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- [00:00]
A
Foreign. Good morning, Dr. Malsberg.
- [00:10]
B
Good morning. How's it going?
- [00:12]
A
Well, I'm not quite so sure.
- [00:18]
B
Tell me more.
- [00:20]
A
I don't know if I want to do that today.
- [00:24]
B
We don't have an opening prepped, and I don't. I don't know how to contain people.
- [00:30]
A
Oh. Oh, boy. I was hoping you'd follow my lead there. What would it be like if you could tell me? What would that be? What are you supposed to think or feel if you were telling me right now the way you were feeling, going meta. Yeah. We didn't have an open question.
- [00:45]
B
I didn't know which level. I didn't know which level to hit.
- [00:48]
A
Follow your instincts. They're always right. There are no wrong answers. Anyway, what's today's topic?
- [00:55]
B
I believe we're talking about therapeutic interventions. And I think it's therapeutic intervention slash, I think, kind of the technical aspects of psychodynamic therapy in particular.
- [01:09]
A
Yeah. Though I do hesitate somewhat to call it psychodynamic or psychoanalytic because there's just too much stigma these days. I would think that the best episode title is the Use of Psychotherapy Technique across Psychiatry, or something like that. That may be a little too academic. So psychotherapy technique in diagnosis and Treatment maybe is really what we're talking about today.
- [01:38]
B
I think it's the basics of psychodynamic technique. But I understand what you're saying because we've talked about how it's complicated with all these terms meaning different things and different and different stuff, but in my opinion, we're talking about psychodynamic technique.
- [01:50]
A
Yeah. So a little elevator pitch. You've probably heard this or you haven't heard it if you skipped previous episodes on a similar topic. But really, psychotherapy techniques, at least, even if you're not going to be doing a bonafide. Psychotherapy practice, in my opinion, are really central to the practice of psychiatry for good reason. Right. Psychiatry was fundamentally not about medications, which did not really exist for psychiatry until about the 60s. Psychiatry is about formulation and being able to give explanations to the patient that are adaptive. So if you don't know this stuff and you don't use it, you are probably being less effective than you should be. So I implore you, listener, to learn these techniques, have them in your mind vividly enough that you can sort of analyze what you're doing in sessions and in interviews and how you might change that. It's kind of like Monday morning quarterbacking yourself if you want to kind of improve iterate on your interviewing technique.
- [03:03]
B
And if you're not doing this to make you feel a little bit better. I'm trying to think how I want to word this. Doing this correctly is a lot about who you are as a person, more so than knowing your exact technique. And I bring that up because I do see people use psychodynamic and psychoanalytic concepts and abuse them in short bursts during psychiatric appointments. I saw recently, I think it was a discussion on Reddit. They were talking about a patient who was demanding medications or something. And then the person said that their response would be like, you must have a tough time with authority. Is there someone in your past who you've given a tough time to like this? And I feel like that to me is a, in some sense like a bastardization of psychodynamic techniques that is used incorrectly.
- [03:54]
A
Yeah, which is why I don't want to call this psychodynamic technique, because I think everyone's going to go straight to that, which is almost an interpretation or in some schools is an interpretation that you should never do until, in my opinion, until the patient is ready for it. You do not just trot that out. So my, you know, view is that if you really understand this stuff, it's going to be natural throughout your use. But to really understand it, you have to kind of think back on moments where you did anything in a interview to produce an outcome and, and ask, what was I doing there and why? You know, because that if you, if you kind of retrospectively look at moments like that just for learning purposes, you may notice times where you wish you had done something differently, and you may notice times where you are actually acting outside the treatment frame, that you're just doing something because you were personally curious or that you were afraid of a bad outcome. You know, it will make you better as a clinician, but I think that's enough, you know, intro. We should probably get into the meat of it.
- [05:00]
B
One. One last comment. I also found when I was novice, I would make things too explicit. I would try to explain everything I was doing. That's a. We'll get there. We'll get there. All right, why don't you start?
- [05:13]
A
That sounds important. Can you, can you say more about that?
- [05:16]
B
Yeah. So in residency we did, we had a long term psychodynamic case. And when I was anxious, I would feel pulled to explain what I was thinking or what I was doing rather than let the process unfold naturally because of the discomfort of sitting in silence or the discomfort slash awkwardness of the therapeutic relationship. I would feel pulled to explain or make things explicit that would have been better left unsaid.
- [05:46]
A
Yeah, that's a really good example. Right. That psychoeducation or information giving is a normal part and parcel of psychiatric care and interviewing. But if you're doing it because of individual clinical clinicians anxieties, then that might not be therapeutic. So good example.
- [06:04]
B
All right, let's get us started.
- [06:07]
A
All right, so the first thing we always have to talk about, which we're going to do very briefly, I promise, is Frame and Therapy Alliance. This has been. There have been whole episodes dedicated to this before, so I'm just going to refer you to those episodes because we're not going to belabor it, but it is a technique, not only a concept. You have to understand the concept of frame and Therapeutic alliance, but the technique is to notice when you or the patient are stepping out of the frame or to notice when there are ruptures in the alliance and how you would prepare that. And we'll probably save that for the end of this or end of part two. This goes into two parts.
