Dr. Fu requested that I open the episode, saying that despite any disagreements he may have about any particular theoretical schools or models, he believes that there are excellent clinicians and therapists across all theories and schools. I suspect he wanted this disclaimer because his energy drink kicked in and he became paranoid, but that's my thoughts.
Good morning, Dr. Malthu.
Good morning. How are you doing?
Oh, not too bad, you know, just drinking my energy drink. You know, we're talking just now that you were, you preferred a little bit more structure. You know, I like to have a structure surrounding things and no structure within it. I think that allows people to be more free and easy, even though there's a safety of the boundary that surrounds the overall process.
You know, I find some people think the surrounding structure is obvious, even when it's not made explicit. And that can make things confusing. But if I don't have structure, I start to get anxious about what I'm doing.
Yet that anxiety may be mobilizing. It's a sign of mobilizing forces that mean more than what we would find if we stayed on one track. I don't know if you know what I'm getting at right now.
You seem like you're in a deeper headspace. Any reason you're thinking more analytically than normal?
Well, I thought today we might just discuss in a more freeform way about psychoanalysis. How is it, or is it, relevant at all to modern psychiatry in this practice, especially in the era where most people are just medication management, so to speak, right? What do you think? In your career so far, How have your impressions of psychoanalysis been? And do you see a relevance in today's psychiatry?
The question's a little bit tricky. Psychoanalysis is not one thing. It's a set of a bunch of different traditions, which we can sort out later. In regards to if it's relevant, saying it's not relevant is like saying money's not relevant because you have a credit card. So much of our modern thinking is developed from it. And the ideas are just like baked into a lot of our theories today.
So I think you're asking more of the more structured classical psychoanalytic approach and whether that matters today. And to me, parts are true and ignoring the whole body of knowledge is a problem.
Well, you know, I would say that you have a strong opinion about it. It sounds like for you, it's indispensable. It's kind of in the DNA of psychiatry, which I generally agree with that. But I don't think that most people feel or think that way these days, especially people who are coming from a more mainstream psychological or biological tradition. You know, they don't quite know what that means.
I think they just think of Kina Sendi and, you know, sexual theory and the phallus and Oedipus and Well, what's that have to do with what we do today? So if you don't mind, would you mind describing kind of a few of the varieties of psychoanalysis that people may mean when they say the word today?
Well, first, I feel like we should get the terms out of the way. People use psychoanalytic psychotherapy, psychodynamic therapy, and psychoanalysis in different and loose ways. Psychoanalysis can mean the broad body of theory from that era. Psychoanalytic psychotherapy and psychodynamic therapy use those ideas in treatment. So some use psychoanalytic psychotherapy to mean higher frequency technique driven work, like meeting two to three times per week. And psychodynamic often means using those principles about the past shaping the present in a more flexible format.
But I guess your initial question was to sketch the main schools out.
So I think, you know, even just by discussing the varieties right there, we're seeing one of the major issues. Psychoanalysis has been around for a really, really long time. And no one really agrees on what the different terms mean. There's no unified dictionary. Even more abstract and specific terms are used in very different ways by different thinkers. And yeah, people can disagree. I think what's important to basically know for most people is that Really, psychoanalysis and psychodynamic mean the same thing.
Efforts to say that they mean something different from a theory standpoint is pretty much marketing. Psychodynamic is a way to sort of disguise that we're not talking about psychoanalytic theories. from the how the clinical treatment is done and psychoanalysis proper is supposed to be the multiple times a week facing away done by a certified analyst kind of thing and then all the other terms for whatever can be psychoanalytic or psychodynamic therapies can pretty much go a variety of different ways to the extent that someone may say they're doing a psychodynamic psychotherapy and all they've done is maybe read some Freud or done a class or two and they've never really been formally trained in the technique.
Let me try to give a quick tour of the major theories and theorists with the caveat that these are... The differences are more for teaching boxes. They're not like very hard, strict borders. Freud begins with drive theory, which we can unpack what that is later. Anna Freud advances defense theory within that frame. Then comes object relations with Klein and Kernberg being the big people. And that focuses a lot on internal representations of self and others and how that shapes our unconscious life.
