Episode 266: Understanding Mature Defense Mechanisms in Psychotherapy: Nancy McWilliams Framework with Clinical Examples from the Tuesday Cohort
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Introduction (00:00)
Welcome back to the Psychiatry & Psychotherapy Podcast. I’m your host, Dr. David Puder.
Today, I’m thrilled to be joined by my outstanding Tuesday 2025–2026 psychotherapy cohort. These talented clinicians spend a full year with me deepening their psychodynamic skills and reflective function. In our last episode, we explored the more primitive defenses. Today, we’re moving into the neurotic and mature defenses.
Kicking us off is the compassionately discerning and quietly authoritative Jason Mallo, DO, an adult outpatient psychiatrist and director of the adult outpatient psychiatry clinic at MaineHealth Maine Medical Center in Portland. Jason is deeply passionate about psychotherapy, and he has led a borderline personality disorder group. Jason will start us off with regression and later cover turning against the self.
Next, we have the nuanced integrator and psychologically astute Olga Kuznetsova, MD, a psychiatrist working in two academic hospitals in Boston. Originally trained in internal medicine in Russia, Olga now excels as an emergency and consultation-liaison psychiatrist while also seeing patients for therapy and psychopharmacology. She’s a dedicated CrossFit athlete. Olga will be covering compartmentalization and later repression.
Next up is the gracefully observant and finely attuned Jeanette Houghtelling, DNP, PMHNP-BC, a psychiatric mental health nurse practitioner in Montana who lives right by Glacier National Park. After years as a medical-surgical RN, a powerful personal therapy experience led her into mental health. She’s an avid hiker, skier, and backcountry adventurer. Jeanette will discuss isolation of affect.
Then we have the genuinely inquisitive and equanimous presence of Jason Kent, MA, LPC, a licensed professional counselor who recently opened his own private practice in Charlottesville, Virginia. After fifteen years in advertising for major brands, Jason transitioned into psychotherapy and now works extensively with addiction and failure-to-launch. He’ll be presenting on intellectualization and displacement.
Next is the subtly illuminating and warm Deana Goldin, PhD, DNP, APRN, a nationally certified Family and Psychiatric Mental Health Nurse Practitioner and Clinical Professor at Florida International University in Miami. She’s the author of Fast Facts for Psychopharmacology for Nurse Practitioners. Deana will cover rationalization.
Then we hear from the courageous and compassionately discerning Katia Ronay, MD, a psychiatrist with a deeply psychotherapy-based private practice in Washington state. Katia grew up speaking three languages and has lived in multiple countries. She’s an avid skier, hiker, swimmer, and dancer. Katia will be discussing moralization.
In the second half, we’re joined by the sagacious and clinically luminous Natalie Dreyfoos, DNP, ARNP, founder of Dockside Psychiatry Clinic in Seattle. Natalie works with adolescents and adults through medication management and psychotherapy, with a special interest in psycho-oncology. She brings a strong psychodynamic foundation along with somatic and holistic approaches. Natalie will be presenting on undoing.
Chris DiDonna, MA, LMHC, the heart-centered and authentically attuned licensed mental health counselor I work with in Orlando, Florida, is deeply passionate about the real-life transformations he witnesses every day in therapy. Chris will be covering reaction formation.
Amanda Sekijima, MD, the finely attuned and developmentally percipient Child and Adolescent Psychiatry Fellow at the University of Louisville, brings a rich background in movement, languages, and cross-cultural experience. She’ll be presenting on identification and will close the episode with a reversal.
Finally, Littal Melnik, MD, the viscerally resonant and psychologically astute psychiatrist who works in an adolescent day treatment program in New York while maintaining a private practice and teaching fellows at Columbia, will bring us a memorable Batman example when she presents on sublimation.
Regression (04:33)
Presented by Jason Mallo, DO
Puder:
Jason Mallo. Take us off with regression.
Mallo:
Yeah. Last night, I was watching this documentary and I just had to share this example because it really stood out to me. So it's a documentary [Mel Brooks: The 99 Year Old Man!] on Mel Brooks. And, he once played this love doctor on a dating show, and the interviewer asked him something like, “When can a heterosexual woman know when it's an appropriate time to get married?” And his response was something like, “Oh, when their boyfriend puts down their rattle.”
Mallo:
Regression is the defense mechanism where people seem to return to an earlier stage of development (McWilliams, 2011, pp. 129–131). It's definitely like a backtracking to an earlier way of coping with stress that can be psychological and or environmental. And, our psychology does develop in stages. We've all heard of Freud's oral, anal phallic… and for the parents out there, we definitely know kids don't progress in a straight line. There's an ebb and flow to development, but there is a progression and typically, with aging, this gets less dramatic.
Puder:
Yes. I've seen it with kids when they get sick, they'll regress to earlier stages, you know, all of a sudden they'll lose abilities that they had before. Yes. So it's normal with kids to regress. Yeah. How do adults do that? How do adults regress? Sometimes?
Mallo:
Yes. David, it totally happens with kids. Like, I know firsthand about sleep regressions, but yeah, it happens with adults too, of course. And it could be natural and adaptive for adults. It's not always pathological. You can think of romantic relationships where you'll hear partners talk with each other like baby-like voices. You know, like smoochie, cutie pie, that sort of stuff.
Puder:
Everyone else cringes. Right? That's not a part of that regression.
Mallo:
No. And yet, we do it as human beings. And capable, well-functioning adults. I mean, you can all probably imagine someone going back to the home they grew up in, and then just suddenly becoming infantilized by a parent, or like a little kid feeling criticized. Or getting into sibling rivalry, that sort of stuff.
Puder:
That's good.
Mallo:
But, then it can be maladaptive, too. I'm thinking of patients throwing full blown tantrums in the office, stomping their feet, getting that fetal position on the floor. And Nancy McWilliams (2011) has pointed out that somatization can be a form of regression (p.130). And it reminds me of how Freud wrote about the ego first being like a body ego (Freud, 1923). And so, the ultimate regression may be a somatic experience in the body somewhere.
Puder:
Yeah, that's good. Or like finally a common pathway to dissociation. Right? But in that, sometimes the regression, it feels like they're regressing to an earlier developmental time. Right? And so we may notice that as providers, we may be curious about it. What do you do? What do you tend to do, Jason, if someone regresses in your office?
Mallo:
Well, you know, it can come in the form of patients who've made strides with becoming more autonomous or just having healthier behaviors, self-agency and yet backsliding. Right? And then someone's drinking again or getting into problematic relationships again. I think the good news is that with this defense mechanism, people typically don't lose what they've achieved. It's just where they're at right now. It's just overshadowing temporarily. And I think helping patients recognize that and become more cognizant of it, and normalizing it too, can help support them actually having some greater control over time.
Puder:
That's good. Yes. It's like maybe their coping mechanisms have gotten more advanced, but then in the regression they go back to old habits. I love your positive view on that. That you have gained the ability to jump out of that faster. I like that.
Mallo:
Yes. And it might be, you have to temporarily be somebody that kind of holds on to their past successes until they can get to a point of recognizing it. But like, you'll hold onto it for them and help them with grounding and stuff like that to get out of it.
Puder:
That's good. Thank you. Yeah, Jason.
Sekijima:
Nancy McWilliams, if I recall, she was talking about the very first defense that a baby has is just falling asleep. Like, when they have stress, they fall asleep. And so, I'm thinking, as an adult, you could regress all the way, like you were saying, back to an early developmental stage. Like if a college student has anxiety about an exam and then they study all night and then sleep through their alarm. And by sleeping, you're avoiding the anxiety of the test itself.
Puder:
Yes.
Puder:
Yes. That's helpful. Because, I have patients who just lie in bed all day, too. It's like they're trying to kind of regress. They're regressing somewhat. Yes. That's good. Let's talk about compartmentalization, Olga.
Compartmentalization (10:29)
Presented by Olga Kuznetsova, MD
Kuznetsova:
Okay. so I got confused about compartmentalization at first, because there's one that is commonly known. Right? And we use it sort of like in everyday life; and it almost feels like it's a good thing to compartmentalize. And so, just kind of a definition, is an act of mentally separating different parts of your life, thoughts, or identities so they don't conflict with each other (McWilliams, 2011, pp. 135–136). So, for example, and we all do it, like a doctor who focuses, or even a therapist, you know, who has some personal problems at home, but he can focus on the problems of the patient and not be emotionally disturbed during the session. Another example that I had is a therapist who leaves work stress at the office and is fully present with family at home. But we all kind of know that's not realistic. We all come home and kind of, you know, we feel like we need some time for ourselves. Right? So yeah. It's very challenging.
Puder:
We can regress to earlier stages once we get home. Right? Because it's a safe place.
Kuznetsova:
Yes. And I think it's normal. Right? And so, as a defense mechanism it's more like the ability to keep conflicting beliefs, emotions, or behaviors separated so that they don't interact with each other; and a person is not feeling anxiety about it (McWilliams, 2011, pp. 135–136). So, it's kind of similar to hypocrisy, which was new to me when I read in Nancy McWilliams’ book about it. So for example, a person who cheats in business, but at the same time, sees himself as a very moral and kind person (McWilliams, 2011, pp. 135–136). Right? But at the same time, kind of does something bad on the side. Or a person who acts lovingly towards family but abuses others and thinks it's okay.
Kuznetsova:
So the other thing that I wanted to point out is that it's similar to splitting. Right? And so there's this tension between those two different beliefs; and it's not integrated. And, in therapy, I was thinking about how I would approach it. I'm sure it naturally came up during my therapy. Maybe just kind of wonder gently why a person sort of acts a certain way. Right? Maybe somebody has other suggestions on how to manage this kind of defense in therapy.
Puder:
Well, I see it as largely adaptive. Right? I mean, there was this guy [Christopher Browning, Ph.D.] who came on my podcast talking about Ordinary Men [see episode 196], and a lot of the time he was very cognitive. And Katia, I know this is one of your favorite books.
Puder:
And he was very cognitive and very emotionally distant. And then, there was this one part where he was talking about this early discovery. He was in Germany, and he found these files and he understood what he found. And he started, he made this connection, and he started getting very emotional. And it's like he couldn't hold that compartmentalization anymore. Right? Where it was probably very adaptive to get to be very intellectual and separate the emotionality when he was really trying to just find the facts and the details about this horrendous thing. Right? So it'd be totally overwhelming to fully grapple with what that was like for the Jewish people to be murdered as they were by the German military officers. So yeah, compartmentalization can be very adaptive if it's happening for good reason.
Puder:
Yes.