- [06:51]
B
Yes. And the podcast is called, I think, the Most Important Topic in Psychiatry, alliance and Frame. So I'd recommend going into more detail on that.
- [07:04]
A
So the number one thing that I want to start with in terms of explicit technique that comes from talk therapies is sort of a mantra. This is a mantra of therapy, and it should be a mantra of psychiatry, too. And it's follow the affect. Essentially, you have to be emotion focused in a variety of different ways, not just cognitively, but in your exam, interpersonally. Affect emotion. That's sort of your main signal to notice things that are happening, both things that are diagnostically salient, and also what is happening between you and the patient. So it's a symptom, it's a sign. It can show you what is happening within the patient. It can show you what's not happening. You know, what will remain unsaid unless you intervene. It's also the key to what we're going to talk about later, which is how I conceptualize the term containment. Okay, more on that later. But broadly, I think a large problem that many people have across all kinds of disorders, types of people, personalities, is affect phobia. People, generally speaking, are usually afraid for good reason of having certain types of emotions. Makes sense, right? It's unpleasant to feel negative emotions. But what we want to do is we want to teach patients explicitly that emotions, while they're unpleasant, are not in themselves dangerous. They can lead to things that we don't want in some Fashion often can do for people who have developed certain habits or maladaptive coping. But in the end, we need to feel them both the positive and the negative emotions, and we need to notice them as clinicians, both in the patient and ourselves.
- [09:14]
B
Affect can be too hot in that you see a patient, you know, really, really coming on strong. And then affect can be too cold in that someone's talking about something that cognitively is affective. You know, the passing of a loved one, a recent traumatic experience, a historical traumatic experience, and there's no affect. So paying attention to cognitive aspect of things and the intensity of things and whether there's a mismatch between those two things.
- [09:43]
A
Yeah. You know, in the talk therapy, you're going to want to make sure that patients are in sort of a green zone of emotional regulation or infusion of affect. You know, this can be talked about as being underregulated or overregulated or being flooded or being isolation of affect, whatever kind of terminology you want to use. Lots of different disciplines in the mental health field refer to this concept. I would say that in my opinion, we aren't so concerned when it comes to over regulation or isolation of affect. When in medication management and diagnostic interviewing. We're not so worried about that, actually. That's more of a concern if you're in a talk therapy. But we're definitely worried about dysregulation, and we're definitely worried about plain disassociation. And that can be easy to miss if you're not following the affect. Because if a patient is having a freeze response or basically zoning out unless they do it in the middle of them talking, you might miss it, especially if you're talking a little too much as the Clodeshian.
- [11:04]
B
Yeah. So I like, I like this green zone. I'm picturing like a speedometer where like 40 to 60 miles per hour is green. And then like above the speed limit at 60 is red, and then below the speed limit is. Is. I'm picturing blue because it's cold. And when. When there's too much affect, you need to do things to contain things and get it back into the green. When there's not enough affect, you want to heat it up and get it move. Move the speedometer up. You know, we're. As you said, this is a part of therapy, but it's also a part of absolutely everything. You should constantly be regulating the other person's emotions and make sure it's. It's not too hot, and then we'll talk about the different things you should be doing when it's either too hot or too cold.
- [11:42]
A
Yeah. And I suppose to caveat to what I said, where I essentially implied that I kind of ignore over regulation or isolation of affect for diagnostic interviewing. I don't think I really explicitly ignore it. I just don't use necessarily typical psychotherapy technique to manage it. But you should notice that even in a diagnostic interview, if someone seems pretty isolation of affecty, if they seem very flat in terms of affectance, not from a primary psychotic disorder, for example, you should at least note in your mind that the patient may be less engaged than ideal. Because unless somebody is really flowing with narrative and emotions, you may be missing information. And it's not because the patient is withholding it deliberately, but they may not even be accessing it if it's. If they're essentially too closed off from themselves. And so you might not be asking the right questions or you might not have enough rapport at that point in the diagnostic interview, if that's what you're seeing.
- [12:48]
B
So. So let's say someone is starting to get dysregulated. It is. Things are getting too hot. Where, where do you start?
- [12:57]
A
Well, the first thing you do is, is what they tell you in emergency medicine, Right. In a crisis or emergency, first you take your own pulse, right?
- [13:08]
B
Yep.
- [13:09]
A
Meaning that you, the clinician, need to, to the best of your ability, stay calm. And if you can't stay calm, you need to, at minimum notice that you are not staying calm. Right. You need to maintain some ability to distance from yourself and your process, to draw back and notice that you're getting a little dysregulated or maybe a little more than little yourself. So try your best to stay calm. And if you do have problems of this, of course clinical experience and practice helps. You know, if it's the first time that you're running into a very difficult situation with a patient, it's normal, it's human to be dysregulated in some capacity. Of course, when you've been exposed to it multiple times and you know how it ends up, then it's a lot easier to stay calm. Uh, but sometimes there can be individual clinical dysregulation because of individual factors, and those can be worked on as part of your own treatment. But we'll move on from that.
