All right, we are going to start. We have David Mince today. He is written a book, Psychodynamic Psychopharmacology. He's a psychiatrist. He has extensive experience treating patients. Right now you're at Austin Riggs, is that correct?

And you have some private practice as well, I imagine. Yes, I do. Yeah. And so tell me a little bit about how many years have you been practicing and what does that look like most of your career just to get just to get a started here? Yeah. So I came to Riggs in the middle of the 1990s, like right at the height of the biomedical turn. And so I came at a time where I was having a very interesting experience of like, I'm at Riggs doing psychodynamic psychiatry and the field is going in the completely opposite direction. Wow, yeah, it's a 35 years. It's 30, 30 years.

30 years, yeah. And so today we're going to be talking about psychotherapy. We're going to be talking about how it relates to medication. And hopefully I will sort of pull from you how medication can evoke some unique things, right? Psychodynamically. Yes. And the other way around, how psychodynamics really shapes the way medications end up working. And I think one of my goals for our session today is to really distill how you view your practice, how you view psychiatry, what you do on a regular basis, like what is this actually look like? Are you prescribing to all of your patients? When do you not prescribe? How do you view that you're different than most prescribers? And how you help your patients view medication, view their identity in the midst of a medical set of issues and where transference, counter-transference comes in and actments, the mind, body split, and how you integrate those. So kind of give an elevator pitch for where you would like, what are the main things you would like people to take away as we kind of think about starting this?

Well, I think the evidence, I will start by saying the evidence, I think is very clear that meaning affects shapes, medication response profoundly across drug types and across diagnostic categories. So when we are working in a way that narrowly thinks of our medications as simply biomedical, we are missing something because our medications are and you know not just both biologically active and symbolically active but for for some conditions like depression, predominantly, it's like a symbolically active. Okay, so maybe talk a little bit more about what you mean by meaning, and the meaning we ascribe to things, right? The meaning we ascribe to illness, medication. Yeah, I mean on some level, I think we're talking about the world view that the patient has. So our patients, you know, and again, many of our patients in psychiatry, and certainly the ones that are treatment or factory, which is the population of a treated rigs, have histories of early adversity, have learned, you know, early on and deep in their bones that caregivers are potentially dangerous. And so they see the world, they come into our offices and they come in with a set of expectations. And those expectations shape the way that they respond. And on the other side, patients who have more hopeful orientation towards care, we know that the placebo response ranges from an effect size of something like 1.4 for antidepressants all the way down to 0.59 for antipsychotic. So the meaning that patients carry, the expectations they have of medications really shape the way that those medications work in the body, and then also the kinds of things we were just talking about, shape the willingness of the patient, even to put our medications into their mouths, right? Because if there's expectations of harm, et cetera, we know that that affects things like adherence. Yeah. So, okay.

So, you said because of their childhood early adversity, they may have an expectation of harm that you will be harming them. We could call this transference. We could call this, what would you call it, or how would you like make sense of it? I mean, I think, yeah, I would tend to think of it as a manifestation of transference, though you could also frame it in terms of the kinds of attachment styles that those early experiences engender in people which really do affect how they relate to care and caregiving figures, but in my work, I'm predominantly thinking of that as the kinds of transferences that patients will bring into treatment that then undermine, I get for a treatment-resistant population, undermine how well those medications have worked in the past. And the idea, I think that I have is that you have to be able to work with those transferences in order to help the patients benefit more from the treatments you have to offer as a prescribing psychiatrist. So let's say they come in with a more avoidant attachment style. What tends to be the things that you see? How does that relate to the medication? How does that relate to how they relate to you? So, you know, patients with more avoidant, fearful kind of attachment style, you know, these are people who predominantly, who have had fairly consistent experiences of hurt in caregiving contexts. Really, that's the theory of how that emerges. And so these are people who are likely to be mistrusting and more likely actually to be actually harmed by medications. They're more likely to have no seabird responses. And so these are patients, like in terms of prescribing strategy, these are kinds of patients that you maybe would start, you know, with a start low and go slow approach because they're when they experience the feeling of the medication in their body, it's much easier for them to interpret that as a harmful experience. But apart from that, I think that maybe in the bigger picture, with patients like that, I am starting a conversation about this with the patient from the first session, probably even before I make any medication changes, actually, ideally, before I would make any medication changes. So it becomes something that we can start to talk about. Like if their body, if they don't like what is happening in their body, we can step back and think. So how much of this is the medication? How much of this is what you carry in? And in a way that, again, there's research and suggests, for example, when you've talked about nose seabull responses before they happen, A, it reduces the likelihood of nose seabull responses, and B, patients are very able to stick with treatment even in the context of negative experiences. Yeah. And what about like within the avoidant attachment styles, do you see kind of like more of the schizoid personality, for example, I tend to think of more as an avoidant attachment style? Do you also see unique interactions with medications with the different personality styles that someone might present with? Yeah, in a sense that, you know, so somebody who is more on the... Well, to start with people with secure attachment styles, you know, we don't... we often don't see those patients in our practices because they get treated by the primary care doctor, they get better and they take