Then comes self-psychology led by Kohut. He reframed patients who he felt were empty or lack cohesion, and he mapped how the self develops and what happens when that development stalls, which kind of reshaped how we think about and treat narcissistic pathology. The next big school, I guess, would be relational.
I know, but it's even worth mentioning. Sorry, guys.
It's big in New York. That's my bias. It's big in New York, though. I know. Oh, boy. Well, anyway, the emphasis there is two subjectivities meeting and the implications of that and treatment. And a lot of my favorite mentors in New York City are more relationally trained, especially at the William Allen's and White School. Influential thinkers here like Henry Stack Sullivan.
I know that Sullivan is so old. You know, I feel like they're relying on a lot of earlier riders but they're really taking a direction and i'm not exactly trained or well read in that area but my impression is that they take it to a direction that spirals down to something else that may not be that helpful. But anyway. Yeah.
Actually, I even considered doing a training at William Allen said white and, uh, was in analysis with a relational analyst. Um, I've seen like one of their programs, they promise like this, like fully integrated frameworks and, uh, knowing someone who went through the training, like the curriculum can really just feel like a grab bag of just writing reading totally different papers um yeah and that like in the end it's not this
like fully integrated thing yeah and for that matter i think that is one of the problems uh it's been around for over a century well over a century and it's basically impossible it's basically impossible for any two year four year seven year nine year uh program to really cover everything in a meaningful fashion you know and anyone that claims to say that i think is making some kind of an error you know the both the most didactic program can do for anyone in a seriously deep field of study or practice is to teach you what to learn and so yeah you know that's just that's not what you get out of any kind of didactic course um you're not going to be complete at the end of it So, you know, that's a nice overview.
I would also mention Lacan because he's just so popular these days. I can't stand Lacan. Probably the effect of Zizek.
To me, I'm not that well read and my knowledge is very superficial, but the stuff that I have read feels very distant or relevant to clinical care.
Oh, that's not true. That's not true. I would say it's much more relevant than to relational people, but, you know. so we have a problem right giant field can't learn all of it um people will disagree on the different terminology and i would say that most of the time maybe 80 to 90 of the time the terminology is needlessly abstract uh to capture you know the information that is trying to be communicated.
And maybe this is some influence from my forensic training, but my impression is that generally speaking, a lot of the writers seem to have been getting to an arms race of seeing who could be more difficult to understand and more cool intellectually. Whereas in forensics, we want to really ideally write our opinions and what we want to communicate in extremely plain language so that an ordinary person can understand it.
If there's one thing I think that psychoanalysis can do to remain relevant into the future, it's to try to write in more plain language. I do think that the work out of Kernberg's group is accomplishing a lot of that. Not that if you read his original writing, it's going to be extremely clear to you if you haven't read a lot of basic theory. But I think they, in their handbooks, in their clinical texts, they really try to distill things down to just the need to know stuff and then relatively plainly.
Yeah, I guess I see a similar issue in the neurobiological framework today. Older analytic papers and writings can feel super dense and abstract and have all these highfalutin words, and you just need to translate it into modern language. But in residency today, I heard all these lectures... for in the neurobiological framework full of cortical networks and circuits and the dorsolateral prefrontal cortex connecting to the medial anterior you know all these things and and then the clinical takeaway in the end was just like oh start searching so i feel like it's not high common like it's common that like high level talk just barely touches practice so i feel like the same human tendency to sound sophisticated kind of just showed up in both eras
Yeah, and I think it's relevant to talk here a little bit. Mark Solms just came out with the revised edition of the Freud standard. uh collection standard edition and the person who translated the original standard edition into english was scratchy uh i think that's how you say his name you should never trust me when i pronounce somebody's name by the way but what he tried to do was he tried to translate it into english in a way that matched how the english language scientific community did things in terms of naming it's quite interesting uh apparently many many cultures of medicine and science try to use sort of international language or highly technical terms to talk about for example neuroanatomical structures uh take the corpus callosum okay that's what we call it in english part of the brain and it's uh you know In Latin, basically, right?
