Episode 265: Primitive Defense Mechanisms Explained: Sexualization, Dissociation, Acting Out, Withdrawal, Denial, Splitting, Omnipotent Control, Projective Identification

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Introduction (00:00)

I’m (David Puder, MD) excited to share with you a special episode on Primitive Defense Mechanisms. One of my great pleasures, joys, in my week is meeting with my year long psychotherapy cohorts, and In this episode, my talented Friday Cohort joins me for an in-depth exploration of the earliest, most fundamental ways our minds protect us from overwhelming anxiety, pain, trauma, and threats to our sense of self.

Drawing from psychoanalytic theory, especially Nancy McWilliams’ Psychoanalytic Diagnosis, we cover key primitive defenses including:

• Extreme Withdrawal

• Denial

• Omnipotent Control

• Extreme Idealization and Devaluation / Splitting

• Somatization

• Sexualization (Eroticization)

• Projective Identification

• Extreme Dissociation

• Acting Out (Enactment)

• Projection

• Introjection

You’ll hear clear definitions, developmental origins, clinical presentations, countertransference implications, literary examples, real-world clinical vignettes, and a group discussion on when these defenses are adaptive versus maladaptive.

This is a wonderful opportunity to showcase the skills, clinical wisdom, and diverse perspectives of my Friday Cohort (2025–2026). 

Meet the Friday Cohort presenters and contributors:

• Dr. Erika L. Reynolds, M.D. – Talented and empathic solo practitioner in north San Diego County, affectionately known as the “mother of the group,” with nearly 30 years of experience treating the whole person in their life environment. She opens the series with clear, well-organized, and clinically rich presentations on Extreme Withdrawal and Denial.

• Aurielle Shatz Wilderman, MA, LSW, PMH-C, BC-ABS – Psychotherapist, founder of the Wilderman Fund for Maternal Mental Health, and expert in reproductive psychiatry, perinatal mood disorders, and complex trauma. She delivered a masterful, in-depth presentation on Omnipotent Control, skillfully integrating PDM-3 criteria, Kernberg references, Transference-Focused Psychotherapy concepts, countertransference implications, and a detailed clinical vignette while exploring its manifestations across personality styles (narcissistic, psychopathic, OCPD, schizoid, paranoid) and in the therapeutic relationship. 

• Michelle Zitnick, PMHNP – Psychiatric nurse practitioner in Florida with 17 years of pediatric nursing experience, who delivered a clear, warm, and deeply trauma-informed presentation on Somatization. She expertly illustrated how unprocessed psychological distress manifests as real physical symptoms, connecting it to alexithymia, childhood trauma, insecure attachment, and personality styles such as histrionic and narcissistic, while offering practical clinical examples.

• Evan Summasup, LCMHC – Psychotherapist from New Hampshire, who delivered a candid, thoughtful, and theoretically rich presentation on Sexualization. He explored how sexuality is unconsciously used to master anxiety, restore self-esteem, offset shame, or transform terror and pain into pleasure; carefully distinguished defensive sexualization from healthy sexual expression; discussed gender differences, personality styles, and developmental origins; and contributed insightful comments on acting out and on introjection.

• Sheila Coles, MSc UKCP MBPsS MBACP – Integrative psychotherapist working in the NHS and private practice in England, with a special interest in complex trauma and EMDR. She delivered a sophisticated, clear, and clinically illuminating presentation on Projective Identification. Drawing on Melanie Klein’s concept of projection “into” (rather than “onto”) the other and Thomas Ogden’s “relational interpenetration of subjectivities,” she shared a candid recent clinical vignette of intense countertransference.

• Dr. Johann Ortizo, PsyD, MSW – Psychodynamic-oriented psychotherapist and longtime advocate for behavioral health equity (LGBTQ+ and BIPOC communities). He delivered a clear, clinically rich, and trauma-informed presentation on Extreme Dissociation, describing it as an unconscious protective strategy that compartmentalizes overwhelming emotional experiences into separate self-states. He distinguished normal dissociation from its extreme form on a continuum, referenced key literature (including Dr. Ira Brenner), and shared vivid clinical examples from dissociative identity disorder (voice/posture/personality shifts, memory gaps), depersonalization, and out-of-body experiences in trauma survivors. He also contributed insightful reflections on grounding techniques for dissociating patients, countertransference when working with flat affect, differentiation from repression and splitting, and thoughtful questions during the acting-out discussion.

• Heidi Linn, PMHNP – Board-Certified Psychiatric Mental Health Nurse Practitioner and co-founder of Haelen Mental Health. She has advanced training in EMDR, psychotherapy, and integrative psychiatry, Heidi delivers outpatient care for children (6+), adolescents, and adults. She presented on Splitting, offering a warm, reflective, and clinically grounded exploration of all-good versus all-bad thinking, its use in borderline, narcissistic, and OCPD presentations, and powerful real-world examples of societal and team-splitting. Her thoughtful connections between clinical work, societal dynamics, and psychological safety enriched the entire cohort discussion.

• Dr. April Staples, PsyD – Licensed psychologist and member of the Kumeyaay Nation (San Pasqual Reservation), who delivered a thoughtful and clinically grounded presentation on Acting Out (Enactment). She offered rich, reflective contributions throughout the group discussions, exploring the adaptive versus maladaptive uses of primitive defenses (especially idealization/devaluation and withdrawal), thoughtfully examining the overlap between acting out and sexualization, and asking insightful clinical questions (including on countertransference with dissociation) that enriched the entire cohort conversation.

• Grant Lemoine, PMHNP – Psychiatric Nurse Practitioner nearing graduation who shared a compelling clinical vignette on acting out and delivered a clear, clinically grounded presentation on projection and introjection, while contributing thoughtful reflections on the adaptive versus maladaptive uses of primitive defenses. His presentation stood out for its excellent balance of theoretical clarity and immediate clinical applicability, offering the cohort practical, real-world takeaways on how these defenses appear in everyday therapeutic work.

• Danny Martino, PA-C, CAQ-PSY – Physician Assistant with a Certificate of Added Qualifications in Psychiatry who brings sharp clinical insight into defense mechanisms, looking at Extreme Idealization and Devaluation. He delivered a clear, engaging, and clinically sharp presentation on Extreme Idealization and Devaluation, illustrating how these defenses manifest across personality styles and in the therapeutic relationship while offering practical strategies for recognizing and working with them.

Whether you’re a clinician, student, or anyone fascinated by the human psyche, I hope these episodes give you deeper insight into how these primitive defenses show up in therapy, relationships, and everyday life.

Enjoy the episode!

— David Puder, MD

Extreme Withdrawal (05:50)

Reynolds:

Yes. Extreme withdrawal is a defense that I don't recall ever learning about until this month, which starts in infancy as an automatic self-protection retreat from a distressing interpersonal interaction (McWilliams, 2011, p. 104). 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 fight or flight, and then we got freeze included, and now withdrawal is also a 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 of 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 a 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 a trauma. And in the worst case, withdrawal can be prolonged, complex, and a process that really takes over the inner life. So that is  a highly undesirable 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. One of the more common personalities that extreme withdrawal is seen in is schizoid.

Reynolds:

So we have a deep voluntary preference for isolation, and an 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 reject it. As schizotypal, I may withdraw due to tremendous perceived social anxiety. So again, we have that fear component in 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, The Vegetarianby Han Kang, 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 sounds like an extreme example and that befits the name of the defense.

Puder:

Wonderful. Great job. Yeah. So, it's that shutdown phase of the fight and flight. So the shutdown, there's no escape. So there's just a withdrawal, a withdrawal into self and fantasy, a withdrawal, like you could see someone curling up in a ball. Yeah, sometimes patients will just kind of end up in their room isolating sometimes after fights, like someone who will withdraw into the garage, shut down. You talk to them and there's no emotion, they're kind of flat, very flat, very distant. Yeah. So great. Withdrawal.

Denial (09:55)

Reynolds:

Okay, and moving on to denial. This 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 in events that could be dangerous or distressing to others (McWilliams, 2011). They just don't see it as a risk. Addiction, also at times contains denial. With more higher severity of substance use, denial of how it 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.

Reynolds:

So those are some interesting clinical sightings of it. And for personality disorders that rely very heavily on denial, are your borderline, narcissistic, antisocial and dependent. This is an interesting example. So denial has been discussed with some of our other defenses. There are some qualities too 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 hints of a higher level defense. 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 Gatsby, [by F. Scott Fitzgerald] where Nick Caraway tells Jay Gatsby, “You can't repeat the past,” and Jay Gatsby says, “Why, of course you can” (Fitzgerald,1925, p. 110). That's my favorite example of denial.

Puder:

Wonderful. Yes, I think the denial is very…. the switch from  something stressful to pushing it down into the unconscious with denial, it's so rapid that the thing that they're trying to hide from is not even registered in their brain. So, whereas  repression, it's registered and then it's pushed down. Denial, it's so instant that they don't even see it.  There, it's almost like a delusion. There's  a delusional quality to it. So with hypomanic defenses, for example, it's a little bit different than maybe bipolar, like how we see it in the DSM [Diagnostic and Statistical Manual of Mental Disorders], but a hypomanic defense, which various people can have, even if they're not bipolar. They deny some bad, negative emotion and see something as positive . So, I've had coaches who have hypomanic defenses, and 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 we're progressing. Like everything is good. You know, and  in some ways, that could be adaptive in that way. Right? to deny and to be able to keep moving forward despite the grimness of a situation. So, thank you, Erika, that was great.

Omnipotent Control (13:48)

Wilderman:

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 and supreme.

Puder:

Yeah. So it's an unconscious belief or fantasy of having absolute power over others or one's environment. So tell me how the PDM-3 talks about omnipotent control.

Wilderman:

So in the 2026, PDM-3 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.

Puder:

Yeah. And it seems that this is linked in a lot of transference-focused psychotherapy with other primitive defenses. It's like they're always listed together throughout articles. What are some of those other primitive defenses that it's listed with?

Wilderman:

Yeah. What comes up frequently in TFP (Transference-Focused Psychotherapy) is the grouping together with devaluation or extreme idealization and devaluation, as well as projective identification, and splitting is really inherent to omnipotent control.

Puder:

Yeah. 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?

Wilderman:

So in the psychopathic realm, essentially there's this controlling of others around them with a sadism component for power. It's not really to destroy but rather to control while they still can control. And I also think about, 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.

Puder:

Yeah, I think psychopathy, it's so centered around power and control, whereas someone with a more dependent personality, it's centered around like, how do I stay connected to this individual, someone with schizoid? It's like, I don't wanna be consumed with someone with OCPD, it's more like 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?

Wilderman:

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 kind of realm is when you see someone rigging the game. People may cheat, they want to set the rules, people will blackmail others or 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.

Puder:

The quest for power, right? 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 dyadic relationships between someone who's more of maybe a dependent personality and more of a psychopathic where they're wanting to control all of their thoughts, so they really isolate them. Great summary. Okay. And then interestingly, when we were looking at narcissism, a lot more of the transverse folks 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?

Wilderman:

Yeah, 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 distress, control of others' perception of the narcissist in more of the depressive personalities or dependent personalities, the masochistic personality types. It really manifests as control. Very good targets for someone in the narcissistic realm.

Puder:

Yeah, the narcissistic person is finding that person with the depressive. With the dependent.

Wilderman:

It really feeds off of those traits of the depressive, dependent, or masochistic personality types.

Puder:

And one thing we have to be careful about as mental health professionals is they can turn the psychiatrist into that ego booster, but then devalue them because maybe they feel some envy of their position or power or authority as a mental health professional. But they really want 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?

