that tens of thousands of ancillary hypotheses along the way, some of which are sound and some of which are unsound, but psychoanalysis has to, when we talk about the scientific basis, we really need to focus on the core foundational principles. And those principles are scientifically confirmed. In fact, much of mental life takes place outside of awareness, and we have multiple lines of research that converge on that, brain architecture, neuroscience, competing, or alternate neural circuits and neural pathways. We have a lot, a lot of research done by research oriented psychologists, not psychoanalytic people, social psychologists, cognitive psychologists, experimental psychologists, many, many demonstrations that thoughts and feelings occur outside of awareness. And we have all kinds of experimental manipulations where you can do things to shift somebody's thought or shift somebody's feeling without the person recognizing that a shift has occurred. I mean, we've demonstrated it so many times over. So when people like scoff at, you say the word unconscious and people just scoff at it, and I mean, the bizarre irony of it is that the people who do the scoffing always align themselves with science, while saying things that flagrantly contradict the existing science, right? We know people have unconscious mental life. We know that early templates, early relational experiences are really encoded in our neural circuits, right? And shape how we perceive and respond to everything that comes after. We know this. It's not even up for debate. So what is up for debate is, what can we do in psychotherapy that is most helpful in helping people change things about themselves that cause limitation or distress? And if we ask that question, then we have to ask, is it really scientific? Does it really make sense to promote as the gold standard of science treatments that take no account of these things that we know scientifically? Or would it make sense to build a treatment on a foundation of actual scientific knowledge and a crude clinical experience over generations of working with real human beings? - That's a wonderful segue to the next section. Which I wanna read one paragraph that demonstrates two skills. One of which is it takes up that question you just asked about working from scientific clinical experience. And it also does it in a perfectly clear logical way to anyone who would care to listen. You write, this is about again, about the past living on in the present. And you write very straightforwardly, consider a child who received from others to undivided attention only when she is physically ill. At these times, her mother dots on her and comforts her. And in adult life, she developed physical symptoms when she fails neglected by her husband, an unconscious effort to elicit his loving attention. Unfortunately, her husband does not respond with doting attention, leaving her feeling confused and betrayed in ways she cannot begin to put into words. In therapy, she talks about her physical symptoms and does not seem to have language for feelings. She assumes, reasonably enough, that her therapist is interested primarily in her physical aches and pains and seems confused by her invitation to talk about her feelings. Now, that's such a clear, straightforward, readily understandable example that is also a commonplace example that we face every day in the office. - Very common. - Which brings us to the next subsection which is called a transference. And again, another very clear common sense example, you write, when I was in graduate school, a friend of mine began therapy with a man whose last name sounded something like "Hiller." In the eyes of her, everyone, you remember this, right? In the eyes of virtually everyone, Dr. Hiller, was a gentle and compassionate man who was rather meek and self-effacing. For a significant period in her therapy, however, my friend perceived him as an aggressive tormentor and referred to him only half jokingly as Hitler. My friend's perception changed over time, but this is your key point that I take from it. But I believe it was important for her to go through this phase and essential that her therapist was able to tolerate this perception of him. Instead of trying to convince her otherwise, he allowed her to have her own perception and patiently explored the thoughts, feelings, and memories that lay behind it. And I dare say this is the most challenging aspect of our work. The phrase that some people have used is to wear the attributes, the attributes that the patient tributes to us, in this case, his Hitler likeness in her mind, and that he accepted it. And that's hard to do, especially when we're really, we don't like seeing ourselves that way. In fact, some people might say that that's how you distinguish analysis from therapy, that in therapy, you'll be more inclined to correct it. And analysis, you have more space and maybe ego structure with which to let it develop. - Yeah, so I don't make a hard and fast distinction. And I think it's hard to defend a categorical distinction between psychoanalytic and psychodynamic therapy versus psychoanalysis. I mean, I see a continuum of interventions and a continuum of the level of depth that you're working at. To me, it is something we address in psychodynamically informed therapy. The patient doesn't need to be coming multiple times a week and