And we have a lot of things in Greek as well. But in Germany, they call the corpus callosum the beam or something like that. It's like they just call it beam, like a support beam or beam that connects two things. That's it. And so the original Freud often actually is much more plain language. You know, ego was called, I think, I. He just said, I, the I.
like me right and then uh id it was just the it it's just it that thing you know uh so you know translation is interesting and i will say this i do think there's some value in getting overly uh complex and jargonistic because ultimately what we're trying to communicate is some deeper meaning that can't necessarily be only communicated through simple words and if you have a reader or a thinker grapple with something difficult they may emerge you know, at the end of it with more than they would have had if you made it very, very concrete and plain and non-abstract.
It is a bit of a metaphor, I think, for a depth treatment process where we're not just coming into a treatment in order to get a simple answer and lead with it, right? It's not about what you get in terms of being filled with information, but with how you engage with the process and how it transforms you.
So you're saying the struggle itself with the complex text is part of the transformation, not just the transfers of facts, like how we learn with Anki and whatnot. The reading and the reflection and the effort put into how you make it is the important process. The one thing that makes these debates hard is that words shift meanings across paradigms. There's a concept in philosophy of science. An electron in classical chemistry is a totally different construct as an electron in quantum mechanics.
So there's a concept of when these two people are talking to each other, trying to make sense of their different theories, they're talking past each other because the underlying framework for what those things are are totally different within the paradigm that they're talking about. And psychiatry does this all the time like schizophrenia and older texts is not the same entity as what we mean today so comparing like apples to apples with the patients with schizophrenia today and the patients of schizophrenia of of the prior era like we're talking about totally different subsets of people so of course it's going to be like your theory makes absolutely no sense
Absolutely. Yeah, that's a big issue. Definitely a big issue. So I think so far we've essentially established that it's a difficult area that's confusing and not in a lot of agreement. I don't know if this is a very good sale to people. I wonder if you could elaborate more on your sense of how psychoanalysis, psychoanalytic theory is baked into modern psychiatry.
Hmm. Yeah. Well, is it baked into the modern neurobiological lens psychiatry as it's practiced day to day? No, not at all. But if we anchor to the DSM there, we can still see the psychoanalytic roots. You know, we see Freud's melancholia influences is a huge part of the melancholic subtype of depression. A lot of the ideas are rooted, are in the diagnoses. Where you see it the most baked in is our psychotherapy concepts.
So time-limited modalities are really drawing on the earlier insights. You know, CBT itself grows from an analytically trained therapist. So in therapy, you see the influence everywhere. The loss in terms of, you know, where the question comes from, is it still relevant today, is that many clinicians aren't as able to think psychologically as they were before.
Yeah. I guess that's kind of the main first point that I would point to. Talk therapy as we conceptualize it in the West since pretty much 1905 maybe didn't really exist properly before psychoanalysis. Psychoanalysis is the original talk therapy and all others kind of come out from that in some way or another. And then because pretty much every reputable and even disreputable psychiatrist up until like 1970 maybe, was trained as an analyst, a psychoanalyst properly.
All the theories and ideas have essentially been baked into diagnostic categories, ways of understanding pathology and methods of treatment and interviewing that really don't have anything to do with modern psychotherapy necessarily, yet are extremely relevant and part and parcel of the normal education. So if you neglect certain aspects of the theory and the history, you are kind of learning only part of what you're doing, and it can become a bit of a cargo cult, I think.
If you take certain things in, let's say, the DSM at face value without understanding the history behind it, you're practicing almost cargo cult psychiatry. When you say cargo cult, what do you mean? I mean that you... essentially say, well, it's written there. It must be true. Okay. Or someone important wrote about this. So that's the only way I can think about it. And of course, this is going to cause arguments again, because people disagree on theory.
But I think one good example is borderline personality disorder. If you don't understand the fundamental theory and history behind borderline personality disorder, you're going to think it's one very special entity that only a small amount of people have. Instead of it being a basically common broad spectrum area of problems that people have through development, not as by some accident, that the DSM has decided to pick a circle of very severe people within that spectrum to call borderline personality disorder.