Wilderman:

I would say that the therapist omnipotence is an important one to be aware of. It also ties back to Kernberg’s views on omnipotence, which he relates to the borderline level of functioning patient. So here, there's this self-idealizling 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 booster, but the patient ultimately devalues the therapist to maintain their position of power. So that'll 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, and 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” (Kernberg, 1967). So what happens through projective identification with the patient, the therapist can start to embody these disavowed emotions or internal states. So the dysregulation 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 a therapist. I mean, even ethical dilemmas. It can even lead to a therapist feeling physically ill and burned out.

Puder:

Yeah, that’s really good. It kind of gives this pattern of they can initially idealize the therapist, but then the closeness becomes too much. 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 Kernberg’s article called “Omnipotence in the transference and in the countertransference”, a great article will link that as well on the website.

Wilderman:

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, omnipotence and omnipotent control protect the patient from dreaded separation, dependency and envy, maintaining the idealized concept of the pathologic grandiose self.

Puder:

That's so good. Let me reread 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” (Kernberg, 1995). 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 all kind of working together. Like devaluation, idealization, they're idealizing themselves, they're devaluing the other, they're maintaining this 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.

Wilderman:

Yes. 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 (Kernberg, 1967; Kernberg, 1975; Kernberg, 1995). 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” (Kernberg, 1967, p. 136). And I think that's a beautiful way of phrasing that relationship, the omnipotence and the devaluation together.

Puder:

Yeah, that's great. I was also thinking about OCPD and how someone who's at the borderline level of functioning with OCPD (Obsessive Compulsive Personality) might take a different flavor than the narcissist. How might it take a different flavor?

Wilderman:

Essentially, controlling others enables order. Others essentially become an extension of the order that people in this position will want to take.

Puder:

And how about with schizoid?

Wilderman:

In schizoid, a lot of control comes out in fantasies.

Puder:

Yeah. So think about how different personality types manifest defenses in different ways. It's really interesting to think about that. Omnipotence is a portion of multiple of these different types of personalities, but with a psychopath, the power is for power's sake, whereas with the schizoid the power is to not be consumed. OCPD is 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?

Wilderman:

Yeah, by projecting negative emotions. Often the negative emotion is anger. The anger that's projected onto the other is interpreted as 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.

Puder:

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, maybe not. Let's talk about that. Is there anything that you can imagine a good use of omnipotent control?

Wilderman:

If you take a utopia view, so like, I think of leaders who may use omnipotent 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 omnipotent control can at least look like a fully functional, well-oiled machine. But again, it's the motivation of the individual, the omnipotent control defense that's playing out, that can make it more like hell.

Puder:

Right? So a leader like Mao used a lot of control to basically control every facet of a whole country. Lots of deaths happened. In his mind, this was gonna 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 leadership research on 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, you know? 

Wilderman:

When folks get a well-oiled 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.

Puder:

Yeah. Before we move on, let's talk about an actual clinical example.

Wilderman:

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. 

Puder:

Wait, wait. That's confusing to me. Like they never felt the need to promote him. What does that mean, exactly? Was that confusing to you?

Wilderman:

Well, when I realized what I was working with, and this omnipotent control at play–after 10 years of being 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. 

Puder:

Yeah, yeah. Okay. Because if you're the best car salesman, then I don't need to be the manager of car salesmen. If I stopped being a car salesman that would be awful. Okay. But I'm also thinking like he's trying to control your view of him to really buy into this narrative that he's this great employee, he's great at what he does. Okay, keep going.

Wilderman:

Yeah, absolutely. And so this controlling, holier than thou, the “I'm just wonderful” narrative. I realize I'm listening to a fantasy story. I'm listening to this narrative which is essentially an effort to control the therapeutic alliance, to distort the narrative, to build up his facade of power.

Wilderman:

It also showed in how he would talk about his disappointment in other people at work. Again, he really would highlight his qualities in the context of work. He would be disappointed in others who just did their basic jobs, never felt the need to rise, never felt the need to go the extra mile in their work. And he would in conversation, brush them off. It was like he felt burdened by them. And interestingly, he would say that he never would want to be like them, right?

Puder:

Strong devaluation, but it's also kind of bolstering up this narrative that he has about how great he is. Look, everyone else is so poor. I'm this great employee. 

Wilderman:

Yeah. So again this defense process allowed this ideal self-image to remain impermeable. There's such a contradiction because of the use of omnipotent control in this clinical example. Another way that this came out, when talking about work, and about how wonderful he was when he was talking about his coworkers, he would tell me that he would never want to be like them, right? But he felt really proud of himself when he took it upon himself to finish their jobs for them. So he actually was doing their jobs, just like them. So again, there's this contradiction, but nonetheless remained this narrative, this false image that was impermeable to weakness or any trait that he devalued and disavowed onto the other. So in his case, it was weakness, smallness, dependency, or inferiority of any kind.

Puder:

Those would be completely intolerable feelings. And so to escape from that, he put those on other people to keep himself idealized.

Wilderman:

Yeah.

Puder:

And this happens in therapy and it's subtle, right?

Wilderman:

Yeah. It's subtle. And in his case, multiple marriages, multiple therapists, what was also subtle, but telling was his initial therapy goal, which was to have a sounding board to bounce his ideas off of. And figure out his own thoughts. The therapeutic alliance is a relationship between people, not an object.

Puder:

You feel very objectified in this position. You feel like you're being used, you feel like you're being just this pawn in this person's novel.

Wilderman:

Absolutely. You become the projective identification, like we talked about earlier. So we have to really watch out for that and realize what we're working with. And it's intense. It can be intense.

Puder:

Very intense. Thank you so much for sharing, and let's keep going with the defenses. Okay, let’s go on to Danny. Breaking Extreme Idealization and Devaluation.

Extreme Idealization and Devaluation (35:26)

Martino:

Yes, sure. With these two, because these two defenses are intertwined, I think I'll just touch on what they have in common first, and then discuss them separately. Because they do, in fact, have their own functions and origins and are used individually. But, extreme idealization and extreme devaluation are commonly considered complimentary defenses, and they're more classically observed in a dyad in the defense of splitting, which Heidi is going to cover in this episode. But, like Erika said, as defenses, they can be a component of other immature defenses that we’ll cover. Extreme idealization and extreme devaluation pop up to some degree of omnipotent control and can be part of projective identification and denial. 

Martino:

So, there are similarities. We'll start there. A common feature of both extreme idealization and extreme devaluation is that they're distorting defenses, like denial. [see McWilliams, 2011, Extreme Idealization and Devaluation].In this case, the distortion is of the perception of oneself or the perception of others. Another commonality between them is that they're both reflective in some way of a deficit in object constancy. Which for me, I'm coming to understand is like the capacity to maintain a stable or a whole or complex mental representation of someone. But here, these defenses lend themselves more to “all perfect” versus “all rotten" kind of perspective. They're also similar in that they both stem from disruptions in core attachments in the first three years of life. Those disruptions being some degree of neglect or inconsistent or invalidating caregiving. 

Martino:

We'll start with extreme idealization. Simply, it's the primitive act of exaggerating the value of one's positive qualities to the point of perfection, while simultaneously overlooking flaws or negative attributes that exist. Colloquially, I think this is the “placing someone on a pedestal” kind of mechanism. You know, “the best", “the greatest”, “the only one”, these kinds of hyperbolic, but absolute, assessments of others. Nancy McWilliams summarizes it really nicely by just saying, extreme idealization is a primitive “need to idealize that is unmodified from infancy” (McWilliams, 2011, p.109). So if we look at that developmentally, idealization emerges in this period when infants are operating with the fantasy that their caregivers are omnipotent (which is just one advancement beyond the fantasy that Aurielle just presented of omnipotent control). So here, the fantasy is that the perfect and omnipotent caregivers allow the infant to entrust them against all kinds of realities or dangers that are outside of our control. Now, in adulthood, extreme idealization is often used to compensate for defects in the sense of self or to defend one's self-esteem or protect that self-esteem.

Martino:

It could also build self-esteem, kind of by association with an idealized other person, and this pops up in say, narcissistic personalities. So, the idealization of another, or making another perfect, a narcissistic character can achieve their own feeling of superiority through association, or through affirmations. Ranking, seen in narcissistic people, is another way of idealizing. Assessing others based on wealth, or beauty, or status is a process of idealization. And to get into devaluation, we'll see this quality. This maladaptive quality of the defense is ultimately revealed because no human is perfect, we're all flawed, and so this idealized person fails to prove themselves perfect, and that's often where extreme devaluation comes in. 

Extreme devaluation is what it sounds like. It's assigning exaggeratedly negative qualities to others, again, to preserve self-esteem or self-image. And maybe a good way of thinking is that by making others feel small, a devaluer temporarily feels superior. It's often deployed after extreme idealization, but not necessarily. And this too, is a defense that develops in some predictable order in development. Here, it's in the separation-individuation process, when a child no longer relies solely on their caregiver for a sense of self, so there's this process of learning to de-idealize or devalue the childhood attachment in this process of seeking autonomy.

Martino:

So that's where it comes from. But in adulthood, the primitive use of devaluation, again, is a protection of self-esteem, avoiding feelings of vulnerability, or being/feeling inferior. You can avoid that by lowering the value of others, temporarily relieving that feeling and feeling more superior, or safe, or in control. It's also used, extreme devaluation is, to manage intense affects. So, a way of detracting from acute, overwhelming, or uncomfortable emotions, you can rapidly shift from say, admiration to contempt; and in that way, kind of protect against those feelings of disappointment, or hurt, or being threatened. So, those are the explanations of what the defenses are. I think in personalities they come up classically in narcissistic characters and in borderline organization. I talked a little bit about narcissism already, but for borderline folks, this is often seen in relationships.

Martino:

So this kind of intense infatuation or kind of “love bombing” of a new romantic relationship and these cycles of extreme idealization and devaluation that come up for borderline folks. Interestingly, it's also present in paranoid personality, antisocial personality, schizoid personality, which I thought was quite interesting in the sense that, in this case, the extreme idealization facilitates the sense of connection, but where the object remains at a distance, where there isn't a risk of interaction. And the extreme devaluation in schizoids comes up in times of retreat. So if there's a sense of engulfment, it can be avoided by then suddenly devaluing the connection or that attachment. And yeah, I have other examples, but I think maybe I'll stop there for the sake of the time.

Puder:

Excellent. That is very good. We've talked about idealization/devaluation. We had Diana Diamond come talk about devaluation, in particular [see episode 250], and I'm curious, as you learned about this, Danny, has it been helpful as you see patients in med management assessments?

Martino:

Yes, yes. I took some time to just kind of think through like a typical day at work and, yes, I think it's been helpful. Mostly in identifying the dynamic and what's occurring in the visit, in a med management visit. So there's a lot of, with a certain kind of cohort of patients that I see, culturally, I get a lot, “I trust you're going to give me the right medicine.” I'll say, “You know, I'll do whatever you say.” You know, a lot of “Thank you, doctor.” Again, I'm not even a MD. I'm a PA [physician assistant], but still, the “Thank you, doctor. You're the only person that's able to understand what I'm going through and will help me.” And often these are comments I hear on the first time meeting someone. Right?

Martino:

So there is this exaggerated, an elevation of my value, or worth, or ability to help that is not, you know, based on any kind of real connection that we have established yet, or information that they have about me. And the contrast I also see is, I mean, I think there's other things going on here, but like, “The only medicine that works for me” comments. “This is the medicine that saved my life. I can't function without it.” This extreme devaluation or idealization of a singular treatment with an elimination of all of the other realities that come into play with taking meds or treatment. So those are helpful, I think, to help frame the relationship early on and anticipate the kind of management. 