lying on the couch, we can address it. And I think you homeed in on exactly the right thing though, which is, I mean, this kind of psychotherapy is a relationship that really has no comparison in any other area of life. There is no other relationship we have. With friends, with teachers, with doctors, with professionals, we really don't have a relationship that parallels what goes on in psychotherapy. So, I'll use this as an example because it comes up with beginners who are just starting, trainees who are just starting to do therapy, but it comes up in other forms with seasoned clinicians and experienced fully trained analysts. So, in this example, we could say, The patient's perception of her analyst as Hitler-like becomes a junior, she's a high-functioning person, right? It's sort of a joke, but not really a joke. She does feel tormented and tortured. We could say that the perception is a projection. We could say that it's in part responsive to something that's going on in the present, but it's also very much colored by something that comes from another in her that was formed in another time in another place. We talk about, if I were talking to analysts, I could talk about containing the projection. If I were talking to people who are not trained in analysis, what everybody wants to do, right? The therapist comes in and what they're aware of is they're trying to help this person. That's what they've come into the field for. They're at least consciously benevolent, well-intentioned, well-meaning, doing their best to be helpful to the patient, and then the patient proceeds to see you and treat you like someone you're not. You're suddenly cast in the role of aggressive tormentor. Everybody untrained. Everybody's untrained. First initial impulse is to want to do two things. First, to convince them that we're not that person. First of all, nobody likes to be misperceived that badly. It feels pretty crappy on the receiving end. We don't like sitting with, containing, tolerating that feeling. We want to help the patient to get it right, and then depending on how things play out, if the therapist has a sort of massacistic streak, they might find themselves apologizing, "I'm sorry, I didn't mean to come across that way." If they have a more aggressive or confrontational streak, they might do something that I've heard it called in the literature. It stuck with me, cramming the projection back down the patient's throat. No, this isn't me. This is you. You're the one who's being this and that, right? Those are natural human responses. What we want to do is something else. Let me ask you a question about this, because this actually demonstrates an important point. The patient who comes in and perceives this self-effacing mild man as Hitler. You're suggesting, and I certainly understand, the importance of his being able to elaborate that for the patient and tolerate it and see what meaning it has for her. There are those who would say, "Well, perhaps this person is picking up some Hitlerian attributes of this otherwise self-effacing person, and it's useful to go that route to see what truth they are discovering about this person, as opposed to finding within themselves the meaning of that assumption of his aggressiveness." Do you have thoughts about that? Well, yeah. You're bringing up the relational view of the encounter as an intersubjective process, something created by two people. It's not the patient doing what they do in a vacuum with the therapist or analyst as an objective observer. They're both creating the experience. I think it's an important thing to hold in mind that multiple things are always going on at the same time. First of all, the patient isn't psychotic. But they're not just fabricating something out of thin air. There's something going on in the present that hooks something in them and something going on between the two people that's creating a unique experience, unique to them. That's one truth. The other truth is that the person's patient's experience of the present is always, and under his patience, all of us, is always colored by past experience. That changes how they perceive the present. Sometimes not just colored by the present, but depending on the person's psychological, personality organization, not just colored by the past, but sometimes so saturated by the past, that the present is almost irrelevant. I don't see these views as being in opposition. I think there are two things that a skilled practitioner needs to hold in mind. There are multiple things going on. One is what the two people are co-constructing. The other is what the lens is in templates that the patient brings with them, which we call Transference. The other is the lenses and templates, life history, that the therapist or the analyst brings with them. All of those things are in the room. Part of the work and part of the skill we develop through training, supervision, our own analyses is how to work in a way that holds all of these possibilities in mind and takes account of them. I would actually strongly disagree with someone who is what the right way to go is to look at what's happening in the relationship where the right way to go is to look at the patient's past, there's no right way. There's an experience happening and we need to create space to be able to explore it and see it more clearly. To attend to more and to notice