them medications. So our practices are much more likely to be filled with people who have more fearful or avoidant or dismissive attachment. So like we're saying, for people who are, have more fearful kinds of attachments, there is that expectation of harm. For people who have more dismissive attachments, it's more like there's an expectation of not being helped, which is a slightly different thing. So we know research suggests that our patients with dismissive attachment styles very quickly become non-adherent. They're less likely to do, you know, follow our recommendations. And these are patients, kind of, it's the opposite prescribing strategy from somebody with a more fearful attachment, that these are patients you want to, you know, you escalate the dose more quickly, because they need to see some benefit fairly quickly, because you only have so much time before they give up. These patients also, there's research and suggests that particularly with the dismissive attachment patients, the negative effect of that dismissive attachment style can be corrected by a particularly good communication by the prescriber. So I get somebody with that attachment style and you know, you should always be, of course, trying to use your best communication strategies with all of our patients, but with those patients, it's especially important. So I think think of people that move away or people that move towards, you know, like so, depressive personality style, they move towards the provider, you know, borderline personality tends to move towards the provider and then away quickly back and forth, right? Whereas like something like schizoid, avoidant personality, they move away, dependent moves towards. So are you saying that people who that move, the people that move towards you initially, they want a faster response. The people that move away, it's almost better to have a lower dose, start slow, don't cause a side effect. Is that what you're saying? Or is the opposite? No, in fact, the opposite. The patients who don't expect, well, I'm thinking in terms of expectations of harm versus expectations of not being helped, which are two different kinds of expectations. And so it's, yeah, I guess I frame it differently than those who move toward our way, more than the kinds of, yeah, the nature of the expectations. Okay. So the people who expect, the people who are skeptical, and the people who are sensitive have a long history, maybe of sensitivity to medication. Yes. Those are the people you would do slowly. Yes. Okay. And the people who are more... With people who are skeptical, you move a little more quickly, because they need to see that something helps before they give up on it. These are people who, you know, like, if they're not feeling better in two or three weeks, they're like, see nobody helps, right? Right. okay. I'm sorry, we're getting,