Adaptive vs. Maladaptive Uses of Defenses (45:08)

Puder:

Excellent. Yeah, I think early on, a lot of the classic how we think about the DSM borderline personality disorder, they will often have idealization initially of the provider in the relationship. Whereas, more of the narcissistic personality disorder will have a devaluation early on. Erika, what were you thinking?

Reynolds:

I wanted to just add, Danny, the idealization on the first visit that you notice sometimes, and these sort of, “Only you know the right medicine for me” in a small dose that can actually be really helpful in terms of placebo response and the patient believing that they will get better in your hands or with this particular prescription, so if it's just a teeny tincture of that, it can actually be, clinically, pretty helpful.

Puder:

Right? We have to have belief in the treatment. Where I think it can become more tricky is if the treatment is also long-term psychotherapy and they overvalue medications, but they're really needing the psychotherapy to get to that next level of not being ill. So, you could be a provider that inevitably needs to change meds almost every time, because that's what's needed to continue that kind of idealization. Whereas, pointing them towards, “Actually, the process here is on what's going to help you” is different. Not all patients want to hear that. Some patients hear that from me and they devalue me in making that recommendation that, “Hey, long-term treatment is going to need something from you.”

Puder:

Alright guys, before we move on to the next defenses, how about we kind of open it up to hear from the rest of you guys what your thoughts are on these different things discussed so far? Extreme withdrawal, denial, omnipotent control, idealization/devaluation. What are some of the things that are coming up for you? April, I saw you kind of make some sort of excited expression that you had something to say. Do you want to say something?

Staples:

Yes, I think I have something to say. I was just thinking about, it came up when Erika was talking about withdrawal and just how it can be adaptive. And so, all of these defenses are adaptive in a healthy range and how they become maladaptive when they're inflexible. And so, when we're engaging in these defenses in an inflexible way, where now we have prolonged withdrawal, or we have prolonged idealization, or we have this prolonged way of using these defenses, that's when we start to see it move from an adaptive defense to a maladaptive defense. And so it's really helpful, I think, just as clinicians to not necessarily see these things as evidence of a maladaptive defense every time we see it, imagining this is maladaptive, but giving time to the patient and for us to establish a relationship with them. And to really be able to sense, is this an inflexible defense, that they don't appear to have a lot of tools in their toolkit to be able to navigate some of the difficulties of living.

Staples:

Or, is this kind of a one-off and this is this kind of where they are today because they haven't eaten or they maybe didn't sleep well, or maybe they have some environmental things going on. So, I think just keeping in mind that there is an adaptive presentation with all of these defenses that all of us engage in in healthy ways.

Puder:

Excellent. Yes, and you can think about how having a little bit of idealization would actually allow you to connect with new people quickly. Right? And, having a little bit of devaluation abilities might be able to protect you from people that you should be protected from. Right? You know, you have hints that this person is not going to be a good person, a healthy person to be around. Maybe this person has some psychopathic or sadistic qualities, but you haven't completely seen it, but you can devalue them, and then that helps protect you. Right? So you could see how that could be helpful in different situations. Grant, I think you were going to….

Lemoine:

Yes. I was going to piggyback off of what you said. When April was talking, that's kind of the same thought I had. Particularly with the idealization/devaluation, how it can be very helpful in a normal bonding of relationship between either child and parent, where you want that child to idealize you and be able to introject some of the positive things that you're trying to teach them. And then later on, as they progress into adolescence, it's okay to have some kind of devaluation there, because if you don't, then you have failure to thrive. So it's not, as clinicians, these defense mechanisms have, kind of, this maybe, bad connotation that we hear in culture, but really, like April said, they're really helpful. They really have a place in a mental health frame. Our job really is to assess and play with, and either bring up or bring down these, almost like how those of us who are providers treat medicine to a degree with playing with chemicals to try to balance things out. The defense mechanisms are very similar to that in a therapeutic way. So I appreciate that point that both of you made so well.

Puder:

And I would say also that we have increased reflectiveness if we notice when they're happening consciously. So, if we feel so shameful that they're happening, then we're going to  find ways to repress them or deny they are happening. Right? So, if we could be curious about them, playful, we could actually have a higher reflectiveness about our own experience. 

Puder:

Erika, did you have anything to share?  

Summasup:

I was going to throw in, I think I remember reading, I think McWilliams wrote it, that she said, in some ways, even the very name “defense” is somewhat unfortunate, in the sense that it's something to be defeated, and it's a relic of Freud trying to establish the very field itself to a skeptical public; and also, she said his fondness for military metaphors (McWilliams, 2011). But like everyone's been saying, that they're not just defenses, they're necessary to a healthy life.

Puder:

Okay. Yes, I think the idea of some defense. Right? So this is a defense, military. Actually, in the delusions episode, I have a nice military reference [see episode  ]. So, hopefully, not all military references are bad. Have you guys heard the idea of “death ground”? Standing on death ground? Sun Tzu, the Chinese military writer, thousands of years ago [481-221 BCE], wrote about “death ground.” He wrote about nine geographical locations, and the ninth, the most severe one is called “death ground” (Sun Tzu, 1910/2005, ch. 11). And essentially, it's when your army is surrounded, or they’re pushed back against water, and if they get pushed into the water, they'll drown, or they're so deep in enemy territory that it's completely dangerous. So this is what “death ground” is. And, one of my thoughts was, psychologically, if you're schizophrenic, or in a psychotic state, you can inevitably put yourself, in your own brain, into “death ground.”

Puder:

Like you're perceiving that you are in “death ground.” And so this is where you're more likely to actually lash out and get violent because you feel like there's no way out, there's no escape, “This is the only way for me to move forward.” Right? And they have found that militaries actually fight a lot more ferociously on “death ground.” They're much more likely to be courageous, much more likely to fight through fear, because they have to. So, that was my military thing. But you could kind of see that as well in, with the rigidity of these defenses. How the defenses, when they break down, you get into a place of psychosis or dissociation. So, without defenses, we would be more likely to be psychotic, we'd be more likely to be dissociating. And so, the defenses are actually protective against us going into more of a psychotic realm. Okay. I see some hands raised. Aurielle.

Wilderman:

I think that's what makes omnipotent control so fascinating. I think that it really is at a core, or at the core level of these other and higher level defenses, or it's seen in everything, splitting, also idealization/devaluation. It's very difficult, I think, to separate them out, because they are part of the same whole. And there was something else I was going to say, but I forgot.

Puder:

Oh, I was thinking about omnipotent control. Imagine this patient that you described earlier, all of a sudden realizes, sees his life, sees all of his mistakes all at once. Or, in that moment, most of us would crumble. Psychologically, we'd curl up in a ball and shut down and not move forward at all. Right? So sometimes it's that sort of blissful omnipotence or that hopefulness that keeps us moving forward, that we kind of end up proving it to be right if we believe it long enough. I'm thinking of, there was a football quarterback, that was, he was third string, fourth string, forever; and that he just kept believing in himself and ended up being one of the greatest football players of all time.

April:

Tom Brady.

Puder:

Tom Brady. That's it. Yes. Yes. 

Wilderman:

He was like the sixth round or something. 

Puder:

He was. He was so low. I think he didn't even start in high school, but he just had this incredible belief in himself. The psychotic level belief. And he just kept obsessively studying the game from that belief.

Wilderman:

Well, what's interesting also though, is as a provider, if you can develop a therapeutic working alliance with people who are really, really with their defenses, who really have a lot of these defenses up, if you can really…sometimes it's a matter of entering into the projection, or I don't want to say getting them to come back, but, essentially that. The times when they devalued the most just gives so much to work with, and in a lot of the cases, individuals may make that phone call, “Oh, I'm done, I'm never coming back. I'm never coming back.” The defenses are so interesting to explore, if you can get them to come back for what is a so-called “closure session”, that ends up being the entree to some of the best work that can happen. And, when it happens, if you can see it, and they can get back into the office, it's like a gold mine.

Puder:

It's great. Yes, and I would enthusiastically support that sort of approach. Expect that some early devaluations are going to happen and you're going to need to work through them and be patient through that. They're probably there for good reason. You know, if every previous person was a very painful relationship, then they might imagine that this might be another painful relationship. 

Somatization (57:49)

Puder:

Alright. So, Michelle, talk to us about somatization.

Zitnick:

All right, somatization basically happens when psychological distress presents as physical symptoms. So I think of it like this, when a person is feeling really stressed or overwhelmed, they can't quite put those feelings into words. So instead their body reacts in ways that reflect that emotional turmoil. It's commonly seen in early childhood since the ability to recognize and express our emotions is a developmental process. As we grow, we should start to connect those, the physical feelings, with our emotions. So somatization, it's common in people who have alexithymia, which is the term used to describe difficulty identifying, processing and describing emotions. And that has been linked to a history of childhood trauma and even sometimes trauma in adulthood. People with insecure attachments tend to have a higher use of somatization as a defense. And, it's commonly seen in people with certain personality traits like neuroticism or negativism [see McWilliams, 2011, pp. 117-119]. 

Puder:

Great. Keep going. That's good. 

Zitnick:

It might show up in people with a histrionic personality type because they can feel easily overwhelmed by emotions, so they turn to somatization as a way to cope with those emotions rather than process them. Or another example is somebody with narcissistic tendencies might emotionally manage criticism through physical complaints to avoid vulnerability. Some common ways that it shows up, that you would see on a regular basis is anxiety showing up as palpitations. People who are nervous, kind of having nausea or butterflies in their stomach. Headaches from stress, fatigue from sadness, but sometimes persistent somatization can present in more worrisome disorders like IBS, pseudoseizures, fibromyalgia, though it's not always the cause of them. But, when there's no clear medical cause it can kind of worsen the psychological and physiological distress from those presentations. In some cases, it is culturally appropriate. In different cultures, they kind of present with somatization as a way to… it's considered normal in their culture.

Puder:

Yes. Yes. Think about, after World War I or World War II, there was a lot of something called “shell shock”, where people had functional movement disorders. Where they were moving oddly, due to their trauma, the PTSD. It was only after the Vietnam War that the normal kind of how we see PTSD came about because there was a lot less social stigma around mental health issues. So, yes, so keep going. Anything else you want to mention on somatization?

Zitnick:

Just that it differs from malingering and factitious disorder because the physiological symptoms are real. Even though sometimes they want to be associated as an emotional presentation, people do experience those physiological symptoms.

Puder:

Yes. Malingering, the patient is flat out lying about something for some gain. You know, usually monetarily or something. And then factitious disorder, there's some secondary gain, like getting attention or keeping the family together. So, somatization, that's good. That's a good psychological defense to understand. I think we all can somaticize from time to time, so I think everyone can have a headache when they're stressed or some sort of bodily symptoms. But I think there's some people that it's the primary way of defending against emotion. Right?

Sexualization (Eroticization) (01:01:34)

Puder:

Okay. Evan, let's talk about sexualization. I'm really glad, by the way, Evan, that you chose sexualization as your….

Summasup:

Yes, I would not have chosen it if I knew at the time that this would be put on the podcast. So, a note on language, they sort of use three different words for this, and they all sort of overlap, they sometimes say “sexualization” in the literature, they say “instinctualization”, they say “eroticization.” And I'm not even, it's not even clear to me that all analysts use those words in the same way. But, using Nancy McWilliams,  who we're basing this off of, she says, eroticization is the process of this when it's not acted out, when you don't actually do anything with this defense, it's only internal (McWilliams, 2011, p. 121).That one seemed a little more clear. But so, sexualization is a defense that people use unconsciously to attempt to master, or at least temporarily reduce anxiety, to restore self-esteem, to offset shame, or distract from a sense of inner deadness.