- [14:11]
B
I, I really like I. During these periods.
- [14:12]
A
I.
- [14:13]
B
Have you heard of the physiological sigh? I really like doing that in these moments.
- [14:16]
A
Uh, we should hear about that. Tell me about that.
- [14:19]
B
So it's. You take a full breath in and Then when you get to the top, you take another pull and then you breathe all the way out really slowly. And it's a very quick way of activating the parasympathetic nervous system. But it's, it's a very, it's a subtle way that someone can't see and it just helps you focus more on your breath and calm down.
- [14:41]
A
Yeah, no, that's good. And you know, that kind of brings us to grounding techniques. If patients are generally dysregulated or under regulated, they may need more explicit education on grounding techniques. Of course, you should try these out for yourself first. You know any kind of grounding or calming techniques, because if you haven't tried them, how can you teach them? Yeah, but if you notice a patient is generally like that, you're not going to necessarily do this in a diagnostic interview. But just practice and teaching of graduation grounding skills can be very helpful. We're not going to go into the specifics today. You can look those up in your resources.
- [15:24]
B
One little tidbit though is I, I, it's worth pulling doing it in the appointment. This is obviously you wouldn't do this on an intake, but like I'll search box breathing on YouTube and then do the box breathing with the patient at the same time. So you don't even have to know it that well. You can pull it up on YouTube and do different grounding techniques with the patient.
- [15:45]
A
Yeah, that's a good point. You can lead a patient without teaching in some grounding exercises. Remember grounding exercises, mindfulness exercises, related types of skills, they don't all have to be still. Some people do better with motion, movement. When I'm noticing somebody, in the rare case, actively dissociating or freezing in front of me, I will start to just point things out. For example, in the environment. You know, I notice you're getting a little different there. It seems like maybe you're being bothered or this is a lot for you. Let's just go over some things right now. Can you tell me your name? Okay. Where are you right now? Who am I? What's the color of the chair that you're on? What's the temperature of the room? Like, what can you hear? Just pointing out things in the immediate environment. Or you may say, could you try standing up for me and clenching your fists? Okay, how about just opening and closing your mouth? Just things that kind of get you back into attention on the present moment to neutral stimuli. All right. Not a, you know, cure all, but still can be useful. What else can you do in the moment if you're seeing dysregulation? Well, try to be clearly. Don't be afraid to be uncertain as you speak. Give assurance, but not in ways that aren't true.
- [17:16]
B
Right.
- [17:16]
A
You should only say things in assurance that you know are true, that everyone knows are true. We're here together right now doing this. You're feeling awful right now, it looks like, but you're not in physical danger. And the extent possible, you should label emotions and anxiety for the patient and say what it might be. It's looking like you're extremely fearful, anxious right now and maybe even a little irritable. It seems like that might be because we started talking about some of your history of trauma. Right. Don't be afraid to repeat yourself and also do what I'm going to talk about as technical containment. But we'll go on to that more later. Now for over regulation detachment. It should be noted that this is perfectly fine in some contexts. As I mentioned, you can probably leave this alone, especially if it's characterological or from Axis 1 disorder. You should.
- [18:19]
B
Dr. Fu, who doesn't like hugs is totally fine with overregulated patients.
- [18:25]
A
It can be constitutional. It's fine. You can leave that alone if it's just diagnostic interviewing or, you know, first session, nothing wrong with that. But you shouldn't leave it alone. Long run or the short run. If it's talk therapy, that should be said. And it's also fine to leave it alone. And you should leave it alone if someone seems overregulated or detached right after a period of dysregulation, okay. They're kind of trying to regulate themselves at that moment. You don't need to, you know, kick them right out of that as well. Okay? So give time, be patient. Now, if you do find that there's a time where being over regulated or detached seems to be getting in the way of the core of what you are doing together with the patient. First things first. Make some kind of observation. You know, this is a classical thing you do. You know, I notice you're talking about something quite painful, but I noticed that you don't seem to be feeling much emotion as you talk about that. Do you notice this at. And that's one thing, but that's not complete. As I mentioned before, I think the main thing might be that you're not directing attention together to the right topics. If people are over regulated, detached, you should be asking more open edit questions and pulling for information on the right topics instead of maybe asking about things that are overly technical or, or concrete or allowing the interviewee, the patient, to simply continue talking about some kind of a. Unrelated narrative that's not emotionally laden, emotionally focused, or pertinent to their mental health.