I'm trying to get on the same page and this is the good aspect of having a conversation here. So okay, let's say this one more time. So the people who are doubtful that you're gonna be able to help for you to do something impactful quickly is very beneficial. Yes. And the other group, talk about the other group again. The other group, these are the more anxious, fearful types whose expectation is is not just that they're not going to be help, but they're going to be harmed. They're going to be harmed. Okay. Yes. So these are people who when they feel that medication moving around in their system, it's much easier for them to interpret that malevolently. Something's wrong, something doesn't feel right. I'm being hurt. Right. Okay. And so these are people that in addition to just having a conversation about that beforehand, so you have a little wiggle room around whether it's a medication or it's them, you would start low and go slow. So they have time to adapt to that feeling in their body. Okay, and so maybe I was getting off track with with the way that you've been thinking about this, with talking about personality styles, because it seems like you could have a different personality styles and be in one of these two categories, and it doesn't really, it's not really dependent on the personality style. Is that correct? Yeah, I guess so. I mean, if we're talking about it through the lens of attachment kind of, and the expectations that go with that, yeah. OK. And then what about the more disorganized attachment style, or in the adult attachment interview, might be like unintegrated, right? What do you think? You know, well, I think those think those are people especially who need a lot of information about what's happening in between you and you're doing everything you can to create a kind of a mentalizing space for them and a space where they feel like they're heard. And I think we're also talking about, you know, I guess the thing we haven't gotten into yet is talking about how we empower the patient because so much of this, so much of the negative stuff that happens really comes down to experiences of powerlessness that people bring in. And so, you know, for people like that, and the patient to expect harm, you know, it's very important, I think, to give them a feeling like they have some control over what's happening. So, how do you, like, so if someone comes in and they feel very powerless, and they, how How would you help that type of person? Well, to start with, maybe just talk about the initial interview, if that's okay, to talk about how we get to this. So one thing, one part of the approach would involve focusing not so much on the illness, but on the patient's developmental goals, where are you trying to get? So we end up framing the treatment in terms of the patients, not a medicalized understanding, but the, you know, but very person centered goals that are about, yeah, not so much about illness. And then the next question becomes, right? How do, so how do your symptoms get in the way of that? So right away that starts framing it around what the what the patient as a person wants that creates a feeling of, you know, that this is about them, not about a, you know, a medicalized understanding that they're getting squeezed into. Certainly there's an element well of, in that initial interview, trying to understand something about their experience of powerlessness. So, as it might go in that initial interview, we start with where they're trying to get, end up talking a little bit about how symptoms get in the way, and then as we talk about symptoms, it would move to a, my next question to the patient might be something like, so how far back did these go? And then we end up talking often. And this is again, a patient population of tumor resistant patients. In my, in patients eye treat, usually their symptoms started somewhere between the age of three and 15, right? So these are longstanding.

And as we push it back and ask about, like, well, what was going on when your symptoms were started, we start to develop the history because they'll tell you if they're authoritarian father or the helplessness they felt in the context of their patients, ecrimonious divorce or whatever it was. And so we're starting to name from early on something about that experience of powerlessness that contributes to their struggles. So it's now it's between us in language. And then at some point in there, there's some psychoeducation about how the experience, patient's experience of powerlessness may shape their medication response. And so when things start to go awry, like I've tried to start what I would call a frontal lobe, the frontal lobe communication with the patient. Because at some point their limbic system is gonna kick in. And if we've already had these conversations, we have a much better chance of going back and having a frontal lobe, frontal lobe conversation about what may be happening that gives the patient a little wiggle room to think about it, to mentalize perhaps about why they might be having an adverse effect or dealing with a lot of ambivalence about taking what we've decided might be helpful. Okay, so I hear from you, and this kind of aligns with your work on therapeutic alliance, finding common goals, aspirational goals, not just the negation of depression, I want you to fix my depression, or I want you to change my medication to fix my depression. So you're looking for more. I should have about person centered goals. Person centered goals. And then secondly, you're looking for the themes of powerlessness that date back as far as they know. Now, I imagine you see a lot of patients who have had a lot of treatment. And with that comes, you know, sometimes they use language that's very like medicalized language. Like you can tell they've been in psychotherapy for years. They're using jargon. How do you deal with that in the midst of this? Well, first of all, you're paying attention to it, right? Like as soon as a patient, I got a patient They talked about this elsewhere, but you know like In the initial intake when I get to the you know the mental status and I ask you what's your mood been like for? You know the last week or so and And he says, and hedonic. Yeah. And right away, of course, I'm hearing, like, so this guy is doing something. Some reason he wants me to see him through the lens of the DSM. And I think in my, you know, and I don't know what it is yet, but in my way of working, I think I would just be likely, most likely to just name that, like just to notice out loud. You know, I notice you use, you know, you're using this very medicalized language. And you know, I'm curious about what that means. And you know, probably in that first session, we don't quite get to it. And I don't