Summasup:

Sometimes it's used to convert even more dramatic feelings, like terror or great pain, into something positive. I think it's also worth mentioning that sexualization is not equal to sexuality, at all. Acts of sex, masturbation, sexual expressiveness, are not necessarily indicating that there's a defense occurring. It is a defense when it's unconsciously or automatically blocking another emotion or preventing genuine intimacy with another person or even with oneself, I suppose. Also, I think it is important to mention that, like any defense, it's not always harmful. McWilliams used the example of a woman that may get sexually aroused by having her hair fondled or maybe pulled. And maybe this fetish developed because of something negative, like an abusive parent who used hair pulling, and the child, again, pretty much fully unconsciously, turned this into a process that became something pleasurable to defend against the fear and the pain that was associated with the punishment (McWilliams, 2011, p. 123).

Summasup:

But potentially, for some people, that just turns into a healthy part of a consensual sex life with her partner. McWilliams did mention gender differences exist, and so, of course, do exceptions to that difference. But more often she said “women will sexualize dependency. More often, men will sexualize aggression”(McWilliams, 2011, p. 122). A really interesting study she mentioned, I couldn't find the study to get the exact numbers, but she did say that there was a study of people who have masochistic sexual preferences, and specifically they need physical pain to experience sexual release. A significant number, she said, of people with that, I guess, fetish, had undergone invasive and painful medical treatments as children (Stoller, 1975). So again, there was something unconscious transforming their fear and terror into something pleasurable, and that stayed beyond the actual causal events (McWilliams, 2011, p. 122). On a more innocuous note, I thought this was interesting,

Summasup:

Mcwilliams commented on the long association of a quote “erotic aura around teachers” (McWilliams, 2011, p. 122), which she dated to Socrates; and I will mention that really was striking to me because it immediately made me remember that I have a few memories of being in like first grade, third grade, just sitting in class, like teachers just teaching, and just feeling like a tingling sensation all over my body. And it felt really good. And this is prepubescent, so I had no idea what it was, but it makes me wonder if that's the kind of thing that she was talking about. I remember I had some really good teachers, and maybe that's just what it was. My sense is the personality style that probably uses this the most is histrionic. It can probably function in opposite ways. They may sometimes sexualize things, kind of on purpose, but without realizing that it's going on to reduce their anxiety or to try to help with low self-esteem.

Summasup:

Probably folks in the borderline level of organization, of various styles, will use this more often than the neurotic level. Especially those who are like many people on that level, they will vacillate in relationships between an intense idealization and a devaluation. So, I think, often in that idealization, there's often an erotic or a sexual component. I thought a tricky one was that psychopathic people probably use this defense and they use it in cruel ways. I mean, they can sexualize violence and that can look like rape. I think in some cases that can look like arson. But I also got the sense that psychopathic people might use sex in a very intentional way for control, which would probably not count as this defense. And I threw this in here, I don't know how many people watched Arrested Development.

Summasup:

It was the best pop culture example I could come up with. There's a scene that a man and a woman hook up in a bar and they go home and they have sex. And only later they realize that she's a lawyer who's actively pursuing a criminal case against the man's family. So, of course, they both have a great deal of anxiety about that, and they sort of look at each other and they say, “We can't do this again.” And then, in their anxiety, they just go back to having sex again. And in the show there's a few rounds of that. So they're both alleviating their anxiety and their dread through having sex.

Puder:

Yeah. This is like when sex is not always sex. Or, there's like…they're defending against some other emotions. Right? Sex is allowing the defense against other, more vulnerable emotions. The pairing of sex with things like violence, I think that it's like with, in more psychopathic individuals, like sadistic individuals. I don't know if that's a defense necessarily, I think it's just personal preference. I would put that more as just ordinary sadism—sadism as a defense. Yeah, I don't know.

Summasup:

Yes. And especially when you're going into pure sadism, not just like a BDSM kink kind of sadism, but with a psychopathic person this is harmful.

Puder:

Right. It seems that's more central to their desire for omnipotent control or just enjoyment of hurting other people. But I think for a lot of people, you know, sex is more than sex. It's comfort to deal with different emotional things that they don't want to feel. You know, that kind of thing is more of sexualization. Anyone else have any thoughts on this before we move on? April, I feel like you have something to say.

Staples:

I kind of do. Did I have a micro expression?

Puder:

No. I could just….

Puder:

I just got a sense.

Staples:

So, I did mine on acting out and so I was thinking about sexualization because, in a way, it kind of almost appears as a defense very similar to acting out. So, maybe you don't have the ability to symbolize in language how you're feeling, and so then you engage in sexual activity in order to discharge that energy in some way or take control over that energy. So I was trying to think, well, while Evan and you were talking, about trying to understand acting out as a defense and sexualization as a defense, and how they might be different and how they might overlap. So those were some of my thoughts.

Puder:

And how are they different in your mind?

Staples:

I'm not sure yet. To me, and part of this might be because I was so focused on studying acting out, I'm having a hard time flexibly thinking about how sexualization isn't a form of acting out as a defense. So maybe, Evan, I don't know if you are able to kind of help me understand that a little bit better. 

Summasup:

Yeah. I'll try. I know that Nancy McWilliams began this chapter by pointing out that some analysts specifically do consider sexualization a subset of acting out (McWilliams, 2011, p. 121). But, there's a couple of distinctions that, again, it doesn't have to be acted out to be sexualization. It can just be happening internally and there's no actual behavior. And just because of the nature of it, she couldn’t categorize it differently because there are just particular, extra things to consider around sex and sexuality used defensively. But I think, in general, that the defenses don't need to be considered as discrete, separate categories. There are overlaps and this is a great example.

Staples:

Yes. I think that's a good point. They're not always discrete, even though we studied these, you know, thinking about them in a discrete way, but recognizing there's a lot of overlap here.

Summasup:

Yes, and in the same way, she said, and she denotes levels of character organization or personality styles, we learn about them separately, but she says some people will overlap, some people will be in a gray area near the boundaries of these categories (McWilliams, 2011).

Staples:

Right. So I think of sexualization as kind of on that boundary line of acting out and sexualization. Yes. That makes sense.

Martino:

If I could pop in, there's something else that McWilliams pointed out in this chapter (Mcwilliams, 2011, p. 123) that maybe helps with the distinction. She also talked about in terms of power, and so, the ability that we have to access our erotic power, so if feeling powerless or not having  a sense of real power in a dynamic, or then, it's like an unconscious, or kind of, internalized way of accessing  a form of power. We do have erotic power and then compensating in that way. So, in that way it's not necessarily a behavior, an acting out behavior, but something more internal.

Projective Identification (01:12:30)

Puder:

Yeah, I think there's a lot of overlap between defenses, actually. And so I'm glad you guys brought that up and how they kind of overlap and there's like a power, an aspect of kind of like a doing something. Some of the defenses are more withdrawal into themself, and some are actually more extroverted in their nature of going out and demonstrating control, or power, or omnipotence. Right? Going out into the world. Some are going into the mind to demonstrate those things through fantasy. So yes, I was thinking about some of the broader categories to understand this stuff, as well. Which I think is helpful to think of through. Okay. Sheila, let's talk about projective identification.

Coles:

Okay, this is complicated. So, there's a lot going on with projective identification. There's a lot going on that is inside the mind, but also between people. McWilliams talks about it as a defense that's characteristic in people with a more borderline level of organization, and particularly, with paranoid personality dynamics (McWilliams, 2011, p.113). One of things that projective identification concerns are representations in the mind of the person who's doing the projecting. And I think it's important to think about what we mean by the representations in the mind. So, kind of, the way that that individual’s self is represented in their mind, the way that another person is represented in their mind, and the way that the relationship between the people is represented in their mind. And it's important that these representations are not just, kind of like images, but they are filled with emotional resonance as well, which makes them so powerful.

Coles:

So, it's about the complexity  of everything that's in that person's mind. It's complicated because it's happening at different levels at the same time, or it's happening in different ways, so this is something that's happening internally in the mind of the person, but it's also happening between them and someone else, and then in the mind of the other person at the same time. So there's lots of different things going on all at the same time. McWilliams describes it as a fusing of primitive projection and introjection all mixed up at the same time. She sees it evident in clinical work. So this is going on. This is something that is happening in healthy ways as well as in clinical situations. So, she sees it as, in a clinical sense, particularly evident where the client lacks reflective function, where they lack self-awareness, where there's a struggle with the separation of what's their feelings and someone else’s.

Coles:

So, to try and describe what happens, I'll give that a go, to describe what happens in this defense. So, the one person is projecting from their mind something that is disturbing. And it might be a disturbing representation of themself, or of someone else, or a relationship. But there is a disturbing affect that they have. It's intolerable in their mind. So, unconsciously, it is put into the mind of another person. And I think that the “into” is really important. Melanie Klein, in the beginning of defining projective identification, talks about the projection being into, not just onto, another person. The into is important because of what happens in the mind of the other person. But, the projector rids themself of this disturbing affect  in their mind. And, because of the way they then behave and interact with the other person, the other person begins to feel that this is their stuff, that this is their disturbing affect, and they behave accordingly (Klein, 1946).

Coles:

So it's gone into their mind and then their behavior brings it out, and then it goes through that behavior back into the mind of the person who projected it in the first place. So then, Ogden describes this as, I think this was a really interesting term for it I think, describes it as a “relational interpenetration of subjectivities” (Ogden, 1992). It's like this is going on between two people at the same time. And also simultaneously between parts of the person who’s done the projection within their own mind at the same time. 

Puder:

Can I say something about that? That penetrating? So imagine the person that's projecting into you this kind of foreign thing. They're penetrating your mind and getting you to identify with it. Right? So these primitive affects, these primitive things that may be very foreign for you, maybe you've never felt these things. And then, because they're penetrating you with this stuff through various complex sets of behaviors, they get you to identify with it, and that feels very foreign to you. And that can feel very distressing to you. And all of a sudden you are playing a role that you have identified with their projection. You're playing this role that you are not used to. So that's why it's so distressing for the provider to be a part of this.

Coles:

Yes, it's really distressing in clinical practice to feel this thing that doesn't feel like you, like yourself. So, a recent example of this, for me in practice, was with a new client who I met for the first time. After setting up a couple of sessions that hadn't gone ahead, they'd been canceled. So, something had been happening before we actually got to meet. This client arrived late, they then took a phone call in the corridor. And this is a set of offices where there's meetings with other therapists going on in other rooms, so it's a quiet area. And once into the session, and settled into just beginning to get to understand what's going on for this person, and trying to get, for me to get a picture of their interactions, there was something really difficult that was about this person deflecting from the very gentle introductory type questions to start to understand them.

Coles:

And I started to get inside more and more irritated, hostile, feeling like I wanted to really be quite punishing of this person. Being really careful about what I said and feeling quite disturbed by the end of it. After the session, I was quite agitated, needed to spend some time walking around, getting some fresh air, looking at the sky, and really reflecting on what was going on that I was taking in this desire to persecute this person. What was that about? What’s in their mind about relational situations with other people? Perhaps, where they've been abused? And really thinking about what's playing into mine, as well. Because the other part of this is, inevitably, when we feel identified with a projection from someone else, what's coming up is, something, in some way, in some small part, perhaps, of something disavowed of our own getting played into this mix. So I was also reflecting on that and thought really hard about, “Okay, what do I need to talk about in supervision around this situation that's come up?” So that's, for me, a clinical example of where this could be really distressing. But like every other defense, this is happening at all levels in different forms and can involve very positive emotions as well.

