All right, welcome to the psychiatry and psychotherapy podcast. I am your host, Dr. David Puder. And today I'm going to be talking with one of my cohorts on primitive defense mechanisms. One of the great pleasures and joys of my week is leading psychotherapy cohorts. We have been diving into Nancy McWilliam, psychoanalytic diagnosis, and one of the chapters that jumped out to me, and I thought would be very helpful to do a deep dive with this cohort is on primitive defenses. We'll be talking about things like extreme withdrawal, denial, omnipotent control, extreme idealization, devaluation, splitting, somatization, sexualization, projective identification, extreme dissociation, acting out projection and interjection. And we'll be going through definitions, developmental origins, counter-transfering simplifications. And this is a great opportunity for me to bring this group of amazing mental health professionals for you guys to meet and see that this is going on, this is happening, this is starting up again in September and I'm excited to continue teaching in this way. So we usually do it twice a week, once a week. For about two hours, we have some special people come on as well throughout the year and give extra two hour lectures. So people who are in this, I'm going to go through their names so you can hear them once and then you'll hear them again or see them if you're on YouTube watching this. Dr. Erica L. Reynolds is a talented psychiatrist in North San Diego County, who is kind of the mother of the group with 30 years of experience, more experienced than me, and comes with a lot of warmth and empathy for the group members. She will be talking about extreme with draw and denial. Ariel Schatz-Wilderman is an M.A. LSW, who is a psychotherapist founder of the Wilderman Fund for Maternal Mental Health and an expert in reproductive psychiatry. She is someone who has been a great joy of having on the podcast and I think you'll really enjoy her dive into omnipotent control. Michelle Zitnik is a psychiatric nurse practitioner in Southern Florida with over 17 years of pediatric nursing experience and does a great job of somatization, which is something that she shows is high in lexatymia, childhood trauma, insecure attachment, insecure attachment, personality styles, like his surrounding narcissistic or neurotic. And I'm excited for you to hear a little bit of her take on that. Evan Summersup from Candidbury New Hampshire will deliver a candid, thoughtful presentation on a rodization and sexualization, which is a defense in which unconsciously people try to master things like anxiety, self-esteem, shame, and terror with sexuality. She, the Coles, is an integrative psychotherapist from England who zooms in once a week from England. part of the NHS and private practice and we'll be talking about projective identification with a lens of a master clinician. And I'm really excited for you to hear from her. Dr. Johann Ortizo is a CIDE MSW who has a special interest in psychodynamic psychotherapy. He is going to be delivering a very clinically rich informed, trauma-informed approach of extreme dissociation. Also joined with us is Heidi Lynn, a psychiatric nurse practitioner and co-founder of Halen Mental Health. She has Advanced Training and EMDR, Psychotherapy, Integrative Psychiatry, and Deliverers, Alpation Care for Children, Adolescent and Adults. She is presenting on splitting, offering warm and reflective clinically grounded exploration in the all good versus all bad. It's use in borderline, narcissistic and OCPD presentations. And she presents powerful real-world examples of societal and team splitting. Dr. April Staples, a CIDE, is a licensed psychologist and member of the KU MII nation and does thoughtfully clinically grounded work and very reflective, highly reflective person. We will be listening to her talk about acting out or enactment and she'll jump into other people's stuff as well. Grant LeMone is a new psychiatric nurse practitioner who is a energetic, enthusiastic learner and we'll be talking about projection and interjection. Finally, Danny Martino is a physician assistant with a certificate in psychiatry who will bring a sharp focus on extreme idealization and devaluation and he's been a joy to work with this last year. Sadly one of our other members who you may have remembered from a previous episode, Daniel Smith will not be joining us. He was unable to make these recording sessions, but you can go back and you can listen to our prior episode together on his recent book and his expertise on things like shame and envy and annoyance. So, all right, let's start the episode. And I hope that this gives you an increased level of psychological bindedness. Erica Reynolds, you're gonna start us off talking about extreme withdrawal. Yes, extreme withdrawal is a defense that I don't recall I were learning about until this month, which starts in infancy as an automatic self protection retreat from a distressing interpersonal interaction. So as an infant, maybe I'm cold, I'm hungry, who knows what an interpersonal interaction at that level is, but this is the definition. This new state of unconsciousness, the extreme withdrawal, exists largely in a world of internal fantasy for the infant. And now, as of 2001, it's even included in the fight, flight, freeze, or withdrawal. Saying, and I thought that was very interesting that an old thing has now been included in the fire flight and then we got freeze included it now withdrawal is also in part of that descriptor sort of for the proverbial deer in the headlights situation. It's a flight into fantasy without a distortion or a misunderstanding reality. It's a rejection of reality, if you will, and escape from it.