That's not written in the DSM, right? That's not written really in one place anywhere. It's something that you have to learn through counsel training or through a broad-based reading.
This is where I really think we've lost something by the loss of psychoanalysis. A lot of clinicians can't formulate how personality shapes a presentation. And then that clinician thinks everything that doesn't respond to meds is some form of treatment resistance. I've seen patients with 10 or more medication trials, and the reason why the person's kind of going through this laundry of things that are not going to work is a lack of a psychological formulation.
If you only see things through a biological lens, you keep repeating the same steps over and over and over, and you miss and can't understand why the person's not improving.
Yeah. And, you know, the irony is it isn't DSM. People just generally don't read it. You know, they're kind of aware that there's a chapter on personality disorders. They might skip to a specific personality disorder diagnosis. But for the trainees that are listening, I'd like to know if you can comment what percentage of you have actually gone and read the general personality disorder criteria and its surrounding text before I've said this.
What percentage of you have gone to section three and read the alternative model for DSM personality disorders? And again, the general personality disorder text. There are specific named personality disorders, but that's hardly the norm. Most people are probably better described as having certain specific traits and general personality dysfunction. It's in the DSM. People just don't necessarily read it. It's just kind of one of the neglected chapters.
Kind of like sleep-wake cycle is in the DSM, but a lot of people don't know that stuff well. And sexual dysfunction disorders is also in the DSM.
Yeah, I mean, I was guilty of that as a trainee. You memorize the criteria to pass the exams and you assume that means you understand something. But the real learning is in the surrounding texts and in the formulations, not these checklists' criterias.
Yeah, you're pointing something important there, right? It's the frame of the education and the testing of education that sort of motivates people to do one thing or another. And I don't think we can point fingers at learners here. I would say that many, many supervisors purposefully ignore personality and formulation and diagnosis. They purposefully ignore it. I think there's stigma. We've probably talked about this before on a previous episode, but people don't consider it alongside all the other categories in differential diagnosis, even though personality is the one thing that every single patient that walks through your door is going to have, as opposed to all the other diagnostic and pathological categories.
But I think we're letting this get away into personality. And I think why personality is more psychoanalytic is because as other categories of psychopathology have been researched and we found, quote, biological treatments like medications or interventions, the final category that continues to escape treatment with medications and biological treatment as of this time of speaking is to personality disorders. And consequently, as the, quote, neurotic conditions went to biological treatments and CBT, then the purview of psychoanalysis and psychoanalytic treatments, I think has become more and more the personality disorders.
I'm going to just pivot slightly. Many learners and psychiatrists think real knowledge can only come from randomized control trials. Now, psychoatlantic knowledge came from careful observation, not controlled trials with placebo group and experimental group. So starting with Freud's early texts without context is off-putting because it's just not in the format of how we accumulate knowledge today. And the language and the metaphors can feel a little bit archaic.
But if you skip the later developments that are easier to translate into today's language, it's easy to dismiss the whole field as kind of just pseudoscience and just nonsense. And that's a big mistake.
Maybe it's worth kind of... hitting the highlights if i can hit some highlights of kind of each major development in my mind that is relevant to psychiatry today uh you think we should
do that yes please and i'll add some some brief commentary
Yeah. Well, we were just talking about personality disorders, and I think this is an important thing to draw a continuum around. And everyone probably knows the classic breakdown of cluster A, cluster B, cluster C. But I think it's important to know that that roughly maps onto a classical way of organizing personality functioning psychopathology along psychotic borderline and neurotic okay so in very brief and simplified terms someone who is neurotic has full contact with reality and doesn't really lose it okay their problems are mostly about worrying and fear and control And they are able to form a full and stable connection with other people and themselves psychologically.
Okay. Psychotic is when there is essentially psychosis in the way that we talk about loss of touch with reality. Okay. thinking process and reality testing is disrupted in some way that is different than normal people especially under stress and then the borderline range is people who are somewhere in the middle they've got characteristics Both, they're basically medium level in terms of their ability to connect to themselves, others, and regulate emotions.
Okay, that's really simplified. Now, I will say, I think the psychotic range is actually due to biological factors. That's my view of it. But as you mentioned earlier, the clinical body of patients that you work with is going to highly inform your theory and your conclusions. Anyway, what do you make of that?