Puder:

Maybe we can pause and just kind of point out a couple things you did really well there, Sheila. First of all, you noticed it consciously. Right? You notice, “Okay,  there's a couple things leading me to start to feel this way.” Right? He's missed a couple initial appointments. Which, by the way, if you're out there and you want to be a good patient, try to make the first appointments on time. Try to be there. So he's missed a couple first appointments, he's loud, he's interrupting other clinicians even. And then when he comes in, there's a certain air about him that is eliciting. So think about the projective identification. There's multiple things that this person is doing. Not just one thing. Multiple things that are now eliciting in Sheila, this response.

Puder:

Now, if Sheila had never learned about projective identification, she would be thinking, “I just don't want to treat this person.” But, for some people, you are getting into their trauma, you're feeling what it felt like, maybe for this person to feel rejected growing up. And now, you are feeling and identifying with this kind of internal rejection. This internal rejection of this person. Right? So if this person was viciously rejected by his father, you're feeling like rejecting him like the father, because he's projecting that rejection onto you. So hopefully, hopefully this is a little bit more understandable, but if you, as the listener, are struggling with this, this is going to take you a little bit of time to get your mind around. And that's okay. This is one of the more difficult psychological concepts.

Coles:

I think a really nice description of where it happens in a really positive way is when we walk into a room at a party. So maybe April and Aurielle did last week, and just kind of felt the sense of joy that’s going. Yes. So, we take in really positive things from other people as well. And maybe that's a very similar process, but in a positive way.

Puder:

Yes. I don't know if you've had this experience, when you have a new friend that's in love and you're hanging out with them and you just feel that… it's like you almost join that celebration. Right? It's so fun. Yes. That's good. Yes. Thank you for working on this one, Sheila. This is a tough one. It's good. Sheila’s from England. So, if you're in England, and you need a good therapist, Sheila Coles, right there. There you go. Okay. So let's go through extreme dissociation. Who did this one?

Extreme Dissociation (01:23:57)

Ortizo:

I did. So extreme dissociation, it's an unconscious, protective strategy to manage overwhelming and intense emotional experiences, separating the self from impending obliteration, arising from the outer world, resulting in a high degree of interpersonal sacrifice (McWilliams, 2011, p. 124). It's quite a mouthful. Essentially, the core mechanism of this is compartmentalization of the experience into self states. It's essentially cutting off awareness, that awareness from unbearable pain, terror, horror that can overwhelm the capacity to cope. And it has a utility in terms of its adaptiveness with survival and tolerance. But it comes at an emotional cost, which is essentially an interpersonal sacrifice. Just to distinguish, you know, I think McWilliams, she uses extreme dissociation as an example. But the difference is that dissociation is a normal reaction that we can all commonly experience as well. It's a normal reaction to trauma, and it exists on a continuum from normal to devastating.

Ortizo:

And she cited Dr. Ira Brenner in one of the research, contemporary clinical literature, that suggests that dissociation is far more prevalent as a psychological defense than what earlier psychoanalytic theory had originally assumed. And so, what Dr. Brenner's work highlighted is that the dissociation itself, it exists on a continuum. And so the research suggested that it's not just limited to rare psychiatric syndromes, but is more of a widespread adaptive mechanism that can shape personality organization. Where extreme dissociation is most associated with is dissociative identity disorder and borderline personality disorder (Brenner, 1994; Brenner, 2001). So in my clinical work, where I have seen extreme dissociation, is in dissociative identity states where a person suddenly speaks in a different tone of voice, posture, and personality, and has no memory of or recollection of what just happened in that moment.

Ortizo:

And it's very distinctive, actually. Some people may experience this gap in the memory, and it feels like they time travel. They essentially, also can feel like coming out of their body, where it feels like an out-of-body experience for them. So an example of this is depersonalization during trauma. A person detaches from their body or sense of self during a traumatic event, it just feels like they're watching themselves from the outside. It's like when a person feels like they weren't really there and that their body wasn't theirs. More specifically, in the work that I do, many people have shared about their histories with sexual trauma and how dissociation helped them cope with the overwhelming emotional experience. So, sometimes discussing the traumatic material itself can feel emotionally activating and the person can suddenly feel detached, or numb, or distant, or feeling like they're not present in the moment as they're describing the experience. So overall, it's serving as a protective mechanism that once helped the individual endure the emotional experiences that felt so intolerable and is allowing them to continue to function while the emotions and the memories still remain compartmentalized.

Puder:

Very good. Johann, thank you so much. Johann Ortizo from California. Appreciate you for sharing. I actually just recorded an episode on DID [see episode 262]. I don't know if it'll come out before or after this episode, with some Harvard experts on it. And you covered a lot of the things, compartmentalization. Talk about that quite a bit. I think I once heard, and I have found this to be true clinically, that you cannot have PTSD without some dissociation. There will always be dissociation in the midst of the life or death moment that led to PTSD. And, so when you are talking to someone about their trauma, they will inevitably dissociate, a little bit, in a different way. Different people dissociate in different ways. And so learning how to sit with someone in the midst of that is learning how to be a therapist. Johann, when you have patients who are dissociating, how do you sit with them? How do you help them?

Ortizo:

So when a patient is dissociating, first, I have to be able to identify in the moment. I do a quick check-in just to see if they're here with me, and I do essentially, I try to ground them in the present moment. And depending on what I understand of the individual and their history, I generally tend to work from a perspective where I am bringing them to the here and now, and not trying to chip at the defense, or not trying to, you know, explore an area that may be emotionally disturbing for them. My belief is that when the person is ready to process some emotional traumatic experiences, they will take me there. So it's coming much more Rogerian and much more person centered.

Puder:

That's good. Yes. I think that there's a gentleness, which I hear from you in that, of allowing them the control over what they share or don't share. Which, dissociation is sometimes the lack of control and then there's coming to the here and now dissociation is the opposite of the here and now. So it's bringing them back into the experience. I would add, sometimes patients appreciate different things to bring them out of dissociation. And so you kind of have to find what helps the particular person. I have one person that just wanted empathy or just wanted me to be with them, and they didn't want anything extra beyond that, and that was what was helpful. Other people almost need to get up and walk around, or they need different things somatically to bring them into the here and now. Anyone, I'm looking at your faces trying to read if there's any desire to jump in here and add something on dissociation.

Staples:

I actually wanted to see if you could talk a little bit, Johann, just about the countertransference you experience with a person who's engaging in a more dissociated defense. I think that's helpful to understand how a clinician might experience that.

Ortizo:

That's a really great question, and it really just depends from person to person. One example I could think of, about actually, was when a patient was describing one of their experiences, it felt as if they weren't having any emotion. They were just talking about it. And I began to feel all sorts of emotions. I felt angry. I felt sad. I felt rageful. I felt a lot of emotions stirring up internally. And I think that's really important because prior to describing the experience, I wasn't feeling all that emotional material. So something is being induced, something is coming up for me and recognizing that this material that I'm holding is possibly something that maybe the patient is unaware of or unconscious to. So that's maybe just an example. I think there's many different countertransferences that a clinician can experience.

Puder:

That's great. And if I could put words to what you just said, it sounds a little bit like projective identification. You're identifying with something that they can't quite identify with. But this is a little bit different too, because they're in a state of dissociation, and so it's like, sometimes as a provider, it gives you a hint at the disavowed from the memory they were unable to express. So, it's like you’re empathically experiencing something that they were unable to experience in the memory. Danny, jump in.

Martino:

Yeah, I just wanted to…. I wonder if this could be helpful. But, as you know, I'm not a therapist, but I work as a medical provider, and often med management or assistance with diagnostic work in primary care settings, and something Nancy [McWilliams] pointed out in this chapter as well, is that for the non- dissociating person they may see the dissociation in their close other as presenting as “moody, unstable, being a liar” (McWilliams, 2011, pp.124-125)). I think she said “untrustworthy” (McWilliams, 2011, p. 125). And so, in my work, I've kind of started including dissociation experiences in that differential when referrals come through for mood swings or ADHD, and really kind of digging in and trying to see if what is being reported by the patient, from what they're hearing from their loved ones or their others in their life, is not the coming back after that amnesic kind of period. And then reacting or behaving in a way that presents as a mood swing, or not remembering, or being told again and again.

Martino:

And I thought that was a good element that she included; and has been really helpful for me.

Puder:

Really helpful, yeah. I'm wondering, April, because I know you do a lot of psychological testing too, how do you differentiate dissociation issues from ADHD, from other things that could look like dissociation?

Staples:

Yeah. So that's a great question. You know, we do a really thorough clinical interview. That's really the first step, going through the full history. Anytime trauma is coming up we're automatically looking at, like you said, there's no PTSD without some dissociation. So, a lot of times during that clinical interview, we'll have a traumatic experience get disclosed and it's never been disclosed to their medical provider or somebody, or the prescriber. And so that's really helpful, just getting a real thorough clinical interview about their experience, how their close relationships, the people around them, how they experience them, feedback that they get from friends, family, things of that nature. Periods of time, like Johann was saying, where there's an absence of memory. I'm going through the clinical interview and they can't really give me any information about their experiences. That's kind of a key indicator for me of maybe there's dissociation going on. And then, of course, we go into all of the assessment and screening tools. You know, like the DES-II is a tool that we use to screen out dissociative experiences and really lean on those along with the clinical interview. And then reports from other providers who have seen them. Going through those and trying to put together a picture of whether or not this is happening. 

Puder:

Excellent. Yeah. And one of the things we talk about in the DID episode is that for childhood trauma, specifically kids who are prone to a little bit more of a dissociative process, and with the combination of a lot of childhood trauma, you know, it's almost like the identity is fractured in the core sense of self.  And as a provider, you're holding and you're discovering and you're putting back together the pieces of that. So I think the severity of the trauma, and the repetitiveness of the trauma, the type of the trauma, the interpersonal trauma increases, magnifies the degree of dissociation that someone's going to have or how easily they might dissociate in the future. So. Great. Well, thank you so much, Johann. I appreciate it. Any more thoughts, Johann, kind of floating around your head on dissociation?

Ortizo:

I think it's going to come up. But oftentimes, with dissociation, it is confused with repression and splitting. But there is going to be… I think the next person who's going to talk about splitting can distinguish that differentiation.

Puder:

Great. Okay. Let's go to splitting.

Splitting (01:39:25)

Linn:

I know that was a good intro. 

Puder:

Heidi, welcome to the podcast, Heidi Linn.

Linn:

Yes, thank you. So I'm going to talk about splitting. Splitting, on a very surface level, is a defense that helps people to organize their experiences in a very simple and polarized way. So, when I was thinking about splitting, I think in a lot of cases, young children learn this as a defense and as a way to organize the world and organize their understanding of how their family behaves or even how they should react to situations. So, it is a very primitive defense. It allows people to categorize these contradictory experiences that they might encounter in order to reduce their anxiety and manage their own internal self-esteem. So we see this defense a lot, it's got a lot of notoriety with borderline personality organization, narcissistic personality disorder (McWilliams, 2011, p. 116-117).

Linn:

And I work with a lot of clients with obsessive compulsive disorder. And I was thinking of how, in many ways, folks that have obsessive compulsive personality disorder, they have a lot of this rigid thinking in the way that, especially if their experiences are, or the way that they're thinking, is ego-syntonic. You know, “The way that my perfectionism allows me to encounter the world.” They might have a lot of internal splitting in the way that they approach things. When it comes to how splitting is shown, I liked how you said some defenses come across as very extroverted. You know, as a psychiatric nurse working on the floor, we often would talk about splitting. And when we had patients come onto the unit and  there was a lot of valuing and devaluing, often it came to a head when it came to boundaries or rules on the unit.