Dreyfoos:
I think about compartmentalization, too. Olga, I like how you separated it with like the tool that we use. And I remember working as a nurse on the floor during COVID and walking into a patient's room. I distinctly remember this older gentleman, and there were two patients on my panel, and both of them were COVID positive. One of them was not doing well at all, tanking. And it was when visitors also couldn't be in the hospital. And so holding that space for this patient, in the distress, and then walking outside the room, kind of putting, gathering myself together, and then I go into the next room where this other patient is also COVID positive, not showing any symptoms, pretty happy-go-lucky. He's able to talk to his family. And I think when I was reading about this, I'm like, “Oh, okay, that makes a lot more sense to me,” in that I needed that tool to be able to do that work and be present.
Puder:
Yes. And, talking about regression and kind of mixing these two together, I don’t know if you all have ever had this experience where you feel sick, you know, maybe you have a stuffy nose, a little virus, and it's harder to compartmentalize. Right? So I'm with a patient, instead of, normally I can compartmentalize, I can be fully present with that person, now it's like other stuff from previous patients is leaking in, stuff from my home life is leaking in and it's like a little bit harder to control the affect. That may be the second arrow of critique towards those things creeping in [see episodes 258 and 259].
Kuznetsova:
Yes, I have. That happens when I switch from one patient to the other. Sometimes it's really hard, you know, when there's something stressful. You know, you can't really get back to yourself and put it away right away. And so sometimes it takes time to kind of…. That's interesting. Yes. I see that happen.
Puder:
Okay.
DiDonna:
I was thinking about the idea of integration, like helping someone be able to handle integration more and more. And specifically the example that came to mind was helping someone who's an addict who is part of a spiritual community where they keep those two parts of their lives completely removed. But I've seen real change happen when you're able to help that person get to the point where they can find a safe person to share this other part of their life. And when that integration happens, I think there's a strength that comes with that that starts to heal some of the maladaptive parts.
Puder:
Yes. Reduces the shame that person is holding too. If someone can hold that part of them. Yes. Okay. Let's go to turning against the self. Turning against the self, Jason Mallo, you're up again.
Turning Against the Self (17:42)
Presented by Jason Mallo, DO
Mallo:
Turning against the self. So this one describes a unique kind of a displacement where an individual becomes their own substitute target for negative emotions about another person. And it's like what the ego does is it literally reverses the direction of things. It does a 180 of external blame to self-blame. And it can present itself in so many different ways. Self-Criticism, self-harm, feelings of real shame, feeling fundamentally flawed (McWilliams, 2011, pp. 138–139).
Puder:
Right. Knowing this, as a therapist, as for you, Jason, as a psychiatrist, knowing this, has it helped you become conscious of it when you do it towards yourself? Have any of you caught yourself doing this now that you're conscious of it?
Mallo:
Oh, yeah. I think so. You know, I think there's some irony and sometimes I will, I'll catch it after the fact. It's really nice when you catch it when it's happening, but, you know, I find myself maybe flustered or frustrated by a patient I'm working with and, for those of us who work with patients who have severe mental illness, it's inevitable. We're going to have strong feelings about them. And so anyway, it's just ironic when that comes up and I'll find myself going out of my way to maybe help a patient, or call them, or spend extra time with them, or something like that. And it's like, “Wait, wait, what am I doing? Like, I was so frustrated and angry, and where did that go? And what did I turn this into? And now I'm meeting with this patient three times this week.” And when you catch it, it's super nice. And I think being in a place where we have good supervisors or maybe colleagues we can trust in, or maybe, you know, David, we're part of a group supervision, your group supervision, where you can process some of that stuff. I think it helps you get ahead of it.
Puder:
Yeah. It's really painful. Right? When you take that anger, maybe the injustice, and you point it at yourself. Right? It could be very uncomfortable. Okay. What would we say to a patient who we see maybe take some anger and point it at themself?
Mallo:
You know, I think one tactic here could be something like getting your patient to try to get their observing ego online. And think about somebody else in a similar scenario. Like think about a friend of yours or a family member of yours who they're in the same exact scenario that you're in. How might they respond to it? How might you feel about them? How would you have compassion for them? Would you critique them as harshly? You know, an example could be something like, you've got this patient who maybe they've got a boss who's super critical of them, but then they find themselves being really critical of themselves and feeling like, “I need to work harder. I'm not doing enough. I gotta step it up.” And then they're offered maybe promotions or something, and they give credit to somebody else, and you're seeing this happening. You know, I think you could ask them to reflect on imagining somebody in the same scenario that's not them. And what would you advise them to do, or imagine how you'd feel for them.
Puder:
That's great. I love that.
Houghtelling:
You know, I've also found that the turning against the self sometimes functions in trauma survivors who have experienced a great deal of powerlessness. And if they make it about them, it creates the illusion that if it's about them, then there might be something they can do or something they can fix. And so it sort of attenuates that feeling of powerlessness.
Puder:
Which is tricky because if you're the provider and you try to take away this defense too quickly, it can make them feel powerless, and dissociate even more.
Houghtelling:
Right.
Puder:
Yes. Like, “I'm the perpetrator.” It could also be anger, guilt towards themselves for putting themselves in this situation, not speaking up, not telling the person to stop more. It also could be like blaming themselves for future stuff. So, I've had patients who say every time, “I am abusing myself.” So they're continually turning against themself with what would be like a normal thing. So it's a trauma-based perpetuation.
Puder:
Okay. Shall we keep going? We're going to repression with Olga.
Repression (22:58)
Presented by Olga Kuznetsova, MD
Kuznetsova:
Repression. Yes.
Kuznetsova:
Yes. So repression is unconscious blocking of distressing thoughts, memories, impulses. So they don't enter consciousness. And unlike suppression, which is conscious, repression is automatic, outside awareness, happens very quickly. And the other thing is that the person is not choosing to forget something (McWilliams, 2011, pp. 127–129). Again, it happens automatically. And I want to talk about an example, repressed anger toward a parent. I see it all the time in therapy, and I don't know if that's related to repression or maybe something else is involved here as well, I'm sure. But when a patient says that they had a perfect childhood and describe a parent as wonderful, and yet maybe you know a little bit of the story to it, and then the patient has some symptoms, could be some somatic symptoms, you know, headaches, or it could be some sort of like anxiety, irritability with authority figures. Right?
Kuznetsova:
So that anger could be repressed. And it's really, I guess, frightening to the patient to imagine that their parent is not perfect. Right? So maybe there's also some regression linked here, as well. So yeah. That's an interesting example. So, the emotion will still leak out. Right? Whatever is repressed, it's going to find its way out. But it's not going to be that obvious. Right? I think that our job as therapists is just trying to link it.
Puder:
Yes. So, repression, in your example, the person is repressing any negative feelings towards their parent. They’re unconsciously pushing them down — it happens automatically, outside of awareness. As McWilliams notes, something must first register at some level before it is consigned to unconsciousness. Denial is the more primitive form, where the memory or the reality doesn’t even come to the surface at all. Denial is more of a wholesale refusal to acknowledge something.
Repression is different: something may register briefly — a fleeting thought or feeling — it’s distressing, and then it gets automatically barred from consciousness. This is what gives repression its neurotic-level quality — it’s more sophisticated than denial, but it still keeps the material out of awareness, often leading to indirect leakage. In your example, it’s great because the adolescent or the adult is maybe having some passive-aggressive anger come out toward other authority figures. Maybe even toward you, Olga. I kind of see that sometimes as a compliment, because you are the safest person in the room — the one with whom they can begin to allow the repressed material to surface in the transference. That’s often where the real therapeutic work begins.
Kuznetsova:
Yes. And I think, maybe part of why they are not comfortable expressing the anger towards the parent is because they're anticipating the parent is going to react a certain way, which will be distressing to them. And I think your job as a therapist is to kind of be neutral and contain the anger. Right?
Puder:
Yes. What about with grief?
Kuznetsova:
Yes.
Puder:
How can repression be a part of grief?
Kuznetsova:
Yes. After losing a loved one, someone reports feeling completely fine, everything is okay, and shows no sadness. And months later they develop depression or unexplained fatigue, for example. I just had a patient today actually in therapy that lost his best friend to cancer when he was eight. And when he got the news, his mom actually told him. It was his mom, my patient, and his sister, who barely knew the person who passed, and when she told him that she passed, both mom and the sister burst out in tears. And he says, “I really didn't cry. I couldn't express any kind of emotion.” And there was, “I didn't expect her to die so suddenly.” Right? And so years later, what we've been working in therapy, he has trouble being there for someone who's grieving.
Kuznetsova:
His girlfriend recently lost her cat, and she had extreme sadness. She was crying and he said, “I was really uncomfortable sitting next to her while she was crying. And I wasn't sure what I could do, and I really wanted her to stop. Not in a mean way or anything, I just didn't know what to do with it, you know?” So, we kind of went back to when he was eight, and I think he sort of dissociated from that, repressed the grief and kind of didn't learn how to maybe grieve in his own way. Right? So we worked around that. I think it was interesting how he repressed it throughout his life and it still kept coming out in a way of this weird feeling that he was experiencing when somebody was grieving.
Puder:
Yeah, yeah, yeah. Somebody else is grieving, “I'm feeling anxious, I want to repress their emotions too.” Yes. And you'll see parents who maybe don't have as much insight as your patient. They'll say things like, “Stop crying.” Right? “Don't cry. You don't need to cry. You're done crying.” You know, “Don't be angry.”
Kuznetsova:
Right. But if you're not crying, it's also strange. You know? So it has to be like a norm. You know what I mean? Like, if the kid is not crying when supposed to cry, something sad happens that also, parents are worried.
Puder:
Yes.
DiDonna:
There was a time when I was repressing some sadness and grief, and luckily, I had a therapist who was really helpful just giving me space. Right? But there were also other relationships I was in where I felt like people wanted me to feel, and there was like a pressure in that. One of the things I found helpful with working with repressed sadness, repressed grief, is sometimes I'll just tell people, “There is no pressure to cry here. You don't have to cry. I don't think any differently of you. I would just love for whatever comes up to let it come up.” And I found that to be really helpful, in my own life, but also for clients to let them know I'm not looking for a specific response, “Repression makes sense in your story, so let's just let whatever comes up, come up. And if it's tears, it's tears. If it's not, then fine.”
Kuznetsova:
In our session today, actually, tears came up, and a couple of times he couldn't really speak. But I like your approach. Yes. It's helpful.
Puder:
I think it's like whatever they're feeling shame for, if you can lessen the shame somehow. So it could be dissociation, “I feel guilty that I feel so numb and I don't feel anything.” It's like, “I want to be with you and the numbness, it's okay to be where you're at. There's good reason for why you're feeling this. Let's be curious about it. Let's try to understand it. Let's see if we can put more words to it.” Right? “So let's see if any other thoughts on other images come up.” But yeah, I think the key point is, people are feeling what they're feeling. They're having these defenses for various reasons, probably reasons that we don't fully understand. If we fully understood, maybe we would have more compassion. Maybe they would have more compassion for themselves.