- [20:07]
B
Just a small plug to leave a review if you can. Leave a review will help other clinicians find our show and will let us keep making it. If you're on Apple podcasts, open the show page, scroll to ratings and review. If you like us, tap five stars. If you're not sure what to put for the review, just say, hi, Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Fu reads absolutely every single one. Let's get back to the show. Today we were talking about. You described these five levels of intervention to me and the way you put it, I'm really excited to hear you talk about it because you really put in a word, some in that I feel like you have to learn through all these kind of different disparate papers and different people describing it. So can you talk to me a little bit about the five levels of intervention and technique?
- [20:59]
A
Well, I can't take credit for this. It was a mentor that really taught me conceptualization of psychotherapy technique into four levels of intervention. I added a level zero because I think it. It's worth being explicit about and being very technical about to understand. I do think good clinicians do it automatically. But what we want to do is not just be automatic, right? We don't want to just be our natural selves in our clinical work. We want to bring that with our. We want to bring that in, but we want to augment it by becoming almost unnatural, looking at what we're doing and why, in the lens of a technical framework. And then having practiced that, return to a naturalistic way of working because the technique should then be so ordinary to you that you can deploy it at will. What are the five levels? Well, the first one I like to call level zero because it's so fundamental and the earlier levels should be happening more often than the later levels. Okay. And then you get all the way to the last level, which is interpretation, and that should be the rarest one. Now, there are schools of therapy that disagree with that and they're right out the gate with interpretations. But this is just my training and what I advocate for. Okay. So level zero is essentially the supportive aspects of treatment, including frame boundaries, psychoeducation, safety, and technical containment. Level one is empathic mirroring. That's not a very intuitive term, but we're going to get into that level two is clarification, that's a little bit more obvious. Level three is confrontation. Again, a little bit misleading of a term. Perhaps better to call it observation, but for historical reasons those are two different things. We can call it confrontation or observation. And then finally level four is interpretation. So those are the five levels. And, and the purpose of this is again more so to understand what you're doing and why in retrospect than to actively guide in the moment of you working. Because if you try to think about what you're doing as you do it, I don't know, it's like trying to walk and chew bubble gum kind of thing. Right. If you're trying to play something, if you're a musician or sing something, if you try to think about what you're doing, it's going to throw you off. For example, like if you try to think about how you're breathing right now, it's probably going to mess up your automatic breathing. Okay. That being said, if you train in a specific manner of breathing for certain contexts, let's say meditative type breath patterns, that may influence your day to day as well.
- [24:03]
B
Yeah. Before we, we jump to the specifics of the levels, I think it'd be helpful to provide a simplistic overview of what, the goals and like what you're trying to do in therapy. Now, I think of therapy, psychodynamic therapy especially, your goal is to help elaborate someone's emotional experiences and to help them better understand their emotional experiences with the hopes of giving them more degrees of freedom in their life. And the way I think about these levels is in some sense in the beginning of any therapy you're going to be starting, it's primarily going to be the, the levels 0, level 0, 1, 2. And then as you build more of that alliance and have more of that bond, you start to do more of the levels 3 and 4. And it's constantly changing depending on where the person's at. But the goal is to allow the person to expand and give, give words to the entirety of their emotional life, their affective, cognitive life. And if you were to start at level four, just interpreting right away, it's, it's not going to be heard. And you, you need to start in terms of a PA as a patient, you need to first feel heard, understood, and like the person cares about you. And I remember my friend was talking to me about a show. I forget the gist, but the person's dad was a therapist and the girl was about to go into a court case and he Goes, I forget the gist, but the girl was about to go in the court case. And he goes, I'm going to summarize. I'm going to fast Forward and do 10 years of psychotherapy in the next 15 minutes and then kind of gives all these interpretations of. Because your father wasn't present in this, in your life, that's why you pursue all these relationships and blah, blah, blah, blah, blah. And any therapist knows that would never work because the therapy is primarily an emotional experience. It's not a cognitive learning experience. It's like learning to ride a bike. You can't just talk in words very quickly and then someone hops on the bike and gets to learn it. Yeah. So I bring all that up.
- [26:24]
A
Process, not an outcome, right?
- [26:26]
B
Exactly.
- [26:27]
A
This is not gonna resonate well for anyone who hated math. I hated math too. But it is like skipping to the end of the textbook and looking at the answers. You've actually learned nothing if you do that. Right. You do need to actually go through the process of doing the math problems if you're going to learn math. So in the same way, a therapy does not work by giving the answers. You give answers to a patient diagnostically, formulation wise, Even if you're 100% accurate, it might as well look like black magic to the patient if they don't have an individual process and experience of how those answers have been derived. You have to show your work. And I want to emphasize, even if this is psychotherapy technique, again, this is not just for psychotherapy. This is exactly the same issues and techniques that can and should be used in diagnostic interviewing and medication management. There's no use giving a diagnosis to a patient that they don't understand.
- [27:23]
B
Okay.
- [27:23]
A
Or that they can't explain in their own words based on what's happened in their lives. This happens way too often. Right. Patients will say, well, I've been diagnosed with such and such disorder. Okay, well, what does that mean to you? And why? Why do you have that diagnosis? What in your life has happened that would support that? And many people can't say at all because there's no time spent on doing early level techniques and building a foundation to justifying and understanding the diagnosis.