more and to put more of that into words where we can think about it together. This notion of pitting these two different psychoanalytic approaches against each other as if they were in opposition, I really don't think it's very helpful. It's well said. You have a section called Defense. I try. When you succeed more often than not, I might add, there's a section you have called Defense. You make the case that repression as a word should be retired and you prefer disavow. You say that Bettleheim thought repression was a mis-translation of the German, but you feel it's important beyond linguistic accuracy. What's your sense of it? I think repression makes it sound like it makes it sound just a little more mystical than it really needs to be. I'll tell you a side story. It's not directly related to this, but I read Bettleheim's book, or mine, A Graph, Freud and Man's Soul, when I was still a grad student. I remember he talked about the word that was mis-translated into English as "Cathexus," which means to be emotionally invested in something. That another, our experience of another person is filled or occupied with our own desires and feelings. He said, "Cathexus was a mis-translation of the German word, and if I remember incorrectly, I'm probably mispronouncing it." I think the word was the German word is "Bizzazzon." It sounded right. Anyway, I think that was the German word. That was where I first encountered the word from reading Bettleheim. I spent part of a summer as an exchange student in a university in Austria. Literally, the first day I arrived there, they put me in a student time, basically a dormitory, and it had an elevator. There was a little light that would come on in the elevator if too many people got in the elevator, and the light said, "Bizzazzon." I saw that. The elevator is definitely not "Cathected." Any German speaker would understand this word to me. It's filled. It's occupied. It's full. It really made me think long and hard about the stretchy mis-translations, I think, of Freud. Anyway, that's the context where he talks about the word repression. What are we really talking about? It's not mystical. It's not mysterious. What's the sound of something being repressed? It's the sound of something slipping our mind. It's the sound of moving on to something else. It's the sound of directing our attention elsewhere. In other words, there is no sound. It's just woven into the fabric of everyday life. There's nothing mysterious about the experience. We attend to some things and we direct attention away from other things. It's just part of the normal way we all function. Part of the work that we do in psychotherapy or psychoanalysis is that we create the conditions where it becomes possible to notice and intend to more. And notice and intend to things that the person might habitually not attend to. The way you write about it is you write psychoanalytic psychotherapy helps us recognize the ways we disavow aspects of our experience with the goal of helping us to claim or reclaim what is ours. And you very generously give a really charming story from your own past. So let me read it. You write. I recall. You know what I'm about to say. And you laugh and smile as I did each time I read it. But I recall starting my own analysis. You write. I scheduled my first appointment two weeks in advance. I thought about the upcoming appointment day and night throughout the two weeks. On the day of the actual appointment, however, it completely slipped my mind. When the analyst and I eventually managed to meet, he asked if it was like me to forget appointments. And I told him with embarrassment that it was not. He shrugged and said, so it seems you have an unconscious too. Please tell me that I'm delighted with a smile. It's just a wonderful lovely way to say hello. Psychotherapy right is an ongoing tug of war between a part of us that seeks change and a part of us that strives to preserve the known and the familiar. However painful that may be as therapists, we side with the forces seeking growth. Is there anything more you want to say about that or is that sufficiently revealing? Well, he's commented a number of things in a condensed, sort of charming way. One is acknowledging that something happened that got in the way. And there's something really wasn't clear to either of us at that chapter, including to me, even though I'm the one who did it. And it also conveyed in a very nice and quick way. This is just how it is. This is normal. This is how we humans function. But what is different in psychotherapy versus all the rest of life, yeah, this is what I was saying, is that we try to create the conditions where it becomes possible for the person to notice and attend to things that are otherwise outside of our attention. And the way I like to talk about it and often say to super visis is our experiences we go through life is things happen. We go from point A to point B. And so on. Point B follows point A, very natural, normal. But actually, you know what the work is, is if we really slow things down, we can start to notice that actually all sorts of things are happening between point A and point B. It's really not as automatic or inevitable as it feels. Right, between point A and point B are thoughts, feelings, memories, images, bodily sensations, you know, somatic experiences, right, all of these things. And