Isolation of Affect (31:19)
Presented by Jeanette Houghtelling, DNP, PMHNP-BC
Puder:
Okay. Let's go on to the next one. Isolation of affect. Jeanette.
Houghtelling:
You are right. I actually think this is kind of a cool one. Isolation of affect is just what the word says. Basically, it isolates feeling from knowing. In other words, it operates by altering internal processing and associative functions so that thoughts are accessible. You can see what's going on, you can reason it through, you can make good decisions, you can still function, but the emotional significance of what's going on is actually blocked (McWilliams, 2011, pp. 131–132). And so you might observe someone that the content of their speech might be emotionally significant, but that isn't coming through, like the emotion is absent or incongruent with what they're actually talking about. It's a super useful adaptive function for anybody that needs to be able to maintain competence in the face of really overwhelming situations that would otherwise be disabling, you know, medical professionals (Killingmo, 1990). I think we've probably all experienced that we needed to use this defense in order to stay competent and coherent with our patients without being overwhelmed by what we're actually seeing, or hearing, or being involved in.
Houghtelling:
First responders use it a lot. You know, combat military members definitely use that a lot in order to stay competent without being overwhelmed (Perry et al., 2015). And so it can be hugely adaptive and functional, but when it becomes maladaptive is when it becomes rigid, or pervasive, or chronic, and you're out of the crisis and you can't shift out of that. You can't then start feeling the emotional significance or processing that. It can show up then in trauma context, where emotional numbing is one of the main symptoms of PTSD (Duek et al., 2023). And so isolation of affect can lead to that, where people just can't feel what they feel or, you know, feel what it was like to experience it. At the most extreme level, it can contribute to dissociation (Popescu et al., 2026; Powers et al., 2015)
It's also in terms of personality style or personality disorder, it tends to show up with the obsessive personalities, where they've done some studies that show there's, that people with OCPD have an attenuated access to their emotional states, and they might be able to reason about them, but they can't actually experience it (Lazarov et al., 2022).
Houghtelling:
And so, there's the benefit that people are protected from emotional flooding, but it can be at the cost of feeling alive and being able to actually participate and experience life and liveliness. As an example, I have a patient that I see on a weekly basis, a 50-year-old guy who went through really extreme domestic violence when he was a kid. And he watched his dad break his mom's arm, and he stepped into the role of protector, and his mom would always side with his dad anyway. And just a lot of horrific stories like that. And as he talks about it, he can describe how terrible he feels, but he doesn't actually feel it. It's like it's very mechanical in how he talks about it. Very rote, somewhat pressured, but the affect there, being able to feel the grief, the fear, the loss, the betrayal, all of that—he can't access that. It's very hard for him to even taste his food or see colors when he walks outside, a sunset or a sunrise, to be able to just enjoy a sensory experience or an experience of relational pleasure. And so it has come at a great cost to him.
Puder:
Yeah. Really, really articulate. Thank you. Thank you for sharing the story and the details on isolation of affect. Yeah. And is it, does this bring up any other thoughts for anyone else?
Houghtelling:
So just, do you guys like that one as much as I do? Like, you know, when you're sitting with someone and they're telling a horrible story, I find a certain degree of isolation affect helpful to be able to sit with them. Do you find that helpful?
Puder:
Go, go ahead. What's the question? I didn't hear that. Janet, can you repeat that?
Houghtelling:
Oh, I just wondered, are you all aware that you use that when you're sitting with patients who are telling difficult stories?
Kuznetsova:
Yes, definitely. I mean, sometimes. I guess it has become such a habit now. You know? So I don't think I'm aware of it, it just happens. I was going to ask you, so you are saying that this patient could not taste food, enjoy sort of outside certain things. Is it because it kind of spread that isolation of affect, and he's….
Houghtelling:
Yes. Yes. It seems like he's kind of globalized it. Right? And I think it's contributed to some alexithymia for him. Also it probably connects with anhedonia somewhere too. For him to experience feeling of emotion or even sensory experiences has become threatening to him. He's forgotten how to do it. So that's something we work on (Luminet et al., 2021; Morr et al., 2021; Normann-Eide et al., 2013).
Puder:
Yeah. It sounds almost like a dissociation. I mean, to dissociate away from your emotions. It's also very adaptive. The memory that came to me was when I went to Haiti as a medical student, between my first and second year. I followed an orthopedic surgeon, and within one week we did 50 surgeries. And I remember just feeling very robotic towards the end. You know? I mean, no painkillers in Haiti, you know, the wards are all open, so the beds are like two feet from each other. It's a very different experience than in the U.S. And I came back and I had video that I shot. I shot video the whole time. So I had like eight hours of video, and I spent a lot of time going through the video, and I felt emotions in a way that I wasn't able to feel then. And I think that was therapy for me, to go back through the video and edit, make a documentary, or a little mini documentary. And that's a great example.
Puder:
It's really helped me kind of come to more of the emotional experience, try to evoke the emotions in other people watching the video, maybe that were hard for me to even feel. And yeah, I think that it can be very adaptive as a first responder. Right? To be able to calm down. I saw this a lot in COVID, in nurses that worked in COVID units. You know, it's like in health professionals, there was a connectedness between first responders, as well, that I saw. Because of the harshness of the conditions at times, and there was a shortage because a lot of people were sick and there was an unknown of how deadly it was when it first came out. Right? And a lot of fear. So I think these are examples of how it could be very adaptive to isolate the affect.
Dreyfoos:
It's so interesting too, David, that when you were saying that with your experience from being able to [isolate affect to being able to relive and process the emotions of the experience], I've never been able to conceptualize it until you were talking about it with kind of then feeling these emotions after watching the experience that you had with the surgeries. When I was working within psycho-oncology, we'd work with patients going through treatment, like chemotherapy and or transplant, and things like that. And they were not able to verbalize what was happening. Or they could not even, you know, they wouldn't work with a psychologist on our staff because they were not in the mental space to be able to do that. But we got a lot of referrals to our team after treatment was completed when they have gone into remission or when they have completed their treatment courses or gone through transplant, because now they're able to really focus and now they're feeling all of these overwhelming emotions of grief, and overwhelm, and distress when they were so hyperaroused in this state during their treatment.
Ronay:
I was going to say that as a therapist, I think it's important to really pay attention to how contagious the isolation of affect can be, because it's very easy to dissociate with people like this. Right? They're so separated from their emotions, and they might even talk about emotions, but in a really flat way that feels, as a therapist, it feels really very boring and deadening. And so it can be a challenge to just stay awake and alive. And to really actually encourage your feelings and not just sort of this distant talking about what happened. Right? Without actually feeling.
Melnik:
Yes.
Mallo:
Katia, I was just, you've just reminded me of clinically how this can come up where we're working with relationships or couples, and this feeds into a gender stereotype, where one of the partners could be more of a fixer or doer and the other one more emotionally; and really trying to give some education or encourage each of the people in the relationship to see the other person's point of view. I think it comes up in relationships where one could be holding onto, “I'm going to stuff these emotions,” and the other being, “I'm going to take action here.” Right?
Puder:
The pursuer, withdrawer, dyad. The pursuer is putting the emotions right out. The withdrawer says, “If I share these emotions that I'm having, it may be dangerous to the relationship. I'm going to hold these in.” And the pursuer hears that as, “They're lonely.” They feel disconnected. They don't know where their partner's at and the partner gets the message, “I'm doing it wrong.” And then they get in this dance, and the dance becomes the attachment dysphoria, you know? Let's keep moving so we can get through half of this intellectualization, Jason.
Intellectualization (42:35)
Presented by Jason Kent, M.A., LPC
Kent:
Intellectualization involves retreating into abstract thinking analysis, theorizing to avoid the experience of the emotional weight of a situation. So the person thinks about feelings rather than feeling them. Think of that as a left brain fortress against emotional right brain experiences. Nancy [McWilliams] states that intellectualization is like a higher order version of what we just talked about (McWilliams, 2011, pp. 132–133). So the intellectuals, the isolation of affect. So, the difference being a person using isolation of affect typically reports no feelings. While the intellectual talks about feelings in a way that just kind of strikes us as emotionless reading of a weather report (McWilliams, 2011, pp. 132–133).
Puder:
Yes. Or they could just move into the theory of emotion. Right? Like, “Let me tell you about the microexpression that I just might have flashed on my face.”
Kent:
I like it. I had an example of trying to engage in an emotional experience of someone with grief and they were like, “Well, I know there's five stages and I think it makes sense that I'd be in the depression stage right now.” You know? Sort of just like a detached way.
Puder:
Or, “There's five stages of grief according to the first theory, but I actually prefer the new theory where there's actually seven stages. And let me tell you why I think that's actually more advanced.” Yeah.
Kent:
Good. Sometimes, for me at least, I get drawn into their intellectualization and you want to banter with them.
Puder:
Okay. So yeah. It could be a distraction. Right?
Kent:
Right.
Puder:
A distraction. It's a wonderful way of avoidance for the anxiety of feeling. Right?
Kent:
Probably common with obsessive compulsive or high functioning depressive personalities. It allows goal progress in the face of emotional weight or public opinion. A lawyer. It's adaptive as long as the feeling's postponed and not eliminated. Obviously, it's maladaptive and you feel a lack of connection with these people.
Puder:
People that go on dates with someone that's a heavy intellectually may say, “He was very smart, he's very articulate, but I didn't feel a connection. I don't even know a sense of who this person is really.” Littal, what are you thinking?
Melnik:
I was thinking that's a really nice example of actually a defense. Right? This guy is so smart, but he's defended and it's protecting himself, but it's actually totally a barrier. I love your example, in that way, it is a defense. You're trying to protect yourself from an experience and what you're actually feeling, but in your protecting, you're hurting yourself.
Sekijima:
Would this be considered intellectualization? So I had a therapy patient that had stage four cancer. So we talked a lot about death, dying. And he was talking about who he wanted to make decisions for him in the end. And he ranked family members, like, “Okay, well, I will say my son first, because he's in the army and he's seen a lot of things. Like he's seen combat, and so he knows death. And then, number two, you know, my wife, because she knows me well. Number three, my daughter, because she's a social worker, so she knows these sorts of things.” And gave a weatherman report on analysis on family.
Puder:
It does sound like intellectualization. Yes. It sounds like… and not all intellectualization is bad. I mean, he may be making a good decision based on that. Sometimes you have to have that intellectual process and then, well, what does your gut say? Right? What do your emotions say? So it's like a mixture of the mind. Right? Cognitive process and the emotional mind.