Linn:

One nurse might allow a behavior, another one would not. And so you had this splitting amongst the team. And so there was often this talk among team members of how do we combat that in the way that we care for the people that come onto our units? And so, the downsides of splitting is that it can cause a lot of chaos and conflict if you're working on a psychiatric unit. But if you are in a relationship, say even with somebody that has even traits of OCPD, perhaps the way that they compartmentalize their experiences or engage in the world can be really frustrating to deal with if you are the spouse of somebody, that they have a very set way that they see the world and see things that need to be done. So, those are some of the big things that I was thinking about. I'm thinking about how it intertwines with dissociation, and  one of the things that Nancy [McWilliams] talked about is that splitting often involves a distortion of reality.

Linn:

And when I'm thinking about, I have some individuals that have dissociative identity disorder, and when they are in dissociative states, it does change the way that they are perceiving maybe the plan that we made as a team. We had a team meeting and discussed the plan of what was going to happen and objectives, and when they are in dissociative states, that plan's all bad, that is out the window. And so, a lot of times we're having to come together to help integrate and acknowledge these different parts in order for that person to have a sense of cohesive whole. We're all working together in order to move things along for your betterment. And so, I think that that's where I've seen splitting occur with extreme dissociative states. I'd be interested to hear if other people have thoughts on that as well.

Puder:

When I think about splitting and dissociation, let's say you're idealizing a person, you're splitting off the bad that you may have to critique. Right? And you're dissociating that part out. Right? So it's like you're disavowing, you're not allowing the critique. Someone who's in a kind of a more distressed, stressed, stressed out state, may go from idealizing to devaluing back and forth within an hour. And so, it could be kind of rapid, switching from idealization to devaluation. So it's like they're dissociating from the bad, and then they're dissociating from the good and only seeing the bad. So in that way, I could see, kind of like, some dissociation linkage.

Linn:

I thought it was also interesting how Nancy [McWilliams] brought up how, even in our society, we see splitting as a way for different groups to gain momentum , both in people joining along with their ideas, that we've seen it with different authoritarian leaders (McWilliams, 2011, p. 116) So splitting is something that we see in our clinical work, but we also see it in our everyday society. So I thought that was worth noticing.

Puder:

I think it takes less energy to have a middle road kind of view on something. It takes more psychological energy to have nuance. It's easier, I think, to just go all bad or all good on… and I think we can enjoy going all good on our sports team and all bad on the opposite team. Right? Political parties, most people who are politically oriented because of the consumption of the media that they consume, will agree with most of the viewpoints of that political party. That's kind of a splitting of sorts. It's not primitive necessarily, but when you have a more primitive personality, who is at the top of the ticket, so to speak, sometimes they will split in the way that they use their words, in the way that they drive a wedge. They see wedges where there is no wedge. They go all bad on anyone who does not completely idealize them. Anyone who dissents from any part of their plan is completely shunned. And if you switch with some of these leaders to idealizing them again, they'll go all good on you immediately, which can be confusing. Or they could stay all bad. They could carry a chip. They could carry that resentment chip. Right? So, Aurielle, what are you thinking?

Wilderman:

Yes. And as both of you brought that up, one thing came to mind. First, Heidi, you were talking about the cohesive whole and how splitting occurs in a society. And then, you were just talking about with the sports teams and where that converged for me was actually, something that came up was a commercial. I believe it might have been around the Super Bowl time. And there was one fan who, they were rival fans, and there was, pick your rival league. Let's just say, Eagles versus Giants, which is what we have. So there is a Giants, you know, team of guys sitting at the bar, everyone's watching the game, and then in walks the Eagles fan, sits down, wants to have a drink, everyone looks at him like he has three eyeballs.

Wilderman:

But then when you see the Eagles fans and the Giants fans together in a foreign country, they realize that they're all united by virtue of their nationality. So again, it's that splitting within a context. And I would argue also that the nuance or the togetherness is actually where there is harmony. It's almost like if we asked any of those fans, okay, but what actually is bad about the other? Why are you using splitting? We can't actually put a finger on what is bad about a fan, just because they're from a different team. So, I don't know that we actually want to devalue the other. So when we have the luxury of being outside of a context, outside of society that expects us to split, in a sense, we actually can unite and come together. And that's also a beautiful other side of splitting.

Wilderman:

And your comment about the social cohesive whole. So it can play out in some ways, and then depending on the context, it just goes away. I think that, Dr. Puder, also I believe it was Dr. Yeomans who brought up in one of the podcasts [see episode 234], we also have the Yankees and the Red Sox here on the East Coast, and it was that example of how you can be best friends, even married. One's from Boston, one's from New York, you're going to hate each other for two hours, but when you walk out of the stadium, you're partners, in love. So I love your examples and your explanation of that as well, Heidi.

Puder:

Thank you. That was really helpful. Yeah, splitting, and does this bring up any other thoughts for anyone else? Oh, one thought I had was on psychological safety. So there's research studies on NICUs, where they look at the psychological safety, which is how easily you give negative feedback to the authority structure. And what they have found is that you have better patient outcomes when there's a higher level of psychological safety. And so I looked at this in the research when I did the connection index and such [see episodes 149  and 198], and I found that it's not a given that there's going to be psychological safety. And I would say, when you have a more authoritarian leader, the psychological safety is completely zero. Right? Like, you cannot give them negative feedback, especially publicly. Right? Maybe privately. Maybe if you use your words in such a way to not make them look bad. But you're kind of trying to coax them towards the truth. But in a more healthy system, there isn't that much of a weight to the necessity of hiding the truth from a leader. Right?

Puder:

So I will aspire to be psychologically safe.

Linn:

Well, I wonder if the piece of that is that when there's psychological safety, people can handle the gray. When it's all or nothing, there's no safety to figure out, “Does my opinion, does my feedback completely fit into their vision, their thought process?” And so people avoid it. They avoid voicing that. 

Puder:

Right. And you could see if a leader idealizes himself completely. Right? If they like to stay completely psychotically idealized, any form of truth that would be seen as a slight devaluation or a slight insult to the ego would be catastrophic to that individual. And they would, they may get incredibly angry and defensive and devalue the person in front of them.

Linn:

Would you say that those who have splitting, as one of their main primary defenses, have low reflective functioning?

Puder:

By the very nature they would be around…. If they have splitting in their adult attachment interview, it goes around a three, it scores around a three. And so, yeah, it is low reflective function by the very nature of the splitting. Holding the nuance is actually a lot harder, which is why, if a patient has only negative views towards a parent, I'm not going to sit there and tell them that they're splitting. I'm not going to sit there and tell them that they're only devaluing and they need to find the gray. But with empathy and with time, I've seen most patients move towards seeing a little bit more gray, the good and the bad. You don't want them to flip from devaluation to idealization. Right? Which is like if they get the sense that you are upset at them devaluing their parent, then it makes them flip to idealization. Which is not what you want to promote either. Right? So it's like there's some…there's a developmental pathway that usually arrives at some knowledge of the gray. That being said, some parents are completely… it's also the potential. Right? That there are people that should be devalued mostly. Right? Like if someone was like… well, Epstein, “I feel like Epstein was kind of good,” and it's like, no, no, no. Right? Like, we need to devalue certain people and we need to have categories for that as well.

Acting Out (Enactment) (01:53:45)

April, why don't you take me through acting out, now. Let's talk about it.

Puder:

Dr. April Staples hailing us.

Staples:

Yes. Yes.

Puder:

With her expertise is going to talk about acting out.

Staples:

Alright, so acting out is a primitive defense, where some feelings aren't able to be symbolized into words, and so they're acted out. So another way Nancy McWilliams talks about this is enactment (McWilliams, 2011, pp. 119-121), which is a word that a lot of us have used as we've gone through this cohort. You know, having a patient enact these old patterns of behavior that they aren't aware of. So they haven't symbolized that behavior into words yet. So this defense helps them to have agency over these feelings that they haven't yet verbalized. So they still exist in this unconscious space, or this non-verbal space, and they can be both positive and negative. Right? So they, some of them can be self-destructive, for example, maybe somebody experienced a lot of feelings of shame, that shame wasn't able to be verbalized,

Staples:

and so it's enacted in the form of bullying. Right? Exerting power over other people. And the unconscious kind of drive there is this feeling of shame that has not been symbolized into words. It can also move into a growth enhancing process. So, maybe somebody has spent a lot of time with a group of friends and they're feeling ignored and they're feeling like there's no place for them and then they abruptly speak up finally for themselves. They act out this, “I want to take control. I want to speak up. I want to have a place here.” They might not necessarily know that it's coming from this feeling of not feeling a part of the group or not feeling seen, or things like that. But the behavior ends up kind of speaking for them.

Staples:

So when there's no words, the behavior speaks, essentially. And so, therapists can experience this, you know, with our patients, where we kind of participate in an enactment with our patients or, our patients act out these kinds of patterns of behavior or these ways of being that they engage in in their other relationships. And we find ourselves in this enactment with them, and we have to kind of try to figure out what is being acted out here. And so that can be really helpful, really confusing for us, at first, to figure out what is getting enacted in the interaction that we're having with our patients. And so, yes, just to kind of summarize it out, it is a process by which a person acts out a preverbal or unconscious feeling; and it allows them to experience a sense of control or relieves the anxiety that is present, due to not being able to verbalize what's actually happening.

Puder:

Really well said. Yes. So fear of abandonment, so they do something to sabotage the relationship. Feeling powerless, maybe they could be a bully. Or feeling shame, they could be a bully. Not to say that that would abdicate the moral responsibility of that act, but they're acting out other deeper things. Right? Grant, go ahead. What are you thinking?

Lemoine:

This came up recently in a session. I was talking and this person was expressing a lot of this painful relationship that this person had with a very close relative who's sick, and then [the client] goes away, comes back and then talks about their activities in the last week. And then expressed how they had this truly emotionally wonderful experience, having a great kind of back and forth with a person who had a similar illness as the person who they're related to, that they have a bad relationship with, and did not put that together at all. And talking about it, they were just expressing how relieving it was to hug and to be with that person, who was experiencing something almost identical to what was going on in their personal life. And so, kind of what April is saying, it's that this enactment is a very unaware process. They have very little awareness of what's going on, but they're trying their best to express it in some way. And yeah, so I always appreciate the point of how unconscious this is.

Puder:

Great. Yes. And we had, someone else had their hand up. Erika.

Reynolds:

I think it's interesting how acting out, like many defenses, has come into the common parlance, and people toss this term out, people that are in treatment, people that are not in treatment, and I have a lot of patients who will describe themselves, “Oh, I acted out”, and what they mean by that is like a return to a compulsion. Like, “I went on a shopping spree”, or “I bought a bag of Fritos.”  So they'll use the term “acting out” as a way to describe an indiscretion that could almost fit or does fit under the category of compulsion. So again, we have this overlap in jumbling of defenses, but I like how there's the common parlance and what the individual means by it. Similar to splitting. People use that term a lot and it means very different things. So, it's interesting as psychology and mental health become more of the zeitgeist and more of what we talk about globally, we have to watch what all these terms mean and who's using them and what the intent is. It's very interesting.