what we're really trying to do in the work is slow down enough to notice the things that are happening in those gaps, right, between point A and point B. And right in doing that comes the freedom to make choices between point A and point B. There are many, many places to make a choice other than the one we've been habitually making. So right, so the freedom comes from slowing things down enough to notice the process that leads from one thing to another, right, and allows us to insert a choice, a freedom of choice. We're previously, there actually wasn't a freedom of choice. And you give a lovely clinical example that I'll ask you to elaborate. It's the patient you call Steve, a man who had a heart attack and was forgetting to take his medication, which was vital for his survival. And he didn't know why he was forgetting, and the clinicians quite understandably gave him more and more, quote, psycho-education education, as what they called it. And you then engage with him. You want to share how that went? Yeah. So actually, it's a, I'm glad you brought it up. It's a good example because it's the dividing line between a psychoanalytic understanding and say a more common therapy understanding like we would find in CBT. It goes back to that distinction between therapy as a didactic process. The patient is going to be taught or learn something. We're going to provide information versus treatment as an exploratory process. There's a puzzle here. There's a question to be answered. And neither of us know the answer to begin with. What we know is there's something that's in need of explanation. So, you know, and obviously Steve's not his real name and details are disguised. But, you know, Steve was an intelligent guy. He understood his medical condition. He understood the purpose of the medication. He knew damn well why it was important to take it. So, something was happening that really we could say was, you know, not voluntary, which is the act of forgetting. You know, not just once, but pretty consistently. Something was happening. And we could say point A and point B. You know, point A is there's the need to take the medication and point B as I forgot what happens between that. And so the work really that I really began with focusing on the something. He says, yeah, I don't know why. And this is actually something I tend to say with patients a lot. You know, they'll hear something as a question and you say, I don't know. And you know, my response is usually some version of, you know, I know you don't know. I mean, that's why I'm, you know, that's why I'm bringing it up as something we could think about maybe begin to know something. And he says, you know, so I never use the word the term free association with patients because it's jargon, it doesn't help. You know, what I, what I did say is, you know, well, you know, let's, let's stay fair for a bit. Let's just slow down here. You know, something gets in the way. Is he, yes, right? To an agreement about the problem. And just what comes to mind, you know, without worrying about whether it makes sense or it follows or staying on topic, just, let's just see what you can notice, say what you notice. Whether it's relevant or not. And the first thing he noticed is, well, there's no uncomfortable feeling. And that feeling didn't have words. All right. So I encouraged him to pay close attention to it. You know, what are you feeling? What, what, what are you aware of? What's the raw data? Is it, you know, is it a feeling in your body? Is it an emotion? Is it, right? So I encouraged him to just elaborate further on the experience. You know, we went into it though. There's a felt sense of discomfort without a name, right? Without words and thoughts attached to it. And as we go explore that and you continue, he says, well, you know, any basics like you, you really want me to just blur it out. Anything that comes to mind. And like, yeah, I really wanted to just blur it out. Anything is, well, I'm thinking about my brother when I was a little kid, right? And this, of course, opens up, you know, opens the door to understanding what was crucial. And basically he had a brother who was always sickly, who wasn't well-liked, who didn't do well in school, who either was or Steve perceived him to be a great disappointment to his parents. And he was sickly and he was always taking medicine for one thing or another. And there was a fantasy behind that, but it had not been an awareness. and the fantasy was, if I'm too. Basically, if I take pills like my brother did, I'm like him. This will make me be like my less loved brother. So for him, it wasn't that he didn't understand the medical reason for taking the medication. The bad feeling was it was associatively linked to fears that he would be less well-loved. He'd be like his brother in that sense. He would lose the love and care and emotional investment of the people who are important in his life. All of this was going on, definitely going on in his mind, but outside the margin of his awareness. This is a lot of different mechanisms and change in psychoanalytic work. But this is one of them that what happened is we took something that was operating in the shadows, not in the light of day. We brought it into the light of day. Seen clearly in the light of day, it loses its power. It's like, "Oh, that." The way you clearly write that is you