expect to. This is something that, especially for people who have a very, very intense attachment to a medicalized understanding, this is work you end up doing over time to, you know, help them, you know, way, you figure out what defenses are in operation around that. and work on it. But for starters, just to name it out loud and so the patient and I have a way of talking about it. If you want to talk about over time, a couple of things, one, if a patient is really sure, like I'm never sure, but patient gets better. I honestly, I never know why. Right. Because the meaning stuff is so powerful that I really feel like what maybe, maybe to talk about what that means for you, that you never know why. What maybe salt with a story that a resident told me, back that I really loved. This was a resident in a military residency, a wife of a serviceman had come in for treatment with depression. The relationship was a very traditional one. So she was home with the three kids taking care of the house and everything in the kids. And her husband who was a middle-level officer, you know, would come home at, you know, four o'clock or five o'clock, plop down on the living room so far, put his feet up on the table and say, you know, honey, it's been a long day to get me a beer. She's depressed. The resident diagnosis or with her depression starts an antirepressant. Her husband, and she, you know, husband comes home. She tells him this and his response is, oh my God, she's depressed enough to need medications. Maybe I ought to do the dishes. And two weeks later, she's, she, she, when she comes in for an ex appointment, she's feeling so much better. Oh, yeah. Right. And you know, that's a, that's a very pronounced example, but it gets at the

ways that I never know. Yeah. How much is placebo? How much is, you know, the patient feels like, oh my god, somebody's seen how much I'm suffering that the prescription has served some other end. And I really feel like I never 100% know why my patient is feeling better or feeling worse. And I often want to convey that to my patients that this mind body stuff is so complicated that we can never know for sure. And one of the implications, if a patient knows for sure, that is a hallmark of some kind of defensive operation. Because you can't know. You really can't. I mean, given the size of the placebo response across conditions, you really can't know. Right. Like some people spontaneously remit. But what you're describing is that her new identity with illness gave her positive things, which can be reinforcing to having an illness itself. Oh, absolutely. I mean, this happens all the time, right, that our patients, you know, this is one of the dynamics underlying treatment resistance, right? Is that our patients don't necessarily get sick because of some kind of meaning or they probably do, but it's not the meaning that's causing the treatment resistance, but something good happens. And now they're in a dilemma, right? You know, as you know, I mean, when that's what people do, you get lemons you make some lemonade But then the but then our patients are End up in an ambivalent place around getting better You know, so one of the implications of what we're saying now is then You know starting to highlight for the patient because they don't know they don't even know this right? They're not they're they're they're In many cases just completely unconscious that they are now ambivalent about getting better. So, I think our task as prescribers is to start to shine a light on that a little bit so that the patient, in some way, so the patient can become ambivalent about their ambivalence.