Yeah, maybe let me kind of repeat some of the things you say, and hopefully I'm not too repetitive. As you mentioned, everyone's got a personality, a way that they see the world, a way they make sense of the world, and the terminology for the level of pathology is a little confusing. Because neurotic means something today. When I think of neurotic, I think of a Woody Allen type of character.
But in this framework, neurotic just means healthy. Or near healthy, at least. It's a personality function that's as close to reality as how we define it. then psychotic is more confusing because I don't use the word psychotic to talk about this type of psychosis at all. So I think of psychosis now as something that's much more biological. I think of it as like the biological schizophrenia, bipolar with psychotic features, drug-induced psychosis.
where the perceptual mechanisms messed up and the person's hearing voices, seeing things delusional. I think of more the psychotic category of diagnoses, whereas in the personality framework, it's referencing the way the personality is functioning in a way that's not in touch with reality, which is different than the perceptual mechanisms that are inherently pathological and schizophrenia or someone who's high on drugs and hearing voices.
Yeah, I know people categorize it that way. My contention here is not really about psychoanalysis, is that the schizotypal and schizoid and the delusional, paranoid, these people who don't meet criteria for schizophrenia and schizoaffective, they have the genes, they have the biology. uh for a psychotic disorder there if you if they marry each other their disposal will be a high risk of having a full-on psychotic disorder it's a biological phenomenon that's linked to some kind of adaptive mechanism of the brain probably i
i i think of it as something a little different maybe it'd be helpful to to discuss the the different personality disorders as flavors of different personality styling. And they all can be in the range from neurotic to psychotic. So someone can have a psychotic level organization of narcissism, or they can have a psychotic level organization of obsessive compulsive personality disorder. So the psychosis here is not implying the psychotic parts of schizotypal or schizoid.
So those are just certain flavors of the personality styles. So all the different subtypes, all different personality disorders are different flavors, and they can all operate in the neurotic, borderline, or psychotic range. And then, as we're saying, borderline means you're less than psychotic, where you're not completely out of touch with reality, and you're... not in touch with reality like the neurotic. So there are periods when you get under stress that you're going to be prone to getting out of touch with reality.
And I think, you know, as we kind of said earlier, these things can happen with a neurotic personality, but someone can lose touch with reality with enough, you know, long-term pressure. But for the borderline level of organization, it's a more regular part of their experience.
Good summary. The next thing that I think is very important to take from a major school of psychoanalysis that is still relevant today is actually the psychosexual theory. We're not going to use necessarily the terms that Freud used when he tried to basically make an evolutionarily derived theory of mental development, but I actually think it's best to use Erickson. I think a lot of people actually see Erickson's stages as mainstream and acceptable, including psychologists who have little to no contact with psychoanalytic theory.
and um you gotta know that they kind of map on each other instead erickson also developed some stages for after puberty actually before you go into the specifics i
just want to emphasize that the core idea here is is simple and in my opinion like self-evidently true so so development has key tasks and when those tasks go off course They leave like a nucleus of conflict that can echo later on in life. So I don't think this is like a controversial, you know, pseudoscientific claim. So Freud's labels do sound dated, and he did try to force it into biological terms.
But the basic developmental insight holds.
Yeah, I always say that the things that Freud got right, everyone just thinks are psychology. And the things that he was off the mark on where people misunderstand, that's what people say are Freud. That's where we are today, mostly speaking. But from drive theory and psychosexual theory, I think today it's relevant to know a couple of things. It's relevant to know that the unconscious probably exists. There's a large part of your brain's workings and your psychological workings that you cannot immediately or easily call into your conscious mind to think about and to manipulate with your executive functioning.
So that's the first thing, right? Think of the old iceberg. That's, I think, absolutely true and still relevant. You can find a lot of research and clinical evidence for that. Secondly, I would say that we're not going to belabor, I think, every stage we run that time today. But basically, you know, the human being starts out and they're already confronted with psychologically developing whether they can trust the world or not.