Houghtelling:
Yes. It feels really close to what isolation of affect feels.
Melnik:
Really similar.
Houghtelling:
Really similar.
Puder:
Yes, it does. Doesn't it? Isn't that interesting?
Houghtelling:
Is it a matter of degree that makes a difference? Or
Puder:
This is where I think the affect is missing in the isolation of affect in the intellectualization. It's more of what they're doing there. They're developing theories and ideas around the emotions or to even take themselves further from the emotions. So, in one of our groups, Littal was giving examples of emotions in game theory and stuff like that. And I was thinking about it afterwards, and I was like, “Well, this is not intellectualization because it's a way of trying to communicate her emotional experience.” Right? So I feel like intellectualization actually moves people further from understanding your experience of emotions. Because it's so heavily intellectualized. You know, a lot of philosophy that's very dry. Or it's like people who have strong erotic drives, the intellectualization of eroticism might not be anything erotic. You know, it could take them further away. Whereas sublimation would take them into maybe dancing or doing something that resembles erotic. But the intellectualization, I feel like, can get someone further distant. So that's the way I understand it.
Ronay:
I think even reading deep psychodynamic text. Right? Psychoanalytic literature, you might be thinking about really interesting, and intellectual, even philosophical, ideas that are actually quite far removed from the emotions.
Puder:
Yes. Absolutely. Especially if the people are talking about things like, “Oh yeah, this is the Oedipal triad” (Freud, 1923; McWilliams, 2011, pp. 144–145), and it has nothing to do with the Oedipal triad. It has nothing to do with… but sometimes the big words almost distract., Right? Or, it's like the reaction formation and the ego-syntonic failings of this person, or, when I listen to all of those words compiled together, I don't even, it's like, I don't even understand, and I've read a lot of this stuff. So it's like, “Do they understand?” You know? And if they don't understand, then is it a way of detaching from the distress?
Ronay:
Maybe they understand, but they don't feel it.
Puder:
Maybe they, yes, there you go.
Ronay:
That's the whole defense. Right?
Puder:
Yes.
Mallo:
Yes, yes. Thinking equals safety. You know?
Mallo:
I'm thinking about those patients who come in and use medical jargon or the DSM [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)] lingo. And, you know, someone was in my office the other day, telling me all about, “I was manic”; and I kept on coming back to this like,"Just take me through more details here. Where were you? I just need more context here.” And I worry, jargon can be, or diagnostic jargon can be picked up and used this way. Like intellectually.
Puder:
Yes. And, I could intellectualize using the very words that we're talking about today to disconnect from the emotional experience. You know… what you're doing right here, Jason, is you're intellectualizing and that's really what's going on.
Melnik:
Is that a regressive voice, David?
Puder:
This is my regression into Nerdom. When I was not an athlete and I avoided people.
Puder:
Yes.
Melnik:
All right. Those nerds are coming back when they're lawyers. You know.
Puder:
You got me blushing here. Oh my gosh. I feel like what that felt like, fifth and sixth grade. You know, awkwardness. Okay, Dina, let's talk about rationalization.
Rationalization (51:08)
Presented by Deana Goldin, PhD, DNP, APRN
Goldin:
Okay. So rationalization is essentially a cognitive distortion where someone would reframe their actions or thoughts to protect themselves from painful realities or unconscious conflict. So the motive or feeling is unconscious, but the person creates a conscious, socially acceptable, logical explanation to make themselves feel better or to protect themselves. And it's used for protection from an unacceptable, maybe impulse or cognitive dissonance, internal conflict to deflect responsibility for actions or outcomes, and also for someone experiencing anxiety or shame (McWilliams, 2011, pp. 133–134). So there's a few different ways that rationalization works. So, one of them is known as “sour grapes.” Right? That's when a person devalues what they can't have or can't achieve (McWilliams, 2011, p. 133), so they'll say something like, “I didn't want that promotion anyway.” Or if they wanted, let's just say, a house that they didn't get, they would say, or they couldn't afford, they would say, “Well, that house is too big for us anyway.”
Goldin:
And the “sour grapes" comes from Aesop's fable [The Fox and the Grapes], where the fox was reaching for the grapes and wasn't able to get the sweet grapes, so the fox just says, “I don't want them anyway.” Right? So that's just an example of one way of using rationalization (McWilliams, 2011, p. 133). Another, is known as “sweet lemons.” And this is where it's a kind of self-deception where a person, to obtain comfort and accept reality, they use a more optimistic approach (McWilliams, 2011, p. 133). Right? So, when something bad happens, and then they'll make it…okay, so for example, something bad happens and they'll respond, “Well, that was a learning experience.” Or if they have a breakup in a romantic relationship, they'll say, “That breakup was great. I didn't really like that person very much anyway.”
Goldin:
Or, “We were very different.” Something like that. Rationalization also can be used to justify a behavior or to put meaning to a behavior (McWilliams, 2011, pp. 133–134). So it can be good or bad. Oftentimes, someone won't be able to justify doing something good for themselves unless they give themselves a good reason to do it, or they can do something not good. For example, someone that is a parent that hits a child and has a lot of aggression and says, “Well, it's good for the child, what I'm doing.” Or, let me think about what else. Or they can eat junk food, for example, and say, “Oh, life is short. I deserve to enjoy what I'm eating.” So they'll justify what they're doing. As far as a defense, it's considered more mature because, although it's unconscious, it does involve some contact with reality and logic and reasoning.
Goldin:
And also to understand what's socially acceptable, they have to have some insight to do that. As far as clinically, it can be a way of not, you can be used to not taking responsibility. Let's just say a client that comes that misses appointments or is resistant during sessions, sometimes defensiveness, so that they don't ever have to really explore the core issue. It can impact trust. And then also it's very important as the clinician to not start to believe the rationalization. It can also not help the patient because it's like they're not going to get to where they need to go, reach what they want to achieve in therapy, or get to their root issue(s). So it's important as the clinician to maybe notice patterns and bring that up or to explore the underlying conflict or something like that, if that should happen. So the defense can operate benignly when it allows someone to make the best of a difficult situation. But the drawback is that it's a defense strategy that virtually anything can and has been rationalized. So it's good and bad, like the sweet and the sour. So that's….
Puder:
Too much and too little. You know?
Goldin:
It's a lot, it's a lot.
Puder:
The soup is too hot or too cold. Right? Yes. Yes. And great job, by the way. Great job going through that. I really like how you separated that with Aesop's fables and stuff. That's good. And you could see how someone would be pulled into this. You could see how we all rationalize. I was even thinking, with the breakup thing, of like, “Oh, you know, it was a learning experience.” Yes, maybe it was, and maybe that's worth emphasizing thinking about what are the things that have been learned from it.
Goldin:
Yes.
Puder:
Or, after a kid's sporting thing, after one of my kids' sporting things, is like, they lost and they're disappointed. It's like, “Well, okay, here's the things that went well, and here's like, you know, it takes time to get better, and so we're going to work on this and we're going to work on this.” And, I don't know, is that a rationalization? Maybe that's not quite a rationalization. Or maybe if the rationalization would be lessening the blow of the loss, you know, instead of sitting in my kid's disappointment, it would be like, “No, this was great. You learned so much.”
Goldin:
Yes. That would be rational. Yeah. It was a learning experience. Like you can, even though you feel bad, you lost. It was a learning experience.
Houghtelling:
I've heard, sometimes someone will say to someone after a really bad breakup, ”Well, dude, you dodged a bullet.” You know, “Count yourself lucky.” Seems like a little bit of the sour grapes.
Puder:
But maybe they did dodge a bullet. Right? Maybe they did.
Houghtelling:
Maybe they did. It might be true.
Ronay:
Well, I think the point is to not have it repress the feelings. Right? So it isn't that it's a problem to have to use one's intellect. Right? To make sense of it, or to make the best of a bad situation. But the problem is, if you're trying to fast forward the feeling, right, the disappointment, the pain, the hurt, the tears, all of that, and then jump straight to, “Oh, don't, don't worry about it. You know, you dodged a bullet.” Right?
Puder:
That's great. I was rationalizing the rationalizing and Katia just cut it to the core.
Ronay:
I cut it down.
Puder:
Good job. Katia.
Ronay:
Thank you. Thank you.
Puder:
She went straight into the higher reflective function position of like, “No, you got to sit with the grief. You got to sit with the emotion.”
Goldin:
I thought Nancy McWilliams, she gave a really good example in her book where a therapist is insensitive and raises a patient's fee and then rationalizes the greed by deciding that by paying more, it'll benefit the patient's self-esteem (McWilliams, 2011, p. 134).
Puder:
Yes. The patient will feel better about themselves.
Goldin:
I think that was great.
Puder:
Go ahead, Katia.
Ronay:
Well, Dina, I was also thinking about how I'm going to be talking about moralization, and it's a really specific kind of rationalization. You touched on some of the issues where it could be a sort of a moral issue. Like, “Oh, well, actually this is going to be good for the patient.” Right? When actually, you just want to raise your fee.
Goldin:
Right? Or like if you're morally corrupt, you then would rationalize….
Puder:
Why don't, because there's so similar, Katia, why don't you go through moralization now?
Moralization (59:50)
Presented by Katia Ronay, MD
Ronay:
Sure. I'd be happy to. We've warmed up and it really is a very specific type of rationalization. So there's quite a lot of overlap. It really, the point of it, well, like a lot of unconscious processes are to protect from painful feelings like shame of behaving in a way that's hurtful or selfish. And to maintain a narrative that one is not a villain (McWilliams, 2011, pp. 134–135). So a benign example would be similar to what Dina was saying, you know, like “I will eat my roommate’s leftover birthday cake,” and I'm like, “Oh, it's for his own good. He's on a diet, he didn't really want to eat it. It's for his own good.” So, you know, this sort of relieves a little mild guilt. It justifies a little misconduct, but it's all fine. But then there's really much more traumatizing ways of using this moralization defense.
Ronay:
And so jumping straight from the benign, a little funny, to a really typical example of justifying sexual assault. And so from a perpetrator's perspective the unconscious moralization would be the stance, it would be something like saying, “Well, this is socially acceptable.” So for instance, a man feels entitled to claim that a behavior, a sexual assault, is normal or ordinary or understandable. Because, for example, “I paid for the date. We went out for dinner. Of course I'm entitled to have sex.” Or, the shifting blame to the victim. That's another type of way of saying, of moralizing, one's behavior and saying, “Well, she clearly invited it. She participated. She actually wanted it. It's for her own good. I mean, she was wearing what she was, you know, provocative clothes.”