And it becomes something that they can start working on with you. Yeah, I like that. It's like another way of looking at this would be I'm a fan of reflective function and this kind of idea of like if you if you have a definitive answer for the why, but it's a fairly cliche answer Like why, why are you like that? I'm bipolar. Why do you go off on these rages? I'm bipolar. And so having a definitive answer can serve some adaptive purpose early on, like you said, like this husband is now behaving differently. He's more engaged. But then it itself becomes a problem, right? If it's so definitive and if it's not the real issue, and he thoughts on those things, are we on the same track? Yeah, so what you're describing, you know, and again, our patients, like us, but our patients are often really filled with horrible feelings, guilt and shame, and that kind of medicalized understanding often does serve a very defensive function for our patients. And in a way, it comes to mean, I'm not responsible for any of the bad things that I do or that happen to me. As if they're not at the same time that they have an illness, also a person, right, with their own motivations and their own stuff. And interestingly, one of the ways that I used to see this a lot more, or the diagnostic categories of changing what it used to, all the time, I would see patients who were somewhere in cluster B. So they're impulsive, their moods are all over the place. And because of that, somewhere along the way, some doctor told them they were bipolar. And these patients, and you may have had some of these patients and many of the listeners will have, these patients grab a hold of that diagnosis. You can any question. They grab a hold and hold on for dear life. They are so attached. And sometimes these are the patients who, it's not just that I have bipolar, it's my bipolar, right? The kind of, the attachment shows up even in the language they use. And the reason that these people get so attached, right, is they are filled with horrible feelings, horrible, horrible feelings, which they manage by splitting, right? They can't stand how bad they feel, so they project it out. Now it's on you, you know, you're the bad one, but then they start to feel guilty about, you know, what they're doing to you and they realize, oh, I'm the bad one. And that badness just flies back and forth in a, you know, very painful way. But you give them a diagnosis like bipolar disorder. And what that does is that allows them to create a kind of a vertical split right down the middle. The good stuff is me. The bad stuff is my bipolar. And that patient, and you watch it, that patient feels better immediately because that diagnosis has relieved them of a sense of guilt and responsibility, right, which they then lean into defensively. And very often, I think one of the reasons that we did it a lot, that this happened a lot, is we also feel better, because this patient rewards us. Right, oh doctor, you know, you're the first person to really understand me. And, you know, and I think what you were getting to in your question is the problem is while these patients feel better, they do not get better and often they get worse, because now they're no longer responsible, feel no longer responsible for their most destructive instincts. And we become. So they, you know, have an affair and blow up their relationship and they're coming back to us. You know, you didn't give me enough lithium or like you need to change my medicines because I just did something really destructive. Yeah. And so the diagnosis with that kind of attachment really keeps some from getting a handle on their lives, you know, having authority over themselves in a way. That's really good. I had Kern Bergon, recently, Yeoman's, and we were talking about idealization, devaluation. Right? So this is a great example of someone who's splitting is idealizing themselves. The true self, you know, the part of them that's who they are consciously right is idealized. And then the devalued self is like, I'm a bipolar. And then you get devalued as soon as you're not keeping that devalued side under wraps, right? Interesting. I think I think the more know people with borderline precise sort of they tend to like treatment. The types of patients that I'm really thinking about they are the people that do not like treatment. They're all over Twitter X you know therapy doesn't work, medications don't work. They're on board with like all the anti-sychiatry stuff. Or they're just like, I don't think this works. I've tried it, you know, I've tried pros act for two weeks, it doesn't work. And I often see this group of people with the complex PTSD as well. So in factor analysis, complex PTSD tends to have more of the avoidant type of behaviors, whereas people with BPD tend to be more aggressively outwards, so they maybe hold their aggression in. So with this group of people specifically, I'm curious what's your approach, because Because they tend to, I noticed devalue me from the get go. You know, if they're not here to see me because they want to, they're here because they were forced, their parents drag them here, their parents threaten to take away things. Imagine you see these people at Austin rigged, they're like, how do you, how do you win them over? What's your approach? I imagine it's the same stuff, but I just want to cure it again. Well, actually, we don't see so many of those people at Austin rigs because I think there's a real emphasis. Like if the patient is here, in maybe get off topic for a second, but if a patient is here at the Austin rig center and they say, well, I just here because my parents dragged me here. The admissions officer is going to say, well, you know, you don't have to be here. We really aren't going to admit you unless you want something out of it. And then they start to come up with, oh, well, actually, and then they find their own reasons. But what about you? I mean, is that your approach? Are you? If I get somebody that, you know, and again, patients are always ambivalent. You know, probably 100% of our patients are ambivalent and some are extremely ambivalent and lean much more on the side of, you know, I don't expect to be healthy, expect to be harmed. And I think part of the trick there, trick is the wrong word actually, but the skill there is, I'm with them in a sense. Where do you join that patient? Our medications, one way you join a patient like that, right, is by the recognition that our medications are not as good as we wish they were. The average patient, you know, the average patient is treated with our medications and gets better is still left with a level of symptomology that a reasonable person would be seeking treatment for. So to, you know, to not square off in getting overly optimistic, right, a kind of humility about our treatments can and cannot do, and to really emphasize, I think, the complexity of the patient's role in getting better, to have conversations about how their attitudes shape these things in a way that attempts to empower them. And usually joining these patients around the goal where, again, it may be a little bit different when somebody has had a