Is the world a safe place or not? Right. That's the first stage, oral stage. Then the next stage is about a matter of, you know, either do I am I ashamed or can I have control? I'm able to control myself and what I put out there, what I keep inside. That's the annual stage. Then we have the stage of how do I navigate three-person relationships? How do I navigate when my favorite person has another person?
It's the edible stage. Also, where we develop a matter of guilt and the ability to feel guilt and also your ability to kind of Push yourself forward by yourself. Okay. Then you have, you know, whether you can work hard or not, you know, whether you can put your nose to the grindstone and get pleasure out of being effective, then you have a matter of who you are and why and who you're going to love.
And then finally, there's some other stages with Erickson that we don't have to get into. But the take home, I think, is that these are universal issues for most people, though you will have to adjust somewhat for different cultures because the human organism probably has kind of a general roadmap that it will develop through, both in terms of the body and the mind and its interaction between the body and the mind.
Yeah, and you did a good job laying it out in everyday language. Attachment theory is a good way of viewing it that translates the three-person dilemmas that you mentioned into modern terms that make sense to us. Early trust, identity, and later intimacy maps well onto what we see clinically.
And you mentioned object relations. I think that's a really, really important one, especially because, again, simpler neurotic issues are increasingly managed by really basic things, you know, primary care, SSRI. workbook, and now AI therapist, quote unquote therapist. Psychiatrists and psychiatry specialists are increasingly going to have to deal with complex cases over time. And that means that we really, really, really want to know about the lessons of object relations because for object relations this is a group of people who were not working with adults primarily they formed the theory they were working with children young children and especially traumatized children people who have undergone traumas right trauma theory is pretty popular these days we're gonna get into that I think you got to know the paranoid schizoid position, the depressive position, manic defense.
The idea that rather than progressing linearly through stages, map to time, that mental development and how we relate to ourselves and others sort of snaps in and out of certain positions, When we're born, we are usually used to conceptualizing things as either all good or all bad, okay? And either inside or outside of us, part of us or not part of us, right? And so when we're under a lot of stress, we can get paranoid.
We can begin to attribute all bad things and all aggression to the outside, and we're all good. Or we can sometimes even do the opposite. We can start to say, I'm awful and I deserve to be destroyed. It's kind of really pre-verbal ways of shifting around our feelings and our way of understanding the world. And that it's only through adequate development. That we can reach what's called the depressive position where we can sort of have a balanced view of ourselves and others as both good and bad at the same time.
And that we can also feel true remorse, that we can feel and understand that we've taken from others, hurt others, and that we should repair that. as well. And that under stress, we can fall out of that depressive position. We can go into the paranoid schizoid again. And that there is an alternative. Rather than going to the depressive position, you can manage intense emotions and distress by saying basically extreme denial in the manic defense and saying basically, oh, I don't need anything.
I can't lose anything. Everything is fine and nothing can hurt me. I think these are all mind states, ways of relating to ourselves and others that everyone can be familiar with, at least superficially, and that definitely can be seen in young people.
Let me try to just restate that without the jargon. We all carry internal pictures of ourselves and others, and a lot of this is unconscious. Early experience builds up these templates of who we think we are and how we typically view other people. In adult life, we actually tend to recreate these templates. If I unconsciously expect closeness to end in disappointment, I'm going to do things that end up finding ways to confirm that initial axiom.
Now, early on, our minds are sorted into good representations and bad representations, and they're not merged together. So mother is either all good or all bad. And with development, those two different neural pathways can merge together so that we can view one person as both caring and disappointing. And that integration brings along with it guilt and a wish to repair. Now, under stress, you can snap back into those simplified representations of either all good or all bad, basically splitting.
Yeah. And that just because you achieve the ability and great doesn't mean you're always integrated. That under enough stress or under the right circumstances, you'll fall right back to splitting. And yeah, I think we're going to highlight these mechanisms. Splitting, right? The idea that things can be perceived as or treated as all good or all bad. This is a very common scenario in clinical treatment. You, the clinician, are going to be made all good or all bad sometimes.