And one can remain perceptive and sensitive to reality while electing or choosing to disengage from it. Some settings in which it commonly appears clinically are an instinctive response to an overwhelming encounter of danger. So this as one gets a little older, this could be helpful escape from something happening to a young adult or an adult past the

infant stage. In the short term, it can help a survivor rebalance after trauma. And in the worst case, withdrawal can be prolonged, complex, and a process that really takes over the inner life. So that is, you know, a highly and is a terrible state. And you might find this in someone who's appearing perhaps catatonic that would be on the differential, somebody very, very ill in the hospital. Some of the more common personalities that extreme withdrawal is seen in are schizoid. So we have a deep voluntary preference for isolation and ambivalence about a desire for relationships. So usually a lack of desire. And then there's emotional detachment. Another personality that uses extreme withdrawal is avoidant. So you can see withdrawal and social inhibition because they're really paralyzed by fear. So they perceive the social situation as fearful and their defense against it is to really withdraw, again, reject reality, not deny it, but rejected. As Guzotipu, I may withdraw due to tremendous perceived social anxiety. So again, we have that fear component and the social construct. And Paranoid, which can show a withdrawal as a defense mechanism towards an unjustified suspicion. A literary example of extreme withdrawal is from the 2016 novel called The Vegetarian by Han Kong, where the protagonist gives up meat and decides to live like a plant. So this is an example of a conscious decision to abandon a malicious act before complete withdrawal from a destructive social environment. So again, this is, this sounds like an extreme example and that fits the name of the defense. Wonderful, great job. Yeah, so it's that that shutdown phase of the fighting flight. So the shutdown, there's no maybe no escape. So there's just a withdrawal withdrawing itself and fantasy. Oh, withdraw. Like you could see someone curling up in a in a ball. Sometimes patients will just kind of end up in their room isolating. Sometimes after after fights, like, you know, there's someone who will withdraw into the garage, shut down. It's like you talked to them and there's no emotion, they're kind of flat, very flat, very distant. Yeah, so great withdrawal. Okay, and moving on to denial. This wait may start as a way for infants to refuse to accept an unpleasant experience. And it becomes an unconsciously motivated inability or unwillingness to acknowledge the existence of a painful emotional, interpersonal, or physical reality. So this is a very broad swath of issues here.

The unstated or unrecognized goal of ignoring the realities is to reduce the anxiety. And the rejection of reality can lead to distortion. So we have a little bit of a distortion factor which can come into play with denial. Three clinical states where denial is prominent are the mania hypomania.

And here the person denies that they are participating events that could be dangerous or distressing to others. They just don't see it as a risk. Addiction? Also, denial, we all know this is severity of the substance use or that it is or could be harmful, you know, denial of how bad the substance use is, and grief, a normal early phase of loss that's seen in the grief process. So those are some interesting clinical sightings of it. And for personality disorders that rely very heavily on denial, your borderline, your narcissistic,