- [27:54]
B
Yeah. So let's get started on our levels. So level zero, can you talk to us to help us understand support and containment a little bit more?
- [28:03]
A
Yeah, I think we'll just pretty much talk about technical containment here, because as we've mentioned, having correct boundaries frame understanding on part of both you and the patient and the other parties involved about what the job is to do and what the limits are and having safety and confidentiality. That's all fundamental. That's hopefully trained so well and covered in other episodes of our podcast as well. I know it's not, but we're not going to spend too much time. Let me talk about containment. When you were in training, did people talk about containment?
- [28:41]
B
My only reminder of a container was when I got my. When I transitioned to the third year, the person who I took over their patients, he said, I want you to close your eyes and picture a big garbage bin. You are going to be a container for all these people's problems from here on out, and it's not my problem anymore. Oh, boy, oh, boy.
- [29:06]
A
I love that story because I think that's how many 30th feel in their training because they haven't been given the right support in the frame, you know, going in. And even if they have been, they can end up feeling that way. For me, containment was something that a lot of people would mention. I think it's because it is in the local DNA of therapy training. But people would just kind of use the term. And I didn't really understand what they meant. And even when I asked them what that meant, they wouldn't necessarily be able to explain it, at least not to a degree that really made any sense to me. And then I went looking into the literature too, and to be frank, it seemed to be used in a lot of different ways. So I say that to acknowledge that it's a more nebulous and abstract term than my definition here is going to be doing it justice for. But I do think that conceptualizing containment in this way, and that's why I call it technical containment as a technique, is useful for all clinicians. And so we should at least consider it. Containment comes from beyond. He's an analyst, a very interesting guy with a lot of history. And I think it's worth going into that his theories, and honest, real honesty can be a little hard to understand in the way that he writes them. But the short version is that he had a theory about thinking in that it wasn't inherently possible for human beings to form thinkable thoughts. That before you could form thoughts into basically words, language that you communicate to other people and yourself, that you would just have sort of undifferentiated internal experiences. Okay. And so that you would actually have to develop a capacity for thinking in a regulated way in order to make sense of yourself and the world. Okay, so how does that usually happen? Well, he thought that if you had appropriate caretaking, mothering, development, that there was something your caretakers would do for you, containment that would allow you to form the capacity for thinking thinkable thoughts. Okay, just on the face of it, does that make any sense? I need this to be tested against somebody else. Do you feel like there's something missing there? I'm going to keep going.
- [31:46]
B
Let's give a concrete example. I think that would be the most helpful. Like a patient coming in with a particular experience and what it would look like for it to be put into a signified form.
- [32:02]
A
Yeah, I think maybe the most experienced. Neil, near experienced, near clinical example is alexithymia. You know, we can come up with a bunch of neurobiological explanations for alexithymia, but you can think of alexithymia, the inability to put your emotions into words or to name your emotions, label your emotions as probably some kind of an incapacity or impairment. Right. Now, in traditional defense theory, people think, oh, they're not naming the emotions because it would be too painful to do so or be unacceptable in some way to their values. And so they wall it off, basically. Okay, but that's a defense model. And I want people to think that maybe people can't name emotions or put their internal experiences into words because of a lack of development. They weren't given the tools or the opportunity to be able to self reflect and to put their internal experiences into words. Right. So that would be a deficit model. And then if that's the case, then pointing out clever interpretations of people's inner workings or saying this and this happened and therefore you're like this, that's not going to help people actually learn to put their internal experiences into words. Right. This can also be seen in not just people who are alexithymic, but for people who seem to struggle to explain how they feel or how they think under a certain situation or stressor. I'm sure most clinicians have seen that.
- [33:43]
B
Yeah, I think maybe, maybe I can provide a small example that might be. I think it's. It's not perfect, but, you know, sometimes you. I provide a clinical concept to a patient and all of a sudden a lot of experiences that felt like disparate craziness all of a sudden has a container on it that makes a lot more sense. I could think of an example in terms of the OCD diagnosis because I think what you're describing with the alpha, alpha and beta stuff is, is, is more specific. But this is an example of a containment that's helpful.
- [34:20]
A
I didn't use the words alpha and beta, you just mentioned them. I don't know if people will know what that means. This is not alpha wolf stuff. It's beyond theory of thinking. I feel like it's overly technical. I'm not going to mention it, but come on.
- [34:31]
B
We're not mentioning it, but okay, so patients with oc, I have a lot of OCD patients that have these experiences of thinking that they're going to murder someone, they're. That they're a pedophile, that they're murderers, and they have all these crazy thoughts that they've had for a long time. And until I give them the OCD diagnosis, they have no way to understand what those thoughts are and take them to be literal. And the OCD diagnosis and the explanation for what occurs with ocd, just by explaining the process. I have seen patients get a ton of relief and. And I find that the concept of intrusive thoughts provides a container for their experience to help understand what's going on. So it doesn't feel like all these wild, unexplainable thoughts and in a sense contains them and makes them feel much better. So the container there is the label of ocd and the individual thoughts and sensations are the intrusive thoughts. And the process of having a name and explanation for what's occurring is therapeutic by itself because it contains those thoughts. It makes sense of them and puts a label and an understanding to them.