Projective identification is also a very important mechanism. That somebody's intense feelings or expectations about other people can create a corresponding reaction in that person. Okay, like if a patient thinks that everyone hates them and then that makes them act very guarded and unpleasant towards all the clinicians, then all the clinicians will end up hating that kind of thing, right? These are important, I think, clinical phenomena. However you want to call them, however you want to explain why they're happening, they do happen.
And by understanding them and recognizing them, I think it's the first step to clinical management of these kinds of issues.
Yeah, I think it's important to look for these processes in yourself. Everyone splits with enough strain. You know, I feel like there's some people who think that there are a lot of clinicians who think that they never do those things. But I think when I was lecturing, I say, like, think of your first breakup. You know, most of us go into the all good or all bad in that moment.
And if you're a particularly depressive and masochistic person, maybe you're listening, maybe you know a friend that's like this after an intense breakup, you just blame yourself. Oh, you know, I was just so awful. I did everything wrong. I'm the reason why nothing broke down, you know, so it just really depends on your patterns. You know, before we finish, I'd like to touch on Lacan and I think he's important.
Boo! No, I don't think... I don't hate Lacan. It's just I feel like a lot of people that are attracted to him are those high-minded, hyper-intellectuals who you ask a very basic question and you get a 40-minute diatribe. And then all these terms, like everything else is defined by something else, which is poorly defined. So that like, you know, le petit object, ah, is the uncritical view of the eye, which is the X factor of the R.
And it's just like all these things that are defined by things that are even less well defined. It's like every word is a Russian nesting doll of more confusing terms that I've never even heard before.
I think it's a fair criticism. I would say that my favorite relevant lesson from Lacan, and maybe a lot of Lacanians will say I'm misinterpreting him, which is fine. But what I get from it is that thinking is fundamentally embedded within language. He's not the only psychoanalytic thinker. It's funny, I almost said psychoanalytic wrinkler, I think, which would be a bit of a parapraxis for you. But yeah, he's not the only psychoanalytic thinker that has put language and symbolism as important.
But I do think that his emphasis on language is important when we think about clinical treatments. And it's that you have stuff within you. A lot of it is unconscious or inaccessible or ill-defined. And it's the process of putting that stuff into a universal language that can be communicated and can be understood by others that sort of tames it, puts it under certain rules, and then makes it manageable.
And this is one of the fundamental mechanisms of treatment. Whether that treatment is a talk therapy or a medication management or a diagnostic session, putting things into words, naming them, and then conceptualizing them calmly but with your emotions, that's important. That's a treatment process in itself.
Yeah, Oase Oftob, who's got a great substack, has written on the Rumpelstiltskin effect that naming a condition can reorganize a person's narrative and that reorganization can reduce stress. So labels can help or harm depending on the accuracy and the fit and the person.
Yeah. I mean, it can go around it too, right? A lot of people come in with a very, very strong, almost culturally embedded idea of what they have. And sometimes that's wrong. Kind of did that last week, last time, but, uh, yeah, um, it's important, you know, the process of naming, the process of thinking, the process of putting into worlds, and also to think on the other hand, that our ability to think and feel is constrained by the words we use.
And, you know, that's like a CVT thing too. Uh, and then the other thing is I think the focus on desire. and that to understand that desire is really ever important in human functioning that we're really shaped by what we want what we think we want and moreover that we can't ultimately reach uh what we want and that to get what we want can be very unpleasant or even distressing so you know And therefore spurring us not to reach an end goal, but to live life in a certain way.
The point of life is not to get some specific outcome, but to live life in a specific process. I get that from what kind of...
Yeah, you know, that reminds me of things like, you know, like the John Lennon quote. I'm probably butchering it, but just like, you know, it's the journeyman, not the destination. I just don't see... the specific clinical relevance?
Well, I'll tell you right away. When I do medication management, I'm not trying to get you into remission forever. It's unrealistic. Okay. I want you to engage in a lifestyle and a process that gets you closer to the things that you want and further away from the things that you don't. Speaking simply. Just having that attitude and I think communicating that to patients is very important.
So you focus for patients on how they're living day to day rather than reaching a goal. So they don't think like, oh, once I get this degree or once I get this partner or once I get enough money. I guess my issue is that that concept, I guess I don't want to go too in detail here, but that concept doesn't need to be embedded in psychoanalytic language.