anti-social, and dependent. This is an interesting example. So denial as has been discussed with some of our other defenses is that there are some some quality of these two that are higher order and mature wrapped into denial. and those can tend towards repression, rationalization, or reaction formation. So denial is not only a very broad swath of things that it could occur with, but it also has handset, higher level, this has. So it may not be just all bad, as we could say. So an example of a strong affection for another, an example of denial may end up as, I don't love you, I hate you, in terms of a reaction formation, somebody may end up saying that. And a beautiful example in literature again of denial is in the great Gaspi, where Nick Caraway tells Jay Gaspi, you can't repeat the past. And Jay Gaspi says, well, I, of course, you can. That's my favorite example of denial. Wonderful. Yeah. I think the denial is very, the switch from something distrustful to pushing it down into the unconscious with denial is like, it like so rapid that the thing that they're trying to hide from is not even registered in their brain. So whereas like repression, it's registered and then it's pushed down denial. It's so instant that it's like they don't even see it. It's like there it's almost like a delusional. There's like a delusional quality to it. So with hypomantic defenses, for example, it's a little bit different than maybe bipolar, like how we see it in the DSM, but a hypomantic defense, which various people can have you if they're not bipolar. They deny some bad negative emotion and see something as positive. So I've had coaches who have hypomantic defenses that it's like anything bad is like, they don't even see it. It's like they only see possibility. They only see that we're moving forward. They only see that, no, we're progressing. Like everything is good. And in some ways, it could be adaptive in that way, to deny and to be able to keep moving forward despite the grimness of a situation. So thank you, Erica. That was great. Good answer. Okay. Aria Willerman, tell me about omnipotent control. Maybe give me just a brief definition. Sure. So omnipotent control is a primitive, primary defense process that can be described as an unconscious belief or fantasy of having absolute power over others or one's environment. So in a maladaptive context, the defense allows one to bypass unpleasant emotional states, distorting or disavowing fear of smallness, weakness, or annihilation into a self-image of the all-powerful end-supreme. Yeah, so it's this great, so it's an unconscious belief or fantasy of having absolute power over others or one's environment. So tell me how the PDM3 talks about omnipotent control. Sure. Yeah. So in the 2026 PDM3, omnipotent control is characterized as treating another as an extension of oneself and insisting that the other person thinks the thoughts assigned to them instead of having their own. Yeah. And it seems that this is linked in a lot of transference, focus psychotherapy with other primitive defenses. Like it's like they're always listed together throughout articles. What are some of those other primitive defenses that it's listed with? Yeah. What comes up frequently in TFP is the grouping together with devaluation or extreme idealization and devaluation, as well as projective identification and splitting is really inherent to omnipotent control. Yes, so it seems like all those three are kind of going together. And I was thinking about Nancy McWilliams chapter on psychopathy and how does psychopathy have omnipotent control as part of it? Yeah, yeah. So psychopathic. In the psychopathic realm, essentially, there's this controlling of others around them with a satism component for power. It's not really too destroyed, but rather to control while they still can control. And I also think about, you know, with reference to Nancy, this element of omnipotent control or omnipotence in the psychopathic position is actually part of a conscious process in the control element as well. So that also is interesting among the psychopathic realm. Yeah. I think psychopathy, it's so centered around power and control.