very serious manic episode that know, dangerous to them or others. But for many of these patients to join them around a, you know, to get to a place of treating them with as few medications as is reasonably possible. You know, so you're joining, you're finding ways to join them that for many patients helps strengthen the alliance. Now what we're talking about is not magic, right? It doesn't work for everybody if there really are, I mean, and chances are if there really are, you know, to their core negative attitudes, these are people that come and then they drop out or they get signed, you know, they don't, they're not going to benefit. You have to have enough ambivalence in a patient like that to work with. Hmm. Thank you. That's helpful. Okay. Let's talk about your own response, your counter transference to their maybe reaction to you or to them. You talk about this in your book and I'm curious if you can speak to that. How do you work through your own? I mean, imagine this point, you don't have any counter-transference. Dr. Mence, you're like a Yoda here with so many years of practice, right? I don't think that takes away counter-transference from anybody. Oh, thank you. You know, there's, I think there's layers to that question. Now, first of all, I think, you just have to recognize, just like the transference, just like there's always going to be transference, there's always going to be to counterchewsference. Different patients evoke different counter transferences, but the starting place is to recognize that, as Eldon Semrad, who was a legendary teacher of psychotherapy in Boston and the generation before me, he he taught the teacher, he taught the teachers that taught me. He described the doctor, patient encounter as an encounter between a big mess and an even bigger mess. We're all messes, we're all unconscious. And I think a starting place is to recognize that I'm vulnerable. Right. So that when, so that I have at least a better chance of catching that I'm being caught up in something irrational. Wait, wait, wait. Did you say everything as meaning though? Is it really irrational? What you're being caught up in? Yeah. I mean, in a sense that, you know, that I'm not fully conscious, patients are pulling on different motivations in May. And I think I mean, maybe you're making the point that I was on my way to make, which is one way to manage or deal with this, is to pay attention to that feeling and ask, how does this inform my understanding of the patient? Right? So to use your counter-transition. Right. Yeah. In the service of deepening the work, um, in the service of understanding. And, you know, it's a value because it gives you a little bit of distance, right? To not just be pushing it away, but by inviting it and being curious about it can help you not get caught up. But that doesn't mean you don't get caught up. Like our patients, including myself who's been doing this with complicated patients, there are patients who pull on your helplessness. They pull on all sorts of things. And so, you know, there are some patients though, though, you know, the majority of my patients end up leaving on fewer medications than they come in on. There are patients who evoke a kind of response to us that ends up giving them very complicated and not particularly rational medication regimens. Right? You know, the patients, I may put another way, in our patients are filled with horrible feelings and they fill us with horrible feelings. So we resonate. Their helplessness makes us feel helpless. Their hopelessness becomes our hopelessness. Their rage becomes our rage. And if we're feeling it enough, it starts to shape what we're doing as prescribers. And oftentimes, you know, there's a piece of the prescribing act is an effort to get away from those feelings. Right? We feel helpless. So with the regimen, we add more and more and more and more because we're trying to get away from feeling the patient is unconsciously put into us. And in fact, I will say when I see a patient, because we'll get those patients right, or we're on, you know, 15 psychiatric medications at rigs. And when I get a patient, because we'll get those patients, right? Or we're on, you know, 15 psychiatric medications at rigs. And, you know, when I get a patient who comes in with that, and my first thought really is, you know, this patient has made some poor doctors suffer an awful lot to get a medication regimen that looks like this. That's some good empathy, but what you're also saying is maybe that helplessness that's more profound and more deep inside of them evoked helplessness in that provider. As providers, we can also be challenged to not join in that. And then over-prescribe out of desperation. Yes. And there's an element of this that I think, you know, maybe you've heard underlying this is to write as a kind of recognition of the limits of what our medications can do. Yeah. Do you do you take home your patients with you? Like, do you think about them while you're reading while you're watching movies, while you're going about your weekend? Absolutely. You know, I'm seeing them for, well, I shouldn't say that. My therapy patients, certainly I'm seeing, I'm seeing four times a week, so they're really under my skin, but my psychopharm patients who I'm seeing for 25 minutes a month. It's a small number. So it's a small enough number that they are in my head. And there's a psychotherapeutic element to it because we are working with meaning and relation to medications. So they are, they are in my head and things will bring them up. And you said under your skin, is that like a negative feeling or is that? Yeah, I mean, that when they're really under my skin, that is a negative feeling. I've not always under my skin. And you know, it, and, you know, it's interesting because we you know, I think what you're what you may also be touching on is the what we learn about what we do with those counter-transferences because, you know, I will often hear from from people maybe especially who are not psychodynamically trained about an effort to compartmentalize. You know, you have your patient box and your clinical box, and then, you know, and they're not supposed to invade your mind or beyond, you know, and I think of it differently. I think compartmental, a person I worry that compartmentalizing is a destructive way to do it. No. Where, yeah, it's like we end up breaking ourselves into pieces, which is not necessarily good for us. I think for me, it's more about having a kind of a formulation that gives us some distance. Yeah. It's like I've been thinking about my own experience and I wrote the other day about how, well, maybe I'll just read it. It was kind of articulates this well for myself. Future therapists may ask, how do you not take home emotions and situations from your patients? I used to say work through your counter-transference or personal therapy. Right? Patients are often in my mind. I can't read your music, watch a movie without thinking of them. And I was thinking about that with like, I mean, I think, yeah, we use our counter-transference. They're putically to increase our empathy and all the time that helps, right?