To me, it's not psychoanalysis. It's other... bodies of, you know, religion and philosophy capture that more than like a psychoanalytic psychiatric lens.
No, but, you know, someone has to talk about it and you have to think about it somewhere. Okay. You know, I realized that I completely skipped over ego psychology, a great disservice to Anne Freud and CBT. You know, that's got to mean something about how I feel about it. Let's talk a little bit about ego psychology.
I may have misspoke earlier. I think I lumped Anna Freud under Freud's theory rather than calling it specifically ego psychology.
Well, she's kind of after Freud, right? She's with Freud and after Freud, Anna Freud. And she's co-occurring with Melanie Klein and object relations people. But ego psychology is basically the idea that you have an executive functioning part of the brain, the ego. Okay. You have values and prohibitions, the superego. And you have, you know, animalistic or automatic drives, desires, wants, needs. Then all these things are being balanced all the time.
The way they're balanced is through our defenses, aka coping skills. or patents you know and so a lot of what people just consider to be psychotherapy today i would argue is really a form of ego psychology because cbt uh cognitive behavioral therapies for the most part especially ones that aim to identify bring insight into and teach various quote skills it's ego psychology it's ego psychology under a different method uh the way you think of the mind and how it works um that there can be quote distortions of some kind that they can be rectified is very ego psychology to me and it's really just a form of defense work so uh it works you know and it may be limited in some places i think it's not suitable for most people who are anywhere even slightly below healthy neurotic range of personality functioning, but it's relevant and it's what we're used to thinking about when we think about talk therapy these days.
Well, let's quickly define the trio. So the id is our animal drives. I think of like our evolutionarily built up, you know, very passionate lizard brain drives. It's not just aggression and sex, but really like anything that's just very evolutionarily built in over time. Now, the superego... is internalized rules about what we should do, who we should be. A lot of it is unconscious, and we learn it from our caregivers and from culture.
Yeah, but it could also make you say, I should be a bad boy, right? So I think how I like to put it is that it's what you should do, what you shouldn't do, who you should be, who you shouldn't be. All those things wrapped up that we get from our parents and society, that's the superego.
And the ego is the you that has to balance these two different forces, these animalistic impulses and these cultural parental expectations and actually act out in the world. So if the it is too strong or the super ego is too harsh, you're going to get symptoms as a result of not being able to find a good balance of those things. So the ego negotiates and outputs behavior.
It's the you. Yeah, it's the you, the awake you, the one that you are that you can feel and experience and act with. You know, I want to sell to people who are not convinced. If you've been listening this far, which I doubt you will be, and you still don't see how this is relevant to modern psychiatry, I would just say that you can look at various groups, concepts of psychopathology.
as defined in the dsm and you can locate how all these different concepts are contributing to making worse or modulating those particular psychopathologies and if you don't have at least a kind of working idea of that then you are having essentially a gap in knowledge and you don't know how a gap in knowledge will change your treatment until you have that knowledge. You can never know what it's like to have something until you have it.
And I do miss the old axis one and axis two split. It was simplistic, but it pushed us to think about personality alongside symptoms. Today, like we, a lot of people just stop at depression or bipolar, whereas personality is going to run through all of it. You know, these aren't just sunglasses that you take off once the mood improves and everything's all better.
I mean, I like it. It was a nice idea to try to force people to think about it, but in practice, everyone just wrote deferred on access to, and that was it. You are so much more complicated than one diagnosis, anyone with any diagnosis. The diagnosis is just a small slice of who you are meant to guide a specific type of treatment. It doesn't encompass who you are.
And this is where psychoanalysis is underappreciated. It gives a rich way to formulate patients. From the last podcast, the help-rejecting patient example shows the value of thinking psychologically instead of just, you know, the patient has depression, I'm going to follow the medication algorithm.
All right. Well, I thought that was a nice little overview. I hope people like that. If there's information that you want or more curious about that you think that we should talk about in the future, please leave it in the comments.
All right. That's a wrap.
All right. See you next time.