Whereas someone... psychopathic wrong. Yeah. I think psychopathy, it's so centered around power and control. Whereas like, you know, someone with a more dependent personality is centered around like, okay, how do I stick connected to this individual? Someone with schizoid, it's like, I don't, I don't want to be consumed. I did with someone with OCPD is more like, I don't want to be, I want to control every little aspect of my environment like in an orderly way. But psychopathy is all about power. And so how might some of these elements of this desire for omnipotence come out practically? Yeah, there's a lot of manipulation happening among psychopaths. So again, unconscious defense, conscious process, some ways that omnipotence will show in psychopaths or in a psychopathic realm is when you see some rigging the game, people may cheat, they want to set the rules, people will blackmail others. Play Kangaroo Court, there's a lot of isolating of the victim, people in this range will often try to turn the family against the other. And even in our position, turn a psychiatrist or a therapist into a controlled substance pill dispenser. So there's a lot of conscious manipulation that may be motivated by unconscious processes. Right. The quest for power, though, they'll do anything to get the power. They want that omnipotent control. They want to control the thoughts of others. You've seen this in kind of awful, dietic relationships between someone who's more of maybe a dependent personality and more of a psychopathic, whether they're wanting to control all of their thoughts. So they really isolate them. Great summary. Okay. And then interesting thing when we're looking at like narcissism, a lot more of the transverse walks therapy articles, they talk about omnipotent control in more of a narcissistic person. What is the goal of control in someone who's more narcissistic? Yeah, I mean, the essence is to promote this grandiose inflated sense of self, but it's really an image, not even a sense of self. So it's this whole fantasy that is about supremacy, control. We see a lot of those other defenses coming in as well here. So there are a couple of just main aspects of that to stress, control of others' perception of you, of the narcissist. In more of the depressive personalities, their dependent personalities, the masochistic personality types, it really manifests as control very, very good targets for someone in the narcissistic realm. Right. So, yeah, the narcissistic person is finding that person with the depressive, with the dependent. It feeds off of those traits of the depressive, dependent, or masochistic personality types. Yeah. And one thing we have to be careful about as mental professionals is they can turn the psychiatrist into kind of like that ego booster, but then devalue them because maybe they feel some envy of their position or power or authority as a mental professional. But really they really want like this, like someone to co-author their narrative about themselves, the way they see themselves. So as therapists, we might have an omnipotent fantasy that we are capable of rescuing a patient. What would you say? I would say that therapists omnipotence is an important one to be aware of. It also ties back to Kernberg's views on a nipotence which she relates to the borderline level of functioning patient. So here there's the self-idealing patient who in order to sustain their fantasy of self-generated power will over-idealize self and object representation. So the therapist is essentially an ego-poster, but the patient ultimately devalues the therapist to maintain their position of power. So that will occur when the therapeutic alliance becomes too much. The patient then will project disavowed parts of self,

that vulnerability, that openness onto the therapist.

So as Kernberg puts it, he states,

end to quote, the projection of that magical omnipotence

onto the therapist and the patient's feeling

magically united with or submissive

to that omnipotent therapist are other forms which this defensive operation can take. So what happens through projective identification with the patient, the therapist can start to embody these disavowed emotions or internal states. So the dis-reculation of self on the behalf of the therapist can shift gradually or abruptly so that the therapist feels the patient's feelings, frustration, annoyance, rage, hate. And these are manifestations of omnipotence and devaluation, ego defenses. So this is an important one to think about as providers, as therapists in this role, because it can have severe impacts on the therapist. I mean, even ethical dilemmas. It can even lead to a therapist feeling physically ill and burnt out. Yeah, it's really good, because it kind of gives this pattern of they can initially very idealize the therapist, but then the closeness becomes too much so then they have to, it's like then they go into the devaluation, but the omnipotent control here is part of that piece and I like how you weave that all together. By the way, if you're curious about this, Kernberg wrote a article called omnipotence and transference and counter transference. Great article will link that as well on the website with this. You know, the word that Kernberg in this paper that we've just referred to, he has some wonderful descriptions of how this plays out. So in the case of the narcissistic personality, and I'll read from the publication in the case of narcissistic personality of nibbatants and in nibbatant control protect the patient from dreaded separation, dependency and envy, maintaining the idealized concept of the pathologic brandy self. That's so good. Let me re-read that. In the case of narcissistic personalities, omnipotence, and omnipotent control protect the patient from dreaded separation, dependency, and envy, maintaining the idealized concept of the pathological grandiose self. When I hear that, I think about how the grandiose self is kind of like this image of themselves that they're trying to portray, the omnipotence helps them maintain that by separating all the bad out. So it's like it all kind of is working together, like this like devaluation idealization, they're idealizing themselves, they're devaluing the other, they're maintaining the exist grandiose self. And that's where I think this other quote here comes into play. Maybe it's worth reading about how omnipotence and devaluation go together. Yeah, so Kernberg on omnipotence and devaluation states that these two intimately linked defensive operations of omnipotence and devaluation refer to the patient's identification with an over idealized self and object representation with a primitive form of ego ideal as a protection against threatening needs and involvement with others. Such self-idealization usually implies magical fantasies of omnipotence. The conviction that he, the patient, will eventually receive all the gratification that he is entitled to and that he cannot be touched by frustrations, illness, death, or the passage of time. A corollary of this fantasy is the devaluation of other people, the patient's conviction of his superiority over them, including the therapist. The projection of that magical omnipotence onto the therapist and the patient's feeling magically united with or submissive to that omnipotent therapist are other forms which this defensive operation can take. And I think that's a beautiful, beautiful way of phrasing that relationship, the omnipotence and the devaluation together. Yeah, that's great. I was also thinking about OCPD and how someone who's at the borderline level of function with OCPD obsessive-compulsive personality might take a different flavor than the narcissist. How might it take a different flavor? The essentially controlling others enables order. Others essentially become an extension of the order that people in this position will want to take. Yeah. Yeah. And how about with Skizoid? Jordan Skizoid, a lot of control comes out in fantasies. Yeah. So think about how different personality types manifest defenses in different ways. Really interesting to think about that because it's all omnipotence is a portion of multiple of these different types of personalities. But with the psychopath, the power is for like their own, for the power is for power sake. Whereas like the scissor, the power is to not be consumed. Those who pd is for order, for narcissists to protect their image. How about someone with paranoid personality? How might they use omnipotence to protect themselves or help their own sense of equilibrium? Yes. So by projecting negative emotions in often cases, anger, the anger that's projected projected onto the other is interpreted as the other project putting anger on me. The other being angry at me. That puts me in a threatening position. Therefore, I don't feel safe. So the natural tendency in this position would be the defensive tendency would be to control them.