Ronay:
“I just did what she wanted.” Almost like justifying himself. And I'm using “himself”, because that's usually what happens. Justifying that it's almost a favor. Another type of moralization is to say, “Well, I did not have a malignant intent.” And so saying, “Well, things got carried away, but I didn't mean to hurt her. You know, I thought she was into it.” The other really big one is a moralization by saying, “Well, everybody does it.” Right? A groupthink type of mentality. And so for a pedophile to say, “Well, it's normal for grown men to like younger women or even underage girls.” And so to justify that, or horribly in wartime sexual assault, it's, you know, that type of behavior is so pervasive that it can be explained the way.
Ronay:
So the treatment for that type of moralization behavior, whether it's more benign, you can kind of let it go and have a laugh. But if it's more severe, you have to really try to get to the shame and to address some of these ways of splitting off. Well, a lot of emotion, but also the splitting of good and bad, which is a part of moralization. And to really shine a light on the shame and then ideally to understand and accept it so that amends can be made.
Puder:
Yes. I was thinking about the pedophilia one. We did an episode on this with Cummings a while back [see episode 93], another episode with some forensic guys. Some of the beliefs that they have are like, “Oh, you know, the kids enjoy sex. Kids are sexual creatures. It's a form, you know, kids want to connect through sex.” And it's like these cognitive lies, these moralization lies allow them to maybe exculpate their own guilt. Right? And so, it's like, no, that is not reality. That is a lie. And your guilt is actually teaching you something about your values and that you don't really value doing that. And so the guilt is underneath, the guilt is sometimes hidden, and sometimes they, you know, people turn to alcohol or drugs or heavy benzo use or heavy sleeping medications to deal with the guilt so that they can cope with the guilt. And it doesn't really quite ever leave them, so they have to numb it somehow. So something I've been thinking about, it's quite possible that…. Anyways, I could go on, but, moralization…. Any of you guys, anyone else have any thoughts come through your mind as Katia wonderfully goes through moralization?
Mallo:
I don't think this really adds to the discussion much, but I just think of the moral with physically abusing kids. One thing I've come across, heard of, is people defending it by saying, “Oh, I'm teaching this kid how to fight for themselves and to be stronger. It's building their strength.” You know?
Puder:
Yes, there's no data to support that, unfortunately, for that person that's lying to themselves with that moralization. Or, they'll use some spiritual verses to support their actions or whatnot, but they're cherry picking, you know, whatever spiritual discipline that they're going through. So yeah, I've had debates with people who believe it's the best parenting method to spank your kids. And you know, I've debated them and said the data doesn't really show that that's not actually the best way of doing it. You know, like corporal punishment doesn't really work.
Goldin:
Or sometimes they'll use it, they'll shame somebody. Right? They'll shame someone and then let's just say what they're eating or something like, “Oh, I'm doing it because I'm helping them with eating healthy.” If something comes out and it doesn't go well, and then they'll….
Puder:
Yes. No, actually studies show if you shame an alcoholic, they drink more alcohol, they don't drink less alcohol. Right? If you shame someone, shame doesn't move people towards mental health.
Goldin:
No, but I'm saying the person that would do that, that they can use moralization….
Melnik:
To justify what they just did.
Puder:
Absolutely. Yes. No, I'm agreeing with you. I'm agreeing with you. I know you're not validating that method.
Melnik:
Yes.
Puder:
When I was reading about motivational interviewing I read that they did this study about shame-based alcohol reduction. It actually drove people to further drink. And yeah, it doesn't work.
Melnik:
No.
Puder:
It's like if you're depressed, I could shame you out of your depression. No, that's not going to work. That's actually going to push someone further into the depression, probably. So moralization, that's good. Okay, let's see.
Undoing (01:07:25)
Presented by Natalie Dreyfoos, DNP, ARNP
Puder:
Natalie Dreyfoos. Can you tell us about undoing?
Dreyfoos:
Yes. So undoing is a defense mechanism where a person performs behaviors or mental acts, and symbolically negates, reverses, or undoes a previous thought, feeling, or action that led to some affect. Usually this is anxiety, guilt, or shame (Di Giuseppe & Perry, 2021; McWilliams, 2011; Perry, 2014). Undoing primarily affects observable behavior rather than internal perceptions. Making it distinct from something like reaction formation (McWilliams, 2011). In that, undoing is performing an external action after the fact to magically erase what happened, trying to cancel out this feeling versus reaction formation, which tends to transform feelings internally, trying to mask the feeling (Di Giuseppe & Perry, 2021; Offer et al., 2000). So, I like this example, because it's just really simply put, when we think about undoing, it can be thinking about trying to unsend a text message, except the person believes that if they perform the right ritual, they can take back not just the message, but the thought or feeling behind it. And, undoing exists on a spectrum. So it is a normal human experience, but it can be problematic when it becomes rigid, time consuming, or causes distress (Di Giuseppe & Perry, 2021; Perry, 2014). And we see it, and it's most clinically relevant in things like obsessive compulsive disorder and borderline personality disorder (Abramowitz et al., 2009; Hirschtritt et al., 2017; Kang et al., 2012; Mendez-Miller et al., 2022; Zanarini et al., 2009). Treatment like psychotherapy can help develop more flexible adaptive ways of managing anxiety (Babl et al., 2019; Perry & Bond, 2012; Zhang & Guo, 2017). And the goal in treatment isn't to eliminate the defense because again, this is a normal human experience, but rather shift it towards more mature ones like suppression or humor (Babl et al., 2019; Di Giuseppe & Perry, 2021; Leigh & Reiser, 1982; Perry & Bond, 2012; Porto Tabeleão et al., 2024; Wang et al., 2022).
Puder:
Great. So reverse, cancel out, neutralize a disturbing thought, impulse, feeling, or action that causes guilt, anxiety, or shame. Does anyone have an example that comes to their mind of this in BPD?
Kuznetsova:
I had an example. I thought it was Nancy McWilliams’ book, or maybe somewhere else, the husband sort of cheating on his wife or flirting with someone, coming home and showering her with love and care. Yeah. Is that?
Puder:
Okay. Yes. So maybe it could be a lot simpler. It could be that they have some attraction to some other person. Right? That feels overwhelming. And then they come home and to undo it, they cancel it out, to reverse it, to neutralize it. They do this kind of behavior towards their wife, maybe bring her flowers,
Kuznetsova:
Right.
Puder:
Or some ritual.
Dreyfoos
That's right. Yep. Olga, it was like this: they had the conflict the night before, and then the husband, the spouse was coming back and giving them, giving the wife flowers, trying to undo this conflict or feeling guilty for having this big altercation.
Kuznetsova:
Yes.
Puder:
So, okay. Like, how about in OCD?
Dreyfoos:
So OCD is doing the actual compulsion. So it's that compulsion, the risk ritualistic behavior that temporarily relieves obsessional anxiety (Abramowitz et al., 2009; Hirschtritt et al., 2017). And so thinking about OCD, there can be like a 45-year-old accountant who has fear of contamination (is a common one) (Abramowitz et al., 2009). But after touching a doorknob, the patient washes his hands in a specific sequence. So he will apply soap three times while water temperature adjusts to lukewarm. He rubs his hands together for 30 seconds and then dries his hands with exactly four paper towels. Now, if any of these steps feel wrong, the entire sequence must be repeated. So it's unrelated to the actual hygiene of washing his hands. The washing ritual is undoing the fear of contamination and that anxiety around contamination (Abramowitz et al., 2009; Di Giuseppe & Perry, 2021; Hirschtritt et al., 2017).
Puder:
So someone with a pure OCD, primarily obsessional, may feel the need to mentally or behaviorally reset their day after they've had some sort of bad thought that's contaminated it. So they may do this by repeating prayers, mentally racing the thought, starting routines from the beginning to achieve a clean state. So that's another example.
Dreyfoos:
And that would be also considered undoing, right? Because it's not just because it's not externally a behavior, right?
Puder:
Yes.
Dreyfoos:
Okay.
Puder:
I think so, okay. Undoing the behavior. Maybe the behavior in that case would be the prayer, the ritual.
Dreyfoos:
The mental..
Puder:
Mental ritual, right?
Displacement (01:12:09)
Presented by Jason Kent, M.A., LPC
Puder:
Okay. Jason Kent, let's talk about displacement.
Kent:
Right. So displacement's the defense in which a feeling of impulse drive or behavior is redirected from its original target to a safer or less threatening substitute (McWilliams, 2011, pp. 139). So it's kind of unconsciously saying, “I can't direct this feeling here, so I'm going to direct it there.” And why do we do that? Why? Directing the emotion towards the original target would produce anxiety or fear, potentially of retaliation or abandonment. Maybe you might have anger towards a parent, but it might not feel safe. Or guilt for being angry at someone you love. Or perhaps some helplessness. So a classic example, which Nancy [McWilliams] puts in there too, is the individual has a bad day at work. He's yelled at by his boss, goes home and yells at his spouse, who in turns, scolds the kids, who kick the dog, and the dog takes it out on a toy (McWilliams, 2011, pp. 139). Just constant displacement down the line. But maybe a more appropriate example for therapy: you know, maybe someone's processing or experiencing a great deal of grief, but they've targeted the hospital, or the doctor, or the healthcare system. Nancy points out when there's been infidelity in a relationship, the betrayed partner will direct the anger at the other person instead of the unfaithful partner (McWilliams, 2011, pp. 139).
Puder:
I've seen that. Yes.
Kent:
Yes. And then, the family, she mentions the bow in family systems, the idea of the triangulation. So maybe the tension between parents gets just shifted to the third child. Which, of course, happens quite a bit. And then there's the sexual displacement or sometimes the fetish of a fixation on feet is a redirected erotic interest from the genitals, that might have evoked anxiety, from historical fears of castration, maybe made that part of their body fearful (McWilliams, 2011, pp. 139-140).
Puder:
Interesting.
Mallo:
Doesn’t scapegoating apply here? I could see how it would with the way you're describing it, Jason. That when people are unhappy with whatever life circumstances, pick out the faulty party and blame them. I can think, on an individual level, or even on a societal level, that when individuals or groups are dissatisfied with something, they look to find fault and assign blame, but place it on perhaps the wrong source.
Kent:
Right. It's a very safe target. Right? It's not, you don't have to, there's no consequences there.
Puder:
I think that would fit because you're displacing a feeling and impulse drive or behavior from the original target to a safer or less threatening substitute. Right? So the scapegoat is the goat. The goat takes the blame rather than the person for their wrongdoing. Right? So yeah, I think that would work.
Kent:
It could, it can show up too, in a session where maybe a client's actually kind of angry with you, but they're not sharing that, they're pointing out their anger at all these other people.
Puder:
Or they could be displacing their anger from other people onto you as well.
Kent:
Right, right, right. Probably more common.
Puder:
Yes. So maybe you deserved 3% of the anger, but you got 100% directed at you.