- [35:49]
A
Yeah, I mean, that's a great example, I think, of how most people talk about containment because they don't get very technical with it and they're not drilling down to the fundamental theory of thinking. So again, totally accurate. And how many people talked about. I just want to emphasize that that's not the. That's almost a second order containment, if you will. Yes. Where there's a framework that's being created that helps reduce anxieties and helps make sense of a mental process. I want to kind of get down to forward development where you have people who even under normal conditions can't put their internal experiences into words or struggle to do so. And I want to link that to the process of trauma or traumatic development. And I think that really informs Beyond's theory of containment. That maybe helps to think about and talk about Beyond's own history as a person. That's really what kind of helped make it click for me. He was a tank commander actually in World War I. And if you know a little history of World War I, you'll know how horrible that war was. He wrote about being in a Battle where he was just trapped in this foxhole. And I, you know, I don't really believe in trigger warnings, but we're going to be talking about something a little graphic here, okay? He talked about when he was in that hole being shelled by the enemy, that he felt sick. And then he wanted to think. He wanted to think. He tried to think, but that he could not. And when he reflected upon this moment, he thought that, I'm quoting here. In war, the enemy's object is to terrify you that you cannot think clearly while you're object is to continue to think clearly no matter how adverse or frightening the situation. So he's trapped in the shell hole. He's trapped in the shell hole. He has a. Another soldier with him. And the soldier asks, why can't I cough? Why can't I cough, sir? And beyond recollecting this, writes in the third person, almost dissociated from himself right beyond turned around and looked at Sweeting's side and there he saw gusts of steam coming from where his left side should be. A shell splinter had torn out the left side of his chest. There was no lung left there. Leaning back in the shell hole, beyond began to vomit unrestrainedly, helplessly beyond revolted and terrified wishes that Sweeting will shut up. Sweeting begs him to contact his mother. And the German artillery barrage envelops them in a silent fiery curtain. And then came the sound, a rushing, pulsating sound which came in gusts against the skin of the face and hands as well as ears. So after the battle, beyond, another officer talk about somebody. The officer says, oh, that other soldier, he cracked up under the pressure, but you didn't. Beyond wrote in his diary at the time, beyond did not believe him. He felt that people who cracked up were merely those who did not allow the rest to. And he actually stopped writing his diary there and later though, the idea is that this theory of thinking is what allows people to understand whether people can learn from experiences or to so called crack up, okay? In short, what is this theory of containment? The theory is that the child or the patient has a internal experience, okay? That internal experience is not put into words, it's not turning into symbols or language. But the caretaker, physician or therapist can perceive that process happening. In the other part, you allow that process to enter within you. You feel it and reflect on it for the patient. And then you communicate it back to the patient or child in words, okay? That is containment, technical containment. The process of receiving and understanding the internal experience of somebody else making sense of it and then giving it back in some way, reflecting it back, usually in words. Does that make any sense?
- [40:36]
B
Yeah, really, really powerful read, Dr. Fu. It's funny, the word container. I actually, if you listen to the podcast, I use the word bucket a lot. Like I say we put a patient in a bucket. I really do picture a container for these things. In what you just described, the therapist is finding a useful container. And in that thing, it's a word or a concept, and then taking all these random parts, I picture like all these objects thrown across the room and I put them in a nice container and I hand it back to them. And that container helps to organize those different pieces.
- [41:19]
A
Yeah, yeah. Then that's really good. Right? And then that's also a good example of why sometimes the diagnosis is containing. Right. In some fashion can be limiting in some fashion too. But in the positive sense, it is containing, it's organizing any kind of organizing principle. But even before that, it's simply a matter of being able to understand what's going on inside somebody else that they can, or not necessarily can put into words, putting it into some kind of words, making some kind of a transformation of it and giving it back to the patient. So I mean, that's the theory, but this is really supposed to be about technique. So what is technical containment? How do you actually do it? I think boiling it down. What you do is that you have to be in a receptive state. You have to be very attentive and interested in what a patient is going through inside, not just what they're saying, not just what they're, you know, displaying to you, but making almost leaps into what is the internal experience of the patient at a given moment. So step one is you observe and hear what the patient is saying and doing in front of you. And also maybe what they're not saying and doing, or even what ordinary people might be experiencing if they're talking about or thinking about that. Then you observe and feel how you, the clinician, are reacting and what kind of thoughts that come up. Third step is that based on that, you form some kind of working idea or hypothesis of what it is that the patient is experiencing or has experienced and then you reflect it back, you communicate it explicitly back to the patient using words. Sort of a four step process there, you know, in terms of observation, being receptive to the internal state of the patient. Step one, reflecting on your experience of that. Step two, forming some kind of a working idea or hypothesis. Step three, and then communicating it back. Step four, several step process. This is A little concrete. I think the best way to demonstrate it is to try it yourself. Okay. And then you're gonna realize that it's actually something you do quite often and unknowingly. But by doing it explicitly, I think it's gonna help, especially in patients that are easily dysregulated or alexithymic.