say, as a result of this awareness, you write, "Steve recognized that taking medication would not, in fact, turn him into his brother." That was an irrational fantasy, in the fantasy operative, like you say, outside of his awareness, but it influences his behavior and could have cost him his life. You have one other clinical example where, again, the free associative model, your way of saying it is. How is it? Let me just emphasize this, because you can't say to people outside of the psychoanalytic world, well, an important part of the psychoanalytic method is free association. What happens is everybody has their associations to what the word free association means. It's good. It's funny. They demonstrate it even as they scoff at it. It goes back to what they read in that intro-freshment textbook. Or what some professor who never saw a patient in their lives miscommunicated, disinformed them about, and they turn off. Versus staying much closer to experience and saying, "Where do your thoughts go? What comes to mind next?" Well, yeah, if you think it or feel it or notice it, yeah, blurt it out, even if it seems off-topic. And what we're doing, and I think it's really important to communicate this to patients and to trainees, is you can think of, you know, mind as a sort of vast, you know, sort of territory, some of which is mapped and known, and much of which is, you know, uncharted, not mapped and known, and, right, this method, we call free association, right, is a way of beginning to map the territory. So we know where we are, and we know where we've come from and we know how to go where we want to go. So a little aside, but just another example of, you know, a technical term or jargon that we use very, you know, automatically that tends to turn off people outside of our own circles. And in that spirit, you suggest a change in jargon from psychic determinism, which basically refers to that his thoughts then went to his brother, that continuity was where the meaning was hidden for you, for the two of you together to discover, and you suggest instead psychic continuity, which I hadn't thought of it, but I think you're spot on with that. And you give one final example in the paper about this. You write. A male patient of mine who was gay made a slip of the tongue and called me by another person's name, let's say James. I asked him what occurred to him about the slip and he responded with the usual protestations that it was a random occurrence and meant nothing. I suggested that we find out by seeing where his thoughts led. What did the name James bring to his mind? He recalled a friend of a friend who was named James and he hastened to assure me this person meant nothing to him. "Okay," I said, "perhaps he means nothing, all the same. Where do your thoughts go?" My patient paused then blushed. James, he said, had been attracted to him and he had wanted to seduce him. I asked, "Why does that embarrass you?" It was not James's attempted seduction that embarrassed him. Rather, my patient had been working hard to push something out of his mind. That something was that I might be gay and want to seduce him. In fact, he had a graphic daygame about it and he had discussed it with his partner who found the possibility intriguing. My patient had resolved not to think about it again and not to mention it, yet here it was. His association to his "random slip of the tongue" ran directly to what was most emotionally charged for him at that moment, as is so often the case. Again, Jonathan, a wonderful example. It's alive, there's no jargon, we all know it from everyday experience. Your final section of the paper is called "What's Good for the Goose," which really picks up on the theme in all of these foundations and all of our conversation today, which is that to do this, we really need to discover what's happening in those spaces and our own minds. Never completely. But hopefully we have enough familiarity with how our mind works so that we discover it in our treatments and hopefully we discover it continually throughout our lives. It's one of the pleasures and privileges of this work. We need to close and it's hard to summarize what you bring for us, Jonathan, and I listed a few themes at the beginning, but participating in this with you two more really come to mind. I think the listener will have their own fantasies, of course. But mind is what you bring that's really very special is the combination of a passion for this work and a passion for getting it right and combined with a clarity of thinking. I dare say that is a very special combination. Actually one could be very clear but is often dry and often if someone is passionate, they're not so clear. I want to thank you for your work and for sharing it with me and our listeners today because it really brings something special and I do hope our listeners read your chapter and continue to follow you because you do have something powerful and important to say. So thanks so much. Thank you very much. Thank you for listening. If I may, I'd like to ask you to help us publicize our podcast by rating us on iTunes or simply sharing it with a friend. You can also visit our web page, IPAoftheCouch.org, we can both subscribe and also add your comments. I'd also like to acknowledge the lovely rendition of Beethoven's Opus 18th St. Cortet by the Allegri St. Cortet on the Vivaat label.