Kent:
Good opportunity for noticing the transference.
Puder:
Yes. Yes. I've seen it from the boss example. Like a guy gets, you know, gets beat up by his boss, comes home, and just tears into his wife; and just really, really nasty displacement. Just awful. So obviously very maladaptive in that context and in that sense. Okay. What about reaction formation? Chris? Talk to us about reaction formation.
Reaction Formation (01:16:20)
Presented by Chris DiDonna, M.A., LMHC
DiDonna:
Yes. Well, reaction formation is when someone is dealing with an emotion unconsciously that might feel threatening to their self-image or to an important relationship, and they turn it into the opposite feeling (McWilliams, 2011, p. 140). Probably, a classic example would be someone harboring a lot of anger and resentment towards a coworker. Right? Kind of undealt with, disavowed, underneath the surface, but on the surface it looks extremely kind, like overly accommodating. So almost to the point where it feels fake. I was even thinking about a recent client that I had. When they first came in, they were describing their marriage. And it almost seemed too good to be true. Right? It's like everything they said about their spouse was, everything was perfect. Right? And so it put me in a weird position where I'm thinking, “This doesn't seem, something doesn't feel right here.”
DiDonna:
So this is the classic alarm that reaction formation is present, when things just feel too good to be true. Sure enough, after about a month or two, this person starts to uncover some deep resentment, and anger, and rage they had towards their spouse; and so much so that they felt like they wanted a divorce. So three months difference. It started with, “This person's perfect,.” They could do no wrong. Three months later, it's, “I wanna divorce this person.” Because, for the first time, they're uncovering all of this anger that had been sitting under the surface. Right? So their reaction formation was from idealization. So they were hiding the anger with idealization.
Puder:
Yes. Yes. And when it comes out, it can come out swinging the other direction sometimes. Right? Where it can go from 100% love to 100% hate.
DiDonna:
Yes. Yes. And the way of thinking about the way to actually work with someone who is displaying reaction formation is to just give them space. So I didn't really have to do much with that client. It was just giving them the space to really open up and figure out what might be underneath the idealization. Right? I didn't tell them, “You have the defensive reaction formation.” I noticed it, but kind of let them wrestle with it a bit and kind of guided the sessions to the point where it became clear they didn't feel like they could hold this, these good feelings they had towards their spouse with the angry feelings they had towards their spouse. So they had to just hang out in the idealization area.
Puder:
I think, also, it could be a momentary thing. So maybe a more normal neurooriented person would have some anger towards their spouse, and instead of being angry, they would go clean the dishes. Right? They would go clean. It's a loving thing to do, potentially. And they're doing it in the midst of anger, which is kind of counterintuitive, but that's a reaction formation, as well. Yes. Any of those simple ones that you guys think of? When do you think of reaction formation?
Dreyfoos:
Somebody, I always think of, is like the little kid who's super jealous of their sibling and really wants to shove them, but instead goes to hug them. Right? Because it's unacceptable to shove your little brother or sister.
Puder:
But sometimes it's not the nicest hug either. Or sometimes it's like too much hug.
Dreyfoos:
Too much hug.
Puder:
You know? It's like the hug that never ends. Olga, what was your thought?
Kuznetsova:
Someone who's attracted to the same sex, it's like this classic example and then kind of repressing, their own homosexuality, basically. And so that, in a way, that they oppose it and sort of maybe join some kind of anti-homosexual movement, or stuff like that; and kind of very vocal about not supporting it, but deep down they're actually attracted to the same sex. So I was thinking that that was reaction formation too, like in a very extreme form, I guess.
Puder:
Oh, I think about, there's been some public cases of pastors who yell vehemently against homosexuality. Right? And then, it's like that is the reaction formation against the desire. Right? That is, the further unconscious these things are, the more dangerous they are. Right? So, if someone is very unconscious of it then, and they're acting out it with very low insight, that's when they can then impulsively go the other direction in a way that could blow up their life, rather than it just be like holding a fantasy and then holding the fantasy of both sides, because that person is acting upon it in a way that's very destructive sometimes. If that makes sense.
DiDonna:
Yes. Instead of just allowing a feeling to be present, it's like you can't handle that. Right? So you have to keep it out of your awareness and allow the opposite to take precedent, like you're saying. So like homophobia, versus saying, “I have an attraction to the same sex.” It's like, you can't admit that. So it turns into homophobic tendencies.
Kuznetsova:
It's like you are undoing it in a way. You know? So like an extreme way of undoing it.
Puder:
Maybe the undoing would be going on X and posting a mean, hateful tweet. To show how much you don't align with this issue.
Dreyfoos:
It was interesting, because when I was looking at undoing and then reaction formation, the distinctions between them, I was reading up on, and I forget where, but there was a school of thought of some individuals, or some providers, think that reaction formation is the first coping mechanism or secondary or first defense. And then, when that fails, undoing can become the one that they rely on. And I think, we're going to just be distinct that this is like unconscious. Right? Because if you know that you're putting something out there that is harmful to a person or a group of people, then you know it’s no longer this defense. Right? Once it's a conscious action, you can't just be like, “Oh, I'm self-hating, or I'm just about this part of myself.” Because now you're conscious. You don't get to fall back on defense is your reasoning. Like once you know it, you know it.
DiDonna:
Yes. Reaction formation is unconscious. Like you said. So yeah, I don't know. What do you guys think? Would it make sense then? If you know you have attraction to the same sex, could that be….
Dreyfoos:
No. Because once you know, and you're doing, if you're conscious, I don't think it counts as a defense. You can still be hateful towards yourself or others, but there is no hiding in the idea that it is unconscious.
Puder:
Well, maybe you don't hate that part of yourself. Right?
Dreyfoos:
But if you're now just bullying other people or punishing other people for how you feel about yourself and you know….
Puder:
This, then, is acting upon with hatefulness. Yes. I agree. Yes. Okay. Let's keep going. Identification, Amanda?
Identification (01:24:27)
Presented by Amanda Sekijima, MD
Sekijima:
Yes. I was actually going to, one of my examples for identification, I'm actually going to tack on to Chris's reaction formation because of Stockholm syndrome; and I'll get more into the identification with the aggressor. But I was thinking, is that a form of reaction formation?
Puder:
Stockholm syndrome's complex. I mean, I imagine there's a lot of defenses at play there. There's denial, right?
Sekijima:
True.
Puder:
It is kind of a more psychotically-oriented reaction formation. There's a lot going on there, right? It's complex behavior. So Stockholm syndrome is if someone was abused and then goes back to the abuser. Right? And so, sometimes I've heard this happen, and then the person feels a lot of guilt, maybe, “Why did I do that? I don't understand why I did that.” So they're unconsciously driven sometimes back to the abuser. And so it's like, why, why were they driven back to the abuser? And in that way, maybe the hatred towards the abuser turns into love. Right? That would be the reaction formation. But I think that there's a lot of other primitive things there, too. Dissociation. They could dissociate the bad out, the bad memory's out.
Puder:
They could deny the bad memories. They could remember only the positive. If there was positive. There could be, so there could be an idealization. Like an abusive, sadistic person demands a level of idealization, or the person is very much abused. And so there could be a forced, kind of programmed idealization of the abuser. There could also be fear of death. Fear of “something bad is going to happen if I don't.” Right? So there could be, sometimes abusive people who, in a way, program people to believe that bad things will happen if they ever say anything, or if they ever leave the person. Or, there's also going to the most feared object. The most feared object is the object to be worshiped in some people's psychology. So if they feel that the abuser is the most powerful person in the world, it's a belief. Right? It becomes a belief out of the trauma. Then they could want to join the abuser until they wake up to that not being reality, not being the case, not being healthy. You know, it's so toxic for them that they are psychologically falling apart.
Sekijima:
Yes. I'm thinking of that case. What was the…? I can't recall it right now. The case, years ago, with the young girl that was kidnapped by the two, it was like a couple. I can't, I'm blanking on her name.
Puder:
Even in the Epstein files. I've heard of this happening in the Epstein files. And so this is where it gets really convoluted. Is this person someone who was abused, or is this a person who was helping Epstein hurt other people? Are they helping Epstein abuse other people consciously? Or is it because they were in a kind of trauma state where they were fearing for their life? You know? So this is that complexity. Jason, you were nodding your head.
Mallo:
Well, I was wondering if you might be referring to, I think it's Smart.
Sekijima:
Yes. Yes. Yes.
Mallo:
Natalie [sic; Elizabeth] Smart; and a documentary was released [Kidnapped: Elizabeth Smart]. It's streaming somewhere right now, recently released.
Mallo:
One thing that was fascinating about it was they interviewed her a bunch, and she's on the presenting circuit. But anyway, I didn't get the impression that Stockholm syndrome actually applied to her, but she was at risk of that happening. And it's almost like a compartmentalization sort of thing happened, and [as a young girl] this woman survived disappearing for a couple of months with two abusers, who took her from her home. And she was found. Her identity didn't seem to be super rattled. And my hunch is she got a bunch of good psychotherapy.
Sekijima:
What were her feelings towards her kidnappers? I'm actually really curious. I'm going to look that up after this.
Mallo:
Yeah, you gotta stream it. It's all in there.
Sekijima:
Okay.
Mallo:
But it reminds me of turning against the self a little bit too.
Sekijima:
Yes.
Mallo:
Like this, it is such a complex thing. I appreciate it. Where too, if you can't beat the aggressors, a possible outcome could be, you beat up on yourself instead; and you just become defeated.
Sekijima:
Yes. So many of the defenses are just so intertwined. It's so complex. But anyways, we kind of went deep into some aspects of identification, but in the most simplest terms, identification is the ability to identify with another person or aspects, traits of another person. And like any other defense, it's an inherently neutral process. And it can have positive or negative effects depending on who is the object of identification (McWilliams, 2011, p. 143–144). So I think, in mainstream language, you know, we say, “I identify with this person that's a mentor.” That's usually in a positive light. But psychoanalytically, we usually think of identification that's more motivated by the need to avoid anxiety, grief, shame, any of the painful effects in order to restore that sort of threatened sense of self and promote self cohesion and self-esteem (McWilliams, 2011, p. 144).
Sekijima:
And in Nancy Williams' book, she talks about how Freud, he was the first one that defined a non-defensive versus a defensive identification (McWilliams, 2011, p. 144). So the positive and the negative. I'll go into the negative, we kind of did a sneak peek with the Stockholm syndrome. But basically, there's elements of both, like a straightforward taking in what is loved, like you identify with your parents, your primary attachment figures initially. And, it's very simple. Like, “I want to be like Mom or Dad,” and you want to achieve closeness. And then a more defensive, operationalization of that would be kind of what Dr. Puder was saying, “I become the feared object. If I become them, their power will be inside me rather than outside me.”