- [43:51]
B
Yeah. And I've. I've heard this process. There's a paper, I forget which one it was, that what you're describing is how empathy is works. Essentially, you're. You're taking the unbearable emotional states of someone. You're metabolizing them in some sense and then returning them in a more digestive form.
- [44:13]
A
Yeah. You know, it's referred to in a lot of different ways. Right. It can just be mirroring statements in some disciplines, it can just be catch and release. I've heard it related to. But it's a fundamental thing. And I think that it's also worth noting that not everyone does this and not everyone has had this experience growing up. You've probably heard people complain that in conversation, some people only seem to wait for their turn to talk. Right. I think that if that is an experience as being had in a conversation, usually it's because the other party has no real interest or attention to the internal state of their, you know, conversation partner. And so if you're doing a real empathic and appropriate interaction with somebody, patient, child, fellow human being, if you're not doing some amount of containment, technically you're not really having a conversation so much as you're both talking at the same time.
- [45:20]
B
Which. Which is very common. Yeah.
- [45:25]
A
Now how do you actually pull this off, though? Again, this is something that you kind of have to practice actively, that you've probably already been doing. And it's something that you have to notice that you're doing. One thing I often recommend is go on YouTube and watch Carl Rogers work. Okay. Carl Rogers, father of, you know, client centered therapy, which spawned motivational interviewing. His therapy technique and theory was. Was only containment in my eyes. It was only reflective statements. So that's all he really ever does. And it can almost be a little frustrating if you want to be more active intervention therapist. But just watch Carl Rogers. But if you're feeling game, maybe we could model it here before we finish the episode. Are you willing to. Able to kind of just talk about some kind of experience modeling a patient? And I'll try to do an example of containment.
- [46:23]
B
Yeah, sure. All right. So things. Things have been so hectic. I had this conversation with my friend. It Reminded me of. I don't want to go into the details, like, what happened in my childhood. And since then, I just feel like there have been, like. I just kind of have, like, anxiety has been through the roof. The. The other thing is, like, my. So I feel like everything's kind of going wrong. Like, my. My friends have not been supportive because I explained to them I was kind of going through a lot with that, you know, that bringing up that emotional event. I kind of feel like just no one's. No one's helping me. And even, like, you know, sometimes in. In therapy, I feel like we're trying to figure out what's going on, but I don't know. I need help in terms of what I'm supposed to do, because it just feels like no one's. No one's helping to take care of me.
- [47:17]
A
It really seems like with the stress that you're undergoing, it's bringing up a lot of thoughts about your past. Yet in that state where I expect you might be feeling a lot of sadness, maybe anxiety or fear, you're also so lonely that other people aren't hearing you. And even hearing the therapy, I'm not hearing you, it feels that you're alone.
- [47:41]
B
Yeah, I guess it just kind of feels like no one's. No one's. Yeah, like you said, no one's taking care of me. And I feel like no one's sometimes taking my anxiety seriously. Like, my. My partner keeps telling me that, you know, maybe it's my fault. My friends are saying it's my fault. And, yeah, I guess I just feel like no one's. No one's got my back.
- [48:06]
A
It's that not only are you alone, but there's no one on your side either. That people are criticizing you, that people think you're not doing the right things. And that seems to be happening even though you're putting quite a lot of effort in, or at least it feels that way. Is that about right?
- [48:23]
B
Well, I guess. Yeah.
- [48:24]
A
So I like how that played out, by the way. And the reason why is because I think some people may be deficient in technical containment because they're a little afraid of. Of being redundant or a bit silly. I think there's a sense from clinicians that they have to add something new or to give something to the patient that is different than what they have inside of them in a jarring or fundamental manner. But a lot of containment may literally sound like that you are simply repeating back what the patient says almost verbatim. But usually it's just Repeating back what the patient has told you in slightly different words. Now done appropriately, it is not literally mirroring. It is not literally. You do that.
- [49:11]
B
Okay.
- [49:12]
A
If you do this right, you have to have perceived the internal state of the patient, allowed yourself to reflect on it and then put that into words. That has to happen if this is done correctly. Okay. Because I think that there's probably a lot going on interpersonally in terms of non verbal things when you are genuinely doing that. And people will be able to feel that. But don't be afraid to simply reflect back. And why is that important? Not only does it possibly underlie the whole development of thinking and emotional regulation, especially in traumatized individuals, but at the minimum, you're proving that you're actually listening. And it also allows the patient to kind of slow down and notice what they're experiencing in a observing ego kind of way. Drawing back and looking at their own process instead of just going through it.
