Key moments, in order
Saying psychoanalysis is not relevant is like saying money is not relevant because you have a credit card. So much of our modern thinking developed from it, and the ideas are baked into a lot of today's theories.
Some use psychoanalytic psychotherapy to mean higher-frequency, technique-driven work, two or three times a week, and psychodynamic to mean applying the idea that the past shapes the present in a more flexible format. From a theory standpoint they mean the same thing; claims otherwise are pretty much marketing.
Someone may say they do psychodynamic psychotherapy after reading some Freud or taking a class or two, without ever being formally trained in the technique.
After Anna Freud's defense theory came object relations, with Klein and Kernberg the big names. It focuses on internal representations of self and others and how they shape unconscious life.
Kohut's self psychology mapped how the self develops and what happens when that development stalls, which reshaped how we think about and treat narcissistic pathology.
Relational psychoanalysis emphasizes two subjectivities meeting and what that means for treatment.
No training program, of any length, can cover the whole field in a meaningful way, and anyone who claims to is making an error.
Most of the time, maybe 80 to 90 percent, the terminology is needlessly abstract. The one thing the field can do to stay relevant is write in plainer language.
Most of the time, perhaps 80 to 90 percent, psychoanalytic terminology is needlessly abstract, and high-level neurobiological talk often barely touches practice. The same urge to sound sophisticated shows up in both; the fix is plain language.
To be fair, a reader who grapples with something difficult may come out with more than they would from a very concrete, plain version.
Never trust a pre-1980 schizophrenia diagnosis, and do not trust any diagnosis until you verify it yourself. Older definitions were too loose, sweeping in anyone with disturbances of thinking, mood and behavior, so schizophrenia in older texts is not the same group of patients we mean today.
Its roots are still visible in the DSM; Freud's melancholia is a huge part of the melancholic subtype of depression.
It is most baked into our psychotherapy concepts: time-limited therapies draw on its earlier insights, and CBT itself grew from an analytically trained therapist.
Many clinicians are not as able to think psychologically as they were before.
It is the original talk therapy. Talk therapy as we know it in the West did not really exist before it, and all the others come out of it in some way.
Taking things in the DSM at face value without understanding the history behind them is close to cargo cult psychiatry.
Without the theory and history, you will think it is one very special entity that few people have, instead of a common, broad spectrum of developmental problems.
Clinicians who cannot formulate how personality shapes a presentation call everything that does not respond to medication treatment resistance. Patients with 10 or more medication trials are often going through that laundry list because no one made a psychological formulation.
The categories in the main section of the DSM are terrible. The DSM-5 alternative model in Section III is very good and worth getting familiar with, yet few clinicians have read it or the general personality disorder text.
People rarely fit into one of ten personality styles. Most are better described by specific traits and general personality dysfunction, and for most the most appropriate diagnosis is probably other specified personality disorder, with traits of several disorders reflecting core problems in self and interpersonal functioning.
Memorizing the criteria to pass exams is not understanding. The real learning is in the surrounding text and the formulations, not the checklists.
Many supervisors purposefully ignore personality, formulation and diagnosis, likely because of stigma.
Personality is the one thing every single patient who walks through your door is going to have, unlike every other diagnostic category.
As the neurotic conditions went to biological treatments and CBT, psychoanalytic treatment has become more and more about personality disorders.
If you skip the later developments that translate more easily into today's language, it is easy to dismiss the whole field as pseudoscience and nonsense. That is a big mistake.
The familiar cluster A, B and C breakdown roughly maps onto the classical way of organizing personality pathology: psychotic, borderline and neurotic.
Neurotic: full contact with reality, problems mostly about worry, fear and control, and a full, stable connection with other people and with themselves. In this framework neurotic just means healthy, or near healthy.
Psychotic: thinking and reality testing are disrupted, especially under stress. In the original sense, it means a problem joining consensual reality, and you see it in many people who are not diagnosably schizophrenic but struggle to stay in reality or hold some really crazy ideas.
Borderline: somewhere in the middle, with a medium-level ability to connect to themselves and others and to regulate emotions.
People with schizotypal, schizoid and delusional or paranoid styles who do not meet criteria for schizophrenia or schizoaffective disorder have the genes and the biology of a psychotic disorder.
The different personality disorders are different flavors, and each can operate in the neurotic, borderline or psychotic range.
Development has key tasks, and tasks that go off course leave a nucleus of conflict that can echo later in life.
The things Freud got right, everyone just thinks of as psychology. The things he got wrong are what people call Freud.
It is relevant to know that the unconscious probably exists: a large part of our psychological workings cannot easily be called into conscious thought and manipulated with executive functioning.
The first (oral) stage is about whether the world is a safe place and can be trusted.
The anal stage concerns shame versus control over what you put out and keep inside.
The oedipal stage concerns three-person relationships and the development of guilt.
Attachment theory restates these dilemmas in modern terms; early trust, identity and later intimacy map well onto what we see clinically.
Psychiatrists are increasingly going to deal with complex cases, which means we really want to know the lessons of object relations.
Under a lot of stress we can get paranoid, putting all badness and aggression outside while we stay all good. Or the opposite: "I'm awful and I deserve to be destroyed."
The depressive position is a balanced view of self and others as both good and bad at the same time, with true remorse: knowing we have taken from or hurt others and that we should repair it.
The manic defense skips the depressive position and manages intense distress with extreme denial: I don't need anything, I can't lose anything, nothing can hurt me.
We all carry internal pictures of ourselves and others, and a lot of this is unconscious. Early experience builds templates of who we think we are and how we view other people, and in adult life we tend to recreate them.
Early on, the mind sorts things into good and bad representations that are not merged: mother is either all good or all bad. Through many minor frustrations, a child learns the all-good and all-bad mother are the same person. Splitting persists when that process is interrupted.
You, the clinician, will sometimes be made all good or all bad. It is a very common scenario.
Projective identification: someone's intense feelings or expectations about others create a matching reaction. A patient who thinks everyone hates them acts guarded and unpleasant toward every clinician.
Look for splitting in yourself. Everyone splits with enough strain, as anyone who has called an ex a bastard after a breakup knows.
Putting inner unconscious or ill-defined experience into shared language tames it and makes it manageable, a fundamental mechanism of treatment.
Naming a condition can reorganize a person's narrative and reduce stress, so labels help or harm depending on accuracy, fit and the person. Putting things into words and conceptualizing them calmly is a treatment process in itself.
Patients often arrive with a strong, almost culturally embedded idea of what they have, and sometimes it is wrong.
The aim is not remission forever, which is unrealistic. It is a lifestyle and a process that gets the patient closer to what they want and further from what they don't.
Ego psychology posits an executive ego, a superego of values and prohibitions, and automatic drives, balanced continuously through defenses or coping skills.
CBT that aims to identify problems, bring insight and teach skills is, we would argue, a form of ego psychology.
It works, but it is limited, and it is not suitable for most people anywhere even slightly below the healthy neurotic range of personality functioning.
Symptoms arise when the id is too strong or the superego too harsh for the ego to balance; the ego negotiates and outputs behavior.
We miss the old Axis I and Axis II split. It was simplistic, but it pushed us to think about personality alongside symptoms; now many people stop at depression or bipolar, though personality runs through all of it.
Any DSM diagnosis captures one slice of a patient's pathology, and a patient can have more than one. It is a small slice of who someone is, meant to guide a specific type of treatment, not who they are.
Psychoanalysis gives a rich way to formulate, so you think psychologically about a help-rejecting patient instead of simply following the depression medication algorithm.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.