Staples:

Yes. I think that's actually really important to discuss. Because, if it is a primitive defense that's occurring, and acting out, it's going to be completely unconscious to the person. They're not actually going to say, “I'm acting out.” Because that indicates awareness of what is happening and why it's happening. So, the primitive part of this is that there's a lack of awareness about why this behavior's getting enacted. It's occurring out of their conscious awareness, and that's where therapy becomes helpful, because once the therapist is in this enactment, the hope is that the therapist can catch the enactment happening and then bring it into the conscious awareness of the patient and say, “Oh, you know, I'm noticing that you're engaging with me in this way,” and try to be curious about if this enactment. Has it happened before and where is it coming from? So it's not a defense, a primitive defense, if it's in the conscious awareness of the patient. And it really has to be. It really is an unconscious process that's happening. And that's by definition, what makes it a primitive defense.

Puder:

Excellent. Yes. So your curiosity, your sort of gentle inquisitiveness reduces the shame, allows for some exploration of what might be going on, what might be underneath the enactment, the acting out. Very good. Did someone else have their hand raised? Johann, did you?

Ortizo:

I did. But I think, April, you actually started to answer my question. You know, acting out in a therapy setting is seen in many different ways. Whether it's a patient that's like missing a session all of a sudden from the previous session or over the weekend they suddenly get into this really intense fight with their partner. Or I've also had patients who have done impulsive behaviors like drinking heavily. And so that gets brought into the session. If you have the opportunity, I was curious about your approach in terms of some of the situations, how you would bring that into conscious awareness for the patient and what does that approach look like?

Staples:

Yes. I think this is something that I am definitely still practicing and working on. I wouldn't consider myself an expert here, but one of the phrases that I do like, I think it was Nancy McWilliams, correct me if I'm wrong, Dr. Puder, but at some point we had read, or we had a podcast… listened to a podcast where we heard, “to strike while the iron is cold” (McWilliams, 2011, p. 229). Right? And basically, there's a lot of wisdom that I think, and an art, that comes to knowing when to approach the enactment and bring it up to the patient, recognizing if they have the capacity to take in this information. Because, if we kind of see them too soon, or reveal something that we're seeing too soon, that can be very dysregulating and overwhelming, and it will almost turn those defenses up, you know, really, really quickly.

Staples:

So  I kind of like to go inch by inch, you know, just kind of a little bit at a time, as much as I can, instead of saying things like, “Here's the enactment that you're engaging in with me.” So I can give a small example. I've had patients in the past where I might ask them a question and every time we're talking there's this kind of way of communicating with me where I start to feel like, “Did I ask this in a way that was aggressive? Did I? Because I feel like they're defending against me.” And then I start questioning my own sense of tone. I start questioning, “Did I ask the question in a harsh way?” And then I'm starting to worry that I'm inducing shame in them, or that I'm not doing a good job in the here and now.

Staples:

And so that's usually a lot of information for me about perhaps how they engage or act out this same way of communicating with their partners or with their friends. Perhaps this is how their friends feel, or their partners feel, when they're trying to ask them a question. And so a lot of times I'll just, I'll do a small…I just  might say something like, “I just want to make sure that I didn't offend you with that question.” Or I try to ask them how it's feeling. You know, “How did you feel with me asking you that question? Was it difficult for you to have to answer that question?” I find any number of ways to bring up that emotion in the room without actually saying, “I think there's an enactment happening in the room.” And so, yeah, I'm still practicing that, but I've found that to be really helpful. I'm sure there's other people who have good practice at this who can provide maybe some better feedback there.

Puder:

Just to emphasize something you said, April, “to strike when the iron is cold,” means that the enactment may happen in one session and then the next session they're coming in, they're more regulated, they're more calm. You can come back to, “Hey, can we talk about the last session? Something happened between us.” So you're striking when the iron is cold there because you're not necessarily trying to do the insight work during the heat of the moment. Maybe you're trying to give more empathy, trying to make sure you understand their perspective (McWilliams, 2011, p. 229). Okay, Ariel?

Wilderman:

Yes. April, it sounds like you're really exploring the resistance piece that is so core in acting out. It's almost like you're exploring the countertransference part of your patient's resistance. There's something that's being acted out in order to prevent others from coming in or, rather, the patient from coming into the self and acknowledging and feeling, that which they are trying to resist. And you're picking up on that  and how one in a relationship with a person who's using that as their defense might feel such a resistance. Feel, “What am I not getting here? What does this person have that I don't have? Why am I feeling like this right now?” So which would also fall back into bullying, pushing people away, putting out the negative onto the other, and bringing in some of the other defenses, but the countertransference piece as well. And then striking when the iron is cold, bringing it up in session sounds like a really good process that's working for you very well. When you allow that sort of reflection piece in between when it's hot and when it's cold. Especially….

Martino:

I'm so impressed. I'm here in this podcast with you all, and I am learning so much. I feel like I'm over here with popcorn and feverously taking notes. It's very impressive. Congratulations, everybody.

Puder:

Evan, what were you going to say? You have more with that?

Summasup:

Yes. I was thinking on this defense, especially, as well as maybe some of the earlier ones. I was thinking about maybe the newer therapist who's listening to this and feeling like this is really hard to figure out how to enact that. Maybe something that, or maybe myself, like a year or two ago, that, especially when trying to highlight maybe, or you're observing that an acting out's going on in a session with a client. And I think it is valuable to wait until the iron's cold. But if you frame it tentatively, if you frame it gently, if you frame it like, “Maybe this is going on”, and you don't just put it out there. If they're not ready to hear it, typically, then they'll just say no. And you move on and you wait for a better opportunity. That as long as you're putting these things in a “maybe this is interesting to you” kind of way. Like, it's not a big mistake if they're just not ready to hear it yet. And you can try again at a later date, or maybe, there will probably be another enactment of a similar sort, and you'll have another opportunity.

Puder:

Thank you, Evan. Yeah, that's good. You don't have to. Right? You don't feel the pressure. Don't necessarily feel the pressure. And Danny, I agree. I'm learning a lot from you guys, as always. Okay. Shall we move on to the next defense of interest? Maybe we will go to Grant.

Projection and Introjection (02:10:20)

Lemoine:

Okay. So I have projection and I think projection, introjection, and then projective identification. The way that Dr. McWilliams kind of groups them and explains it was very helpful to me. A lot of your listeners are obviously in the mental health field, so we read about this a lot, but the way that Dr. McWilliams goes through it helped me really grasp it. So I'll try to do my best to put it in my own words, but with all the primitive defenses at their core, there's an issue or a permeation between self and the world (McWilliams, 2011, p. 111)). And so, with that in mind, you try to take that principle and apply it to each of these primitive defenses with projection introjection. And then, at the far end of projection identification, it's very easy to see, if you think about what happens in an infant, when an infant experiences pain, they don't understand that the pain is coming from within or without/outside. Whether it's an upset stomach or that they're being swaddled too tightly.

Lemoine:

They just know, “Hey, I'm in pain. This is not good.” And so, from that, and as the infant matures and develops, they develop the ability to have projection introjection. And so, if you think about it that way, I think when you start building on further, when you think about projective identification, which Sheila beautifully explains, it might help frame it better where there's a permeation. So, it's also helpful to kind of think of them in a spectrum of the amount of permeation. So at a relatively healthy level, projection can be a good thing. And then, at its far more extreme permeation between self and outside world, then you have this projective identification that can be, at times, very painful to the other and the self. So just to do a definition though of projection, what it is in particular. As we all know, it's a process, in which, the inside, or what you're feeling or experiencing inside, is misunderstood as coming from the outside (McWilliams, 2011, p. 111).

Lemoine:

So, kind of the stereotypical, “I'm not mad, you're mad,” kind of experience. But as Dr. McWilliams beautifully brought out, there's a healthy aspect to this. She brought up empathy, which was a new kind of way for me to think about that. And I thought that was really a nice point. I'll just try to briefly kind of relate it. But she mentions that to understand someone else's experience, you can't go into that person, so what do you have to… what resources can you do? Well, you can easily reference a past experience or emotion that you felt, and then assign that to that person. And by doing so, you are having this kind of emotional reciprocity and being able to have empathy for that person (McWilliams, 2011, p. 111). And a very similar psychic kind of dynamic is done with intuition. And so that's a nice point because it proves that these defenses are not always defensive, but that they are just ways of handling the world around you. And then, of course, you have the negative aspect of it where you are disowning these negative emotions and putting them onto others, which doesn't feel good for the other person. 

Puder:

Or,  you could put your positive things on other people.

Lemoine:

True, true. Yes. 

Puder:

You could project your positive. 

Lemoine:

I need to do more of that.

Puder:

Don't you do that. Grant, I could see you doing more of that one.

Lemoine:

I try.

Puder:

Everything is awesome.

Puder:

I'm projecting on Grant that he projects his positivity on other people, imagining other people to be positive, because you're a very positive person, Grant. And I hope that's not just my projection on you, that you're positive.

Lemoine:

I'll gladly introject that and make that true. 

Lemoine:

One thing I thought that was helpful, even before this cohort and reading and listening, I would often hear about these defenses and be like, “Okay, how do I make sense of this? I need to kind of solidify this.” I think for me, what's helpful in the differentiation between projection and then projective identification is the force to make the projection reality. So with someone who is just projecting, they can project, but maybe  there's some resistance. Right? Like, “No, that's not true. Okay, let's talk about it.” Whereas, a projective identification, it is imperative that that person has to disavow what's inside and has to make it reality. Because, if it wouldn't happen, that would be so painful. And that was helpful for me to kind of conceptualize, but also to give a lot of empathy for patients who are going through a projective identification kind of episode or spell that it really is distressing. It's kind of painful. They need that to be reality. 

Puder:

How might someone who's paranoid project their paranoia, or what is paranoia?

Lemoine:

Others can definitely comment on this. I did think about this briefly. I have someone, who I know well, who I believe kind of maybe falls into that paranoid personality kind of typology. And I find that there's a true disavowing of their own fear and a rejection of it. And because, when that happens, it often is thrown where these worst case scenarios are being put on others or motive is put on others. But thinking if I stay with that person long enough, it ends up that the conversation tends to go back to that. There's just fear inside of that person. And rightfully so. You go back into the childhood and you see this perfect explanation as to not trusting authority or being fearful. That's kind of how I look at it. But maybe others would have a better explanation. But that's how I see it.

Puder:

Paranoia is like, “I'm incredibly fearful, but the world is out to get me.” Right? “The world is persecuting me. The world is embodying the fearfulness against me.” And if that's the projection of the fear, “Others are hostile. Others are angry at me.” I don't know if… you may have a patient at some point that says, “I'm sitting here and I think that you hate me.” Right? That's the projection they're projecting on you.

Lemoine:

Well, one thing I'll say on that, Dr. Puder, is that I think this was on a podcast that maybe Dr. McWilliams talked about, that I found very helpful, was with paranoid personality type, if you were to confront or disagree with their paranoia, they become more distrusting. You would need to almost kind of work along with it a little bit or have more kind of truthfulness or more transparency (McWilliams, 2011, ch. 10), maybe. I think that is how she put it. And it brings down that amount of angst.

Puder:

There's a statement that there are some people that only feel truth in negative critique or, if you're too positive, it's almost like none of that registers. They only register the negative (McWilliams, 2011, ch. 10). 

Wilderman:

Yes. So what you just said about only registering the negative, something was coming up for me there. But just backing up a little bit, with the paranoia, and I'm thinking about my patients really high on the psychotic side of the organization with the paranoia and the projection. And also, your comment about how you really have to kind of be patient with that. You have to let it kind of come out. Otherwise, there will be that fear that you too are shutting them down. Thinking about this, was a case a long time ago, no longer a patient. I've changed some things to not give away the identification. The concept of the world is a video game. We're all playing in a video game, and we're all being manipulated. We're all being put into these little mazes and moved around and we have no… everyone's watching us all of the time.