Sekijima:
And so, I possess that. Since I'm a child psychiatrist fellow, I'm always thinking developmentally. So I kind of think of identification, I'll explain it chronologically through the lifespan. So, like I was saying, first identification is when you're a child with your primary attachment figures and you kind of become like this hybrid person kind of taking little bits of people that you like, mentors throughout your life. And so it becomes kind of like a nuanced mosaic person that you become, is how I think about it. And it positively, if you think about it, it's the basis of empathy. Being able to identify with others. And Nancy McWilliams gives the excellent, the biggest example of therapy. So the propensity of the patient to identify with the therapist is the magic secret sauce in therapy (McWilliams, 2011, p. 146).
Sekijima:
And having that reparative relationship with the therapist. So those are the positive examples. I'll go into the kind of Stockholm syndrome we were talking about. So that is what Anna Freud first described as identification with the aggressor. And I never understood that term until this class, I had heard it, and then it finally stuck. So that's kind of the defensive identification where you identify with the bully, the aggressor. You consume them, you become them, you take it inside, you internalize that representation of them, become them. And so, an example is child abuse. A parent abuses a kid, the kid goes and bullies kids at school, and then grows up and then abuses their kids subsequently. So it's the mechanism of which, like intergenerational abuse, continues.
Puder:
Which I'm actually doing an episode on, kids that were sexually abused and the rates of future sexual abuse. And it's actually, it can be as low as like 3% in some studies. So, you know, this could also be, abuse could also be stemming more from other personality pathology that's unrelated. Like sadism and psychopathy, and, you know, stuff like that.
Sekijima:
They were talking about psychopathy, how, I read somewhere, where it's like a failure of identification or you don't identify with the values of society and then you….
Puder:
That's a trait of psychopathic personality. Right? They're the people they maybe look up to are the least savory people.
Sekijima:
Yes.
Puder:
But identification with the aggressor, I'm so glad that you figured that one out.
Puder:
Very, very helpful.
Puder:
Adopt and imitate. Internalize aspects of the aggressor, internalize, adopt parts of them, like the bad things that they're doing. They see themselves. It's either doing the bad things in fantasies of their mind, or in actuality. Right? Or like, “I am the abusive person.“
Ronay:
You see it a lot in therapy with somebody who's maybe grown up in a very critical environment, and the person goes and really internalized that aggression. And then, what you see in practice is somebody who's always feeling guilty about anything and always kind of really hard on themselves, criticizing themselves. And, I'm thinking a lot of times it's a real identification of the aggressor. They've really sort of internalized that critical voice, and they're constantly putting themselves down, making themselves pay.
Puder:
That's, yes. Amazing. Yes. Very good.
Ronay:
Thanks.
Sekijima:
Yes. Because it was adaptive when they were younger or necessary for them to survive.
Ronay:
Totally adaptive. Yes. And it's actually adaptive even as adults. Right? Because people who are following the rules and doing everything right are generally widely beloved. Right? But they suffer internally.
Sekijima:
Good point.
Puder:
See this, sometimes, I've read some stories of true crime, you'll get someone who's doing a lot of criminal activity at a very young age: 17, 18, 19, and their dad was a con artist. So they were watching their dad do this their whole childhood. Right? They're sort of absorbing that. They identify with it. They go on in the criminal sort of behavior, criminal acts. You could see it in cults. I think, Amanda, are you going to talk about that at all?
Sekijima:
Yes. Cults. So that's a big example that Nancy McWilliams adds. I spoke about how this defense is used to build that self cohesion, that ego identity. And so people that are more easily influenced by others or have some identity confusion are more prone to joining cults. And going back to kids, from an Ericksonian perspective, that time when they're adolescents is when they're developing their identities and their ego identity. And so adolescents are really impressionable in that regard (McWilliams, 2011, p. 145–146; Parkin, 1983; Strandholm et al., 2016).
Puder:
Yes. It is. Like people with the identity diffusion, they're almost like stem cells: if they're put in a good environment they may adopt a lot of that good, but if they're put in with some very abusive person they could become a counterpart of that abusiveness. And so, it's really…. What makes me think of it…
Puder:
In pop culture, you hear some very narcissistic, grandiose personas online. It'll be like, “Oh, yeah, I like to date girls when they're super young and blah, blah, blah.” Right? Like, they'll say, “So I can mold them how I want them to be,” and they have a track record of a wake of destruction behind them interpersonally. Right? So it's cringe for me because I'm like, “Yeah. And then I'm going to be this therapist trying to put these people back together.” Or training therapists that are putting these people back together. So yeah, the identification is dangerous. Right? When you're young, when you're impressionable. And I think talking about it, putting it out there, developing a knowledge of it gives us power. Right? Think twice when we think about who we want to consume, who we want to kind of allow into our brainwaves. Right?
Sekijima:
One thing I wanted to ask everyone is the difference between introjection versus identification. I couldn't, Nancy [McWilliams] mentions it in the book, but I can't figure out the nuanced difference. I think she described introjection as like the precursor to identification, but it sounded similar to me, like introjecting, like taking internal representations of others when you're younger, kind of consuming that (McWilliams, 2011, p. 112). So are they interchangeable? No idea. Is it a matter of degree? I have no idea. I went down a rabbit hole on the internet. I could not find it or a good satisfying explanation for it.
Puder:
So, the way that I see it is that introjection is a much more primitive version in which you swallow whole all of the things of the other person, their ideas, attitudes, judgments, standards, values, all of them. You treat it as if it's your own reality, your own voice, your own values (Parkin, 1983).
Puder:
I think the identification, you adopt portions. Right? Becoming like, like I have a lot of identification with Dr. Tar. I differed in some things. Right? If I was maybe more primitively oriented, I would introject and I would almost sound like Dr. Tar in all of my answers. Instead, I take in little pieces from different mentors throughout my life. Right? I introject and there’s identification. I have identification with various mentors, and that's a good thing. Some mentors I know in person, some I don't know in person.
DiDonna:
That's a really good example of what it looks like from a healthy perspective and from an unhealthy, dysfunctional perspective. It's like when people become almost the other person, like you said, like their tone of voice, everything. That's the defense.
Puder:
Also, I think introjection, you end up with a lot of these “shoulds.” Right? And it's like a super ego structure. So for example, if you had a strong introjection of Jonathan Shedler, anytime you broke the frame, you would be crippled with guilt for days. Right? Because you've gone against your favorite introjection guru. Whereas, the good side would be to adopt a lot of the good and to appreciate the good from different people and different styles. Right? So when I would watch videos of residents, I never expected them to have the same verbiage, the same style as me. I wanted them to have empathy. I wanted them to have, you know, but for different people, that looks differently.
Kuznetsova:
For some reason, it came to my mind, I don't know if you know Josh Shapiro, who's the governor of Pennsylvania, who sounds and acts just like Obama. Oh, he's literally the same. Phrases just like Obama, so definitely kind of introjecting a lot of Obama.
Puder:
And then sometimes I think to myself,
Puder:
What's going on with America? And I pause, like this, every couple seconds. And if you do that, you know how to capture someone's attention, you string words together just the right way. We're not blue states or red states. We're the United States.
Kuznetsova:
Really good. That's good.
Puder:
I haven't practiced that, so I'll practice it.
Kuznetsova:
That's impressive.
Puder:
Let’s do a role play. I'll be Obama. You be a therapist who's pretending to be… Okay. Yeah. It's hard to know does guy just love Obama? And he listens to Obama on repeat, hundreds and hundreds of hours.
Dreyfoos:
Yeah. We'll probably start to sound like you eventually, like we've heard hundreds of hours with David Puder.
Puder:
No, no, no, no, no. Because you're not, you have some identification. You don't have the full introjection.
Dreyfoos:
Okay.
Puder:
I have some therapy clients who I've seen like twice a week for years and years and years. Some of them are therapists and they've pulled in a lot of the good, but they have their own style. You know, they have their own life trajectory experiences. They have their own populations they like working with. And that's, that's great.
Dreyfoos:
That is great.
Sublimation (01:44:34)
Presented by Littal Melnik, MD
Puder:
Sublimation. Littal.
Melnik:
Okay. I actually want to take a pause because we're doing mature defenses, and I want to recognize that these are, these drives, these negative self states that we can see without any distortion. So we're working on them or trying to work through them, but we are doing it clearly. So different from some of the examples, we can be totally aware with mature defenses, and sublimation falls into that category of consciousness. And so, now that I'm fully mature, I want to start with an illustration of a guy we all think of as really well put together. And I wanted to just start with Batman. For those of you who don't know who Batman is, he's a superhero without any superpowers living in the city of Gotham, which is in comic book land. And he has a really traumatic childhood where he witnessed his parents being murdered.
Melnik:
And right there, we feel his helplessness, he feels helplessness, lack of control as that develops, you can imagine rage building within this guy. We can imagine a desire for vengeance totally brewing with that kind of loss and that kind of circumstance. And rather than identifying with the aggressor, or totally falling apart with this loss, he's able to sublimate it. He's able to take it and focus it into something that is ultimately considered to be prosocial, and that is taking out bad guys. So the lack of control, he is so regimented about these workouts. If you ever see a Batman movie, this guy's working out, no matter who's adaptation, he is all about the science, has to have the best tools, the best weapons, costumes, whatever it is. He wants to make sure he is not going to let this happen again.
Melnik:
And that rage also comes out, we see him throwing guys through brick walls. We see him destroying lots of Gotham City. But the motivation behind it is to try to make the city better and life safer for people. That is the sublimation aspect of it. And that really connects to what Freud saw about this defense, is that it can actually bring civilization forward, not just the individual forward . So it's not unique to that man to feel rage, to feel that the world around you needs to be put in order. And Freud credits sublimation with a lot of government, with religion. Like these are ways that people have taken these similar feelings and not just moved themselves, but moved everyone around them forward (McWilliams, 2011, p. 147). And I want to go back. I picked Batman because we can see him in a black and white world. In his representation, none of these bad guys have their own trauma history. They are all just bad guys. No one had absent parents. No one is hungry and doing crime for that reason. We can just see it as moving society forward. We don't have to see it complex. That was my example thinking [why I chose that example].
Melnik:
And so we are transforming, potentially very harmful, potentially very devastating drives into something that is progressive.
Puder:
Yes. Like dancing, sexual tension. Right? In a young person it becomes dancing, something like that,
Melnik:
Right. And I think the classic examples are always you have this desire to hurt and you become a surgeon or a dentist. Like, that's usually what we see in the board review books. We see that come up a lot. Right?
Puder:
It's kind of dark. Not everyone who wants to become a surgeon does that.
Dreyfoos:
Not everyone. No.