Right. Because if you can control the person that's angry at you,

then you're safe. Even though you're the one that's projecting the anger on the other person.

You know, there can be some

positive

ways that we could think about omnipotent control, but maybe not. Like let's talk about that. Is there anything that you can imagine like a good use of omnipotent control? I mean, I can and like if you take a utopia view, so like I think of leaders who may use a lipid and control in a sense they're demanding, but they're also creating conditions where when one has all the power, you could have a utopia, everything could be stable, but it could also be hell. So depending on the context, outcomes of a lipidant control can at least look like a fully functional well-wilded machine. But again, it's the motivation of the individual, the omnipidant control defense that's playing out that can make it more like hell. Right, so it's like a leader like Mousie Dung used a lot of control to basically control every facet of a whole country. Lots of deaths happened in his mind. This was going to lead to a utopia of sorts. So was it successful to have that much desire to control every little facet? It was successful for himself, right? It wasn't necessarily successful for the most possible people, which is where I think like, you know, leadership research on like high psychological safety leaders probably don't have a need for omnipotent control, whereas they aspire to give other people power and control and empower other people. Right. So what's mostly got a well-awaited machine or stability in a society, again, what is the leader's drive? What is that coming from? Is it really utopia or is it hell? So it's an interesting position to think about. Yeah. Before we move on, let's talk about an actual clinical example. Sure. A clinical example of omnipotence, one patient that I worked with initially presented as highly educated, a natural born leader, had this strong moral compass, was respected and well liked by all, according to how he described himself. At the time, I learned he was approaching his 10th year of working as a department store clerk and claimed that he loved his job. And in this very superficial but humble manner, he shared that he was the best employee because his managers never felt the need to promote him. Wait, that's confusing to me. Like they never felt the need to promote him. Wait, that's confusing to me. Like, they never felt the need to promote him. What does that mean? Was that confusing to you? Well, when I realized what I was working with, then this was a nipotent control at play. After 10 years to be the best employee, but again, still not a

manager. His managers never felt the need to promote me because I was so great. I was

so good in my position. I was the best of the best in this position. It would be foolish

to promote me.

Oh, yeah. Okay. Because like, like, I'm so like if you're car salesmen, like, I'm the

...