Like, I'll be sitting about a patient,

thinking about them and I'll be like,

oh, I feel like I really miss them in that. And it bothers me, you know, and the next time I'll see them and I'll say, you know, I feel like I really miss you that and it really is meaningful for them.

Minicop would call that a kind of primary maternal preoccupation.

Right.

Well, and some patients love to evoke in you a primary maternal preoccupation, right? Yeah. And, yeah, and maybe in most patients, you know, want to know that they're on your mind and that there's that kind of carrying there. I've been preparing for an episode on Kafka and Skizoid personality. And the more, at first when I was reading about Skizoid, I'm like, I'm not like that. You know, I'm not alone, isolated in my room, I'm extroverted. But then the more and more I read about Skizoid and this fear of being consumed, this fear of having your mind overly colonized, right? Kafka had this one line and his letter to his father, which was like, it's like your body was outstretched over my world, and there were no more parts that I could, or it was almost like there was no more meaningful room for myself in it. And so Kafka went internal, didn't talk about his what's going on, right? And then wrote about it beautifully in literature, which is, and in his letters and diaries, which I imagine he would be turning over in his grave if he realized we're all reading this and enjoying it. But I'm reading this and I'm like, yeah, I can resonate with that, right? And so I think what you said earlier, like there's parts of us that are broken or parts of

us that like maybe our experience isn't too far from different people's issues, right? But then

maybe we're just not in touch with it until we're really working deeply with a client that

evokes that struggles with that. Yeah, absolutely. And I think to be comfortable with that, for it to be okay, that the injured parts of me are resonating with the injured parts of my patients. It makes it a very different experience than if you feel like, oh my god, that shouldn't be happening. Right. To let it yourself. Yeah, I think a lot of providers have a lot of guilt about not being fully arrived or not being like a Yoda-like idealization that they imagine they should embody, right? Yeah. Yeah, and you know, on this, I think there's something for me, there's something about recognizing, there's a way of recognizing that those, those resonances or those feelings that get stirred up are both real and unreal. You know, because, because, you know, once we get into talking about things like projective identification. Like I am feeling, I am feeling

anger, right? Or frustration or whatever. And at some point, and I think more, you know, the longer I do this, the quicker this happens, I go, oh my God, I can barely handle this feeling for an hour. And my patient lives with this.

Oh yeah. Like all the time. Yeah. Right. And in a way, it restores me to a place of empathy. It gives me some distance. And when I teach about this, I will often show that the clip from the matrix where when Neo has, as, you know when Neo has been shot and he's down and they're watching the screens and get up and he gets up and the agents all pull out their guns and they start shooting. But now he sees the code falling. Oh wow. And he puts up his hand and the bullet stop right before they hit him. And he

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