Wilderman:

And yes, while this individual had full-blown psychotic illness, at the same time, this is a human being with whom I'm doing a very psychodynamic style of psychotherapy. And, you know, you just feel the terror. You feel the fear, you feel everything that this person is lacking in control, lacking in trust of others and this self-deprecating torment that's going on within. And there's one individual where I really experienced it. But that experience, and looking at the projection with the paranoia, is one of the… I can say, I'd be interested to hear other people's opinions of working with people on the more psychotic range. It was never really explained that people who are very, very high on the psychotic, are dealing with issues of normalcy just like everyone else. It really helps to destigmatize that, when we just recognize the level of fear that is in individuals no matter what their level of attachment to reality. There is that element of fear and shame and lack of control and powerlessness, and literally just feeling like your life is one big manipulation by a power that you just don't have. I find that to be really fascinating about this defense and really entering into it and really holding empathy and space for our patients or parts of ourselves who are feeling that fear and feeling that power struggle.

Puder:

Yes. And with the psychotic realm, what we're really referring to is no insight into the delusion. It becomes a delusion. The projection becomes a massive delusion of, like, it's not that the CIA could be spying on me, the CIA is spying on me

Wilderman:

Correct. 

Puder:

And wants to kill me. 

Wilderman:

Yes, absolutely. And to not challenge that, not to support it in the sense that I think, in general, there's a notion of, “Oh, don't argue with someone's delusion.” Well, no, it's to be supportive in terms of getting into the projection and working through the projection that makes a difference.

Reynolds:

About paranoid structure and paranoid personality disorder, Nancy McWilliams makes a point to say that extreme withdrawal is one of the defenses that they utilize or draw upon towards fear, or her term, “unjustified suspicion” (McWilliams, 2011, ch. 10). So, there we have, again, that note of “lost base, lost touch” with reality. So, it's an extreme withdrawal to avoid fear for something that is distorted in the difference between how they're saying it and what it really is. So, I thought that was an interesting link.

Puder:

Great. I know we have one more to get through. So let's just jump to the last one. Introjection.Is it interjection, projection, introjection? 

Staples:

Yep. That's it. 

Puder:

Introjection with April. April, take it away. 

Staples:

That's me. All right. So introjection is basically the opposing part of projection. So projection is taking something within and putting it out. Introjection is taking something outside of yourself and introjecting it, or Nancy McWilliams uses the word “swallowing.” A swallowing of affect, of behavior, of ideas, cognitions, things like that, to the point that you don't recognize them as the other, as something that has come from outside of you. You start to identify with it. And so it feels like your thought, your affect, your behavior (McWilliams, 2011, ch. 3). And this can happen in a healthy way. It's an important part of development, where we learn internalized love, internalized comfort, safety from our caregivers, people, our spouses, our friends. We introject all those positive things about them. So an introjected voice in a healthy example might be, you're having a bad day, things are tough, maybe you're nervous about this podcast today;

Staples:

and then you hear a voice that says, “It's all right. You're doing your best. You're gonna do great. It's gonna be fine.” Right? So perhaps, at some point in time you had a primary attachment, secure attachment with somebody who you have introjected that voice, that supportive, loving, caring voice on the opposite end of the negative aspect or the unhealthy parts. Nancy McWilliams discusses how we can engage in introjecting parts of our abusers, or negative aspects. And so, identification with the abuser would begin to take on the behaviors, the beliefs, the ideas, and thoughts of the abuser. And this becomes adaptive because it's taking an unconscious powerlessness anxiety and giving the psyche a sense of control, “If I can be like my abuser, I can predict that behavior, I can maybe keep myself safe.” It creates a sense of power within the psyche (McWilliams, 2011, ch. 3).

Staples:

And keeping in mind, this is not conscious, again, it's an unconscious process. So, you know, identifying with the abuser, taking on, is not a conscious thing that happens. It's a process that allows the psyche to remain whole, to not have to wrestle with this powerlessness that they experience being in this abusive situation. So, the introjected voice that might come from an unhealthy relationship or a situation where a child maybe had parents that weren't as supportive in loving and caring, they might grow up and then, as adults, when they are trying to rest, for example, they might hear a voice that says, “You're lazy. You're worthless. You don't try hard enough.” And they kind of take in this voice as their own voice, that it's their thoughts, not recognizing that this has actually been introjected, it's been swallowed, or taken in, from outside of them.

Staples:

One of the best examples, or an example, that I thought of, that I thought was kind of fun, and this is, I guess, kind of in a more healthy range, is in the movie Inside Out. Riley's parents are frequently telling [her], “You're our happy girl.” Right? “You gotta be happy. Just do your best” (Docter & Del Carmen, 2015). And they're kind of always positive and always kind of trying to get her to disavow her sadness. Right? And disavow her anger. And so you see this in the movie, where Joy is always at odds with all of the other emotions and trying to just take over Riley's internal world. And so Riley has introjected this belief from her parents that she should be happy all the time that “Riley is a happy girl” (Docter & Del Carmen, 2015). Right? And so, that's kind of a fun way of understanding introjection. It's just the taking in of affect, beliefs, and ideas from outside of us, and then believing that they're ours at some point.

Puder:

Yeah. And one thing I want to say, just for anyone who's listening, because you could think like, “Oh, do people who, let's say, boys who are molested at a young age, do they become future abusive molesters because they've introjected trauma?” Actually, the rate is very low. In one cohort, I remember it's about 3% of people that have been sexually molested as boys, that will become later people that will do something similar. So, the majority do not. But many more than that 3% can have intrusive, sometimes obsessive, almost like an OCD level obsession, of “I'm going to hurt another boy.” Right? Or, so they could be kind of an unwanted, distressing thought, which would be kind of an introjection of that trauma, that they would be the abuser, not because they want to abuse, not that they be not, if not because they are abusing, but because they've introjected a piece of that.

Puder:

Another client, I'm going to change the details a little bit, but she, after being abused as a child, thought she was abusing herself when she would…. She thought she was molesting herself, so she became the abuser towards herself before the event, the sexual violation. She believed she was just playing with herself afterwards. She's molesting herself. So, in a lot of people, this therapy can really help them untangle this and decrease the shame, and understand why they might put themself as the abusive role in their mind, in their fantasy mind. Right?

Staples:

So one of the, one of the things I thought was helpful is thinking about the countertransference that you might experience when somebody is communicating an introjected belief or idea, or something like that. And one of the things I read was the therapist might find themselves thinking the introjected thought (McWilliams, 2011, p. 115). So maybe there's a patient that's really frustrating to you and you're having an experience where you're thinking, “Why won't they just do it? Why are they being lazy? Why are they X, Y, and Z?” That question of why are they lazy or why aren't they trying, or whatever thoughts, questions that might come up that actually might be introjected material that you are kind of getting access to from that patient. And that can be really helpful for them being able to ask the patient, “Can you tell me more about these questions you have about this?” Or, if they start communicating some of their experience it allows you to kind of ask them where they first heard that or how they came to believe that or to kind of be curious about their narratives that they have about their own behavior. And that can be really, really helpful, I think.

Puder:

Excellent, excellent. Anyone confused on this one? This is a tough one to understand, becoming the aggressor in your own mind, siding with the aggressor, not necessarily becoming aggressive, but in your own mind introjecting maybe the components of what is going on. I think it's very helpful.

Summasup:

I think the quote that was on the document from Fairbairn helps a lot, “For someone who introjects a lot, which often is someone who's a depressive style, better to be a sinner in a world ruled by God than to live in a world ruled by the devil” (Fairbairn, 1943, p. 66). It's this defense that doesn't usually, I think, help empower the person, but it gives them a sense of having some more control than they actually have. And there's, I think, there's some comfort in that, even though it's usually, it's actually disempowering in terms of their actions.

Puder:

It's also like in medical school, you learn about a disease sometimes, and you'd start to think like, “Oh, do I have this disease?” You're kind of like introjecting the disease into you. Right? So you, as the listener of these defenses, might be saying, “Oh, do I have this problem? I have this. Oh, do I have this defense?” Right? It's also a way of mastery, of kind of trying to make sense of something. Yes, there can be a dissociation away from the anger pointed in the direction of the perpetrator, which sometimes will come out more as therapy progresses. Like, you'll feel more angry at the person that did the actual bad thing. Right?

Staples:

Yes. And I thank you for bringing that up, Evan. Because I think that Nancy [McWilliams] actually talks about how introjection is primarily associated with a depressive personality style. And she actually, I actually highlighted it, she said in working with introjectively depressive patients, one can practically hear the internalized objects speaking when a client says something like, “It must be because I'm selfish.” The therapist can ask, “Who is saying that?” So the patient kind of takes on these qualities that they think led to the abuse. Because if it's their fault, then it's potentially something they can fix. Versus having to accept or acknowledge that the situation they were in was somebody that was just abusive. So it's adaptive in that way for them to help give them, reduce anxiety, give them a kind of a continuity of self kind of an illusion of control (McWilliams, 2011, ch. 11).

Puder:

Right. Like a patient with domestic violence going on. Their spouse is abusing alcohol. It's not the spouse's problem. It's like, “Man, what could I have done differently when my spouse came home drunk that could have not elicited them to be so angry at me? I must have been such a bad wife. I must have been…like the house must have not been clean enough.” So, as a therapist, you're listening to this and you may be thinking,  “This has nothing to do with you. Like, what are you talking about?” Right? Or if you're a friend or a family member of someone going through that.

Ortizo:

Yes. And, to add to this from a declining perspective, infants introject the good and bad objects. And so, if, for example, if a caregiver is nurturing the child is introjecting the good object, on the other hand, if the caregiver is harsh, the child is introjecting the persecutory object. And so,  in the example that you both were talking about, the child essentially has these mental representations of a persecutory object and the devalued self other, so they're devaluing themselves in certain situations. So these two mental representations are internalized. On a more positive note, an example I want to provide is teachers can also play a very positive role in terms of a child's upbringing. And so, teachers can have these positive messages that can be internalized. And so there's some research behind teachers having a more positive message on students. For example, if a teacher is highlighting a student's intelligence and how good they are, there's a behavioral aspect to that, but in this regard, they're creating this message that's being internalized, and the child takes that on. Now, we don't know if the child's IQ is actually really smart but they continue to take that on and it shaped the way they navigate their academic journey.

Puder:

Yes. I see these sports parents, there's one in particular, after a game just completely railing on their kid. Every mistake. That gets internalized. The kid's not going to enjoy sports long term, you know, a couple years in they're going to get burned out. It's like, compare that with a parent who is positive. Right? Emphasizing the good that the kid did, but also, I would say not creating a delusional child like, “Everyone was not passing to you under every condition, and the refs were calling everything. And the only reason you lost is because of everyone else.” Right? That's creating a delusion of sorts. But to say something like, “Hey, we're gonna continue to work hard. We're going to continue to take steps towards improving and our hard work is going to pay off.”

Puder:

Right? That kind of message. So it's positive messaging, like there's many steps to the top of the mountain. I would say that combination of things allows for thriving. So they can introject a positive force, but also a sense of like, “Okay, I can work hard and obtain my goals.” Sort of that hero's journey. 

Puder:

Alright guys, we'll leave it here for today. Once again, thanks for being a part of this and if you're listening still, congratulations. You understand psychological defenses more. We'll put up the transcript on the website, psychiatrypodcast.com. Okay, we'll leave it there for today.

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