Puder:
But I love your example of Bruce Wayne and Batman. That's such a good example. That's such a good example of turning that anger into, “I'm going to make the world a better place. I'm going to fight for justice.” Yeah, it's good.
Kuznetsova:
But that's connected too, because his parents, I didn't know that part, by the way, that they died from the criminals. Right? So he's kind of trying to undo that a little bit.
Dreyfoos:
In a way. Yes. There was some undoing in there. There's a ton of defenses and…
Puder:
Yes. Okay.
Houghtelling:
But, I think of some groups, like there's this support group of mothers who have lost kids to overdose with drugs, and then they unite to develop a support group for other parents who lose their kids. That feels like a really good example of sublimation, too, of taking that grief, and loss, and anger and then turning it into something that can help derive support and healing for other people.
Puder:
That's wonderful. Or like someone who's had a bad childhood and knows what it's like to suffer as a child will go on and become a child psychiatrist to try to help other people, or that become a researcher to solve, you know, maybe their mother died of cancer. They'll go become a researcher and spend their life trying to solve that specific type of cancer. These are, the world is a better place for this. And actually, sometimes with patients, I'll kind of try to encourage a good sublimation. Viktor Frankl wouldn't see it fully as a defense. He would see it as actually like the path of meaning and meaningfulness.
Dreyfoos:
It seems like it ties into reflective function. Right? Like, why are we doing what we're doing?
Puder:
I think most, yes, a lot of us told our stories of why we're doing what we're doing. And a lot of it had to do with a good reason. Right? A sublimation of sorts.
Dreyfoos:
So if we're doing well, we can identify this in ourselves in some way. Okay.
Puder:
Yes. Absolutely. And also humor. Right? Tell us about humor.
Dreyfoos:
So tempted to come on here with a Batman mask, but I just didn't.
Puder:
That's awesome.
Houghtelling:
Disappointed. That would've been humorous.
Dreyfoos:
Because if you could pull it off, you know….
Puder:
I've just gotten into… I just bought some Batman comic books. Like, it was just like omnibuses. I never knew you could go back and research different decades, and then they package them all together. It's amazing. Wow.
Melnik:
So, right. I think humor is more Spider-Man though. And that's both in crime fighting and talking to girls. If we remember Spider-Man, he's always nervously telling a joke, and it's to lessen the tension. It's not to avoid it, but it is so he can move forward. Right? Going back to that superhero. But there's this movie called The Avengers, where he meets all the other superheroes, and he's this high school kid, brand new to his powers, and he just doesn't have that experience. And so it is, they're all introducing themselves; and he said, “Oh, we're using our made up names? I'm Spider-Man, right?” So he just tells a joke to lessen his nervousness and his anxiety, but he can do it. Right? He can still stand up with all these bigger guys and show up.
Melnik:
So yeah, humor lessens the feeling and allows us to move forward. I actually wanted to give a personal example as opposed to a patient example. I was recently at a memorial for a friend who passed and it was just, I couldn't even imagine starting to speak. I was frozen, just overwhelmed with grief and sadness, and it was my turn. And I told a humorous story. This was a very straight-laced dude. And I shared about a moment where we jumped a fence in Costa Rica to explore some river, as a contrast to his very Batman, regimented style. And everyone laughed and it allowed me to have my walls come down and allowed me to actually face the stress and face the sadness that I was feeling.
Melnik:
And that was me using humor. And I think I heard this quote the other day, and I wrote it down so I didn't get it wrong. I don't know if you guys have heard of Victor Borge, he was a composer, but his line is, “Laughter is the closest line between two people.” And I think that reflects, in that moment, that allowed me to transform the distance from anyone else in the room. And it also is a good line to myself. If I know I'm just cracking a joke in a setting, sometimes it is because of nervousness or sadness and allows me to come into it. So laughter's this great step into confronting or seeing other emotions and working through them and facing them. And if you want the board review example, it's somebody coming to their primary care doctor's office with erectile dysfunction and cracking a sex joke to break the ice. So I'm giving you the textbook example as well.
Puder:
Yes. So I love the idea that the only one who could speak truth to a king is the comic. Right? So you have this, the jester is the only truth teller of the king. Everyone else is a sycophant, and everyone else is telling the king exactly what the king wants to know. And then the jester comes up and says what everyone else is feeling or thinking. And then it's just like, it's funny. So it works. He can get away with it. Right? He can get away with saying things that no one else can say.
Dreyfoos:
It's like this truth telling that can happen to humor that even brings down the other person's guard. Right? Not only is his guard down, but everyone else’s in the room, and the person hearing it.
Puder:
And you think about how much humor is based on forbidden impulses wishes. Right? And it's kind of like that, or even sarcasm. Sarcasm can be like a sense of humor, but it can also carry a little bit of truth.
DiDonna:
I'm thinking about specific comedians. Two people that keep coming to mind are Chris Farley, I don't know if you're familiar. And I think about the self-deprecating, I mean, he was hilarious, but you think about it from this point of view, it's very maladaptive. But then I think about someone like Bill Burr. Do you know who that is?
Dreyfoos:
That, I don't know.
DiDonna:
He's more in like higher RF [reflective function]. He's in touch with his own humor and how he covers up things with his humor. And there's actually a different type of funny. I feel like that comes along with that, where it's less maladaptive. I don't know. Do you guys, are you guys familiar with Bill Burr at all? Or a comedian like him?
Kuznetsova:
Yeah, he's kind of straightforward and kind of rude.
Dreyfoos:
Yes. But he knows it.
DiDonna:
Yes. Yes. He's from Boston. He's got the Boston accent. Yes.
Kuznetsova:
I actually love him. I think he's great.
DiDonna:
I do, too.
Kent:
I was thinking of Conan O'Brien. He was on the podcast with Jason Bateman, and his parents had died. Both parents died like in the last year. And he just went and told this elaborate funny joke about how Bateman had killed his parents. And it was, you could just see that was his way of dealing with the uncomfortableness of that story.
DiDonna:
Yes. I heard that one. And yes, he and all his friends went along with it because they knew that he was dealing with it in this way.
Puder:
That's good.
Sekijima:
And he went with it.
Houghtelling:
I also think humor can be really useful in really stressful situations. I have a number of combat veteran friends who talk about when they were under fire. Humor, they would crack jokes and that helped them diffuse the stress and just stay focused on what they needed to do. Or when I used to work in ICU, sometimes situations would get really stressful, or tense, or sad, or whatever. You know, a few jokes really helped to kind of just lighten the mood so that you could carry on and do what you needed to do.
Sekijima:
And network with Spider-Man.
Houghtelling:
Yes. Yes.
Puder:
Yes. Sometimes therapists can have some dark humor; and I tend to try not to do any patient-directed humor on this podcast, or in real life. I don't think Chris has heard me do too much patient-directed humor, just because it's better just to get in touch with the real emotions underneath and process them. Rather, but yeah. So humor. Okay. And we got one more. Reversal.
Reversal (01:58:24)
Presented by Amanda Sekijima, MD
Sekijima:
Okay. so reversal is, it's a really interesting one. So basically what happens is,
Sekijima:
You transfer from a passive position into an active position. So from switching passive to active, like victim to victimizer, you basically shift the power aspects of a transaction with another object that you're interacting with in order to deal with that psychological threat in your situation. So the example I'm always going to give, the therapy example, since it's relevant for us therapists, but Nancy McWilliams gave the example of how therapists are uncomfortable, not all therapists, but a lot of therapists are uncomfortable with their own dependency needs. And they actually yearn to be cared for. And they vicariously are cared for through the care that they provide to their patients. And so they unconsciously identify with that person's gratification. So that's the more adaptive version. You know, altruism is a good, simple example (McWilliams, 2011, p. 142–143).
Sekijima:
The more maladaptive examples are like fraternity hazing or like any hazing, abusive rites of passage, like where you are switching from that passive position, getting hazed, and then when you're the upperclassmen being in the active transformation. But with that, or with that sole transformation the affect around it changes, it's a more positive thing. And I was actually thinking about that example. I was like, “Oh yeah, I remember getting hazed in sports when I was younger,” and it was the worst thing when you're going through it, but then the next year you're like, “Oh yeah, this is so awesome.” And I'm like, “Whoa, okay.” I haven't even thought about that until I had to do reversal for the podcast. But yeah, repressed memory unlocked, and so I understand reversal.
Puder:
What other, does anyone else have any other examples that come to their mind of reversal? Could it also be positive, like you're being taught and then you become the teacher. Right?
DiDonna:
I think you see it sometimes in sports where someone's extremely nervous, but they don't seem that way. They push through, they become overly confident, and sometimes I think, they actually might be better in that fearful state.
Sekijima:
Or kind of going back to sublimation, doing that positive switch, you know, from a more helpless position, a powerless position, to using that pain to go to a more powerful position. Like how you were giving the example, Dr. Puder, where people go into medicine because of that reason and what they experienced when they were younger.
Puder:
Yes. So maybe when they were a child, they were abused, they felt powerless. Now they're having a reversal where they are powerfully helping someone overcome it. So they're in a position of power in the therapy office helping someone through the trauma that they themselves got through. This is a really wonderful ripple effect of positivity. Right? It's like we need more of that. So I, yeah. That's where I kind of get into this is no longer a defense mechanism. It's not like there's something underneath it that's better. Right? It is good. Now, if they maybe were working 100 hours a week and couldn't stop, and crossing boundaries of patients, maybe that would be a place of necessary supervision or some direction outside of that, where they can live life and not feel in a compulsory position to always help. Right?
Ronay:
I don't know if this is another example of reversal, but I think of people who have survived food insecurity or an eating disorder who grow up to become a chef or a dietician and there's a therapist component, but there's also even the dependency for food that we, that of course you have and to reverse that hunger into literally feeding somebody else.
Puder:
Yes. Yes. Or you'll see someone who's very high in disgust, high in order, go into infectious disease and they're fighting off the disgust and the putridness of bacteria and viruses and, you know, they, infectious disease doctors, always have the longest, most detailed notes. Right? Which is part of orderliness. Yes. That's a good example. Katia,
Mallo:
I wonder if this might apply. It might be a stretch, but I saw someone present recently who is a fabulous speaker in front of others, and they spoke about their nervousness and anxiety with public speaking. And I'm thinking of performers who can experience, I imagine, a number do not, maybe not everybody, but a number, have a lot of anxiety and just psychological tension, and then you head out onto the stage and it's like an escape. Maybe there's some euphoria that comes with it, but I wonder if that could apply here?
Puder:
Yes. I think they're mastering that fear. Right? And they're switching from a place of weakness or fear into strength and success. And I think that can feel very gratifying. Yes. Great. Alright guys, I think that is where we will end.
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