- [50:05]
B
Yeah. And going back to how I started that. The point of this is for the person to expand on their emotional experiences, get a better idea of their emotional experiences and give credence to all the different parts of a person. Like psychiatry and medicine. It's. You have a problem and we have a treatment. And this really runs counter to that because you're not. There's an instinct of like, okay, let me give you something for the fact that, you know what I was describing of feeling alone. Let me give you something to make that go away. And that would really miss what the person's experiencing. And it wouldn't allow them to elaborate and understand what they're experiencing. You talk about the deficit model. It's like, I have a deficit and, and you're going to fill my deficit. Rather than let's, let's understand what's going on. And thinking of kind of what, you know, what you did versus what I see. A lot of times you can call it quote unquote supportive, but it's not. But we'll talk about that later. Imagine if at that point you had said, your partner's an asshole, your friends are asshole, you need. You need. What we need to do is we need to get you better friends and a better partner. And I fear that maybe I have, you know, a straw man. I fear that that's what occurs in a lot of therapies is just unconditional support for the primary process of what the person's experiencing rather than a curiosity and a desire to expand and understand.
- [51:34]
A
Yeah. And to stay consciously within the emotional experience of what is Happening or what is being talked about. Right. That. That's key too, along with what you said. You know, and it's not like you can never reassure or do that kind of supportive stuff. Right. That people generally consider supportive, which may be allying too much with one aspect of patient's experience. If you're not sure why that's a bad thing, primarily, I would say it's because if you just agree with one aspect of a patient, you are cutting off access to the other complex parts of an individual who might feel differently or think differently at other times. Uh, but yeah, you know, just being able to withstand and to sit with and to reflect both positive and negative things. It's a huge part. And again, not just for therapy. If you do technical containment within a interview for diagnosis, for example, judiciously, you will, in my opinion, Jod Ulster, even in that moment, the patient's ability to elaborate on experiences, and it builds rapport too. And it really helps you get them more information.
- [52:49]
B
Yeah. And keeping that in mind, that the goal is to expand and understand and see more. Not. Not.
- [52:56]
A
Yeah. Not to constrict or delimit.
- [52:58]
B
So I'm paying attention to time. Unfortunately, we're running close to the end of the time. I am a little worried. I think we only got to level zero, and I don't think we got to the. You know, I'm worried people are going to walk away and feel like they didn't get any. Like enough that they. They learned something from what to do with psychodynamic technique.
- [53:20]
A
Yeah, I. I get that. You know, we kind of said, oh, this is going to be psychotherapy technique. I talk about five levels and what I talk about level zero, you're getting appetizer and no main course.
- [53:29]
B
We didn't get to level one. We're levels, Dr. Levels.
- [53:35]
A
I just think, by the way, in my talks, I show a picture of Kramer, if you're a Seinfeld fan and you know, the episode where he has levels in the apartment has a little aside.
- [53:45]
B
I. I think it's good that we could do the levels, but we don't want to.
- [53:51]
A
Yes, I. I think it's good that we end here. And the reason why is because I don't want to give an impression that level zero is level zero because it's unimportant. If anything, it's completely fundamental. And if you can actually master doing level zero and practice it actively, I think you're going to find yourself far, far more effective in your work than anyone else who is just focusing on the rest of the techniques. So I do want to end here, both because I can't continue, but I want to punctuate this. I want to say this is the most important fundamental thing to effective work. Personality development and change, most likely. So work on that and again, watch videos, reflect on yourself. You can do deliberate practice type stuff where you simulate it similarly to how we just did with practice partner and reflect on how you like what you did.
- [54:54]
B
That's interesting. So you feel like containment. If you kind of just know that then you're doing a lot more than you're doing a lot.
- [55:05]
A
Oh yeah, because like, you know, I don't know how many motivational interviewing trainings that you've had in your career, both as a trainee and as a teacher. But like, I feel like a lot of motivational interviewing people tried to boil it down to like, oh, pre contemplation, post contemplation, oh, readiness for change. Change. That's just concepts. The actual core of motivational interviewing is the ability to do this technical containment, the Rogerian type mirroring and in it allowing patients to actually notice areas of discrepancy within themselves that would not otherwise be noticed without these kinds of reflections. Right. You are building the capacity for thinking and holding multiple disparate parts of a person within their conscious mind. So yeah, super fundamental. It's the actual core action in a lot of treatment, you ask me.
- [55:56]
B
I used to think of the, you know, a good therapist is like, they're nailing that interpretation of like, have you ever thought that this reminds you a little bit of your mother, this guy? And, and the truth is it's, it's not this brilliant intellectual exercise. A lot of it is, is these fundamental things. And one thing that's important to notice is I. You heard this described as very narcissistic depleting and that this is not, this is not hot and sexy stuff where you're, you know, thinking of all these complex, you know, interactions and delivering the best interpretation. This, this is sitting there, being with the patient, processing the patient, hearing the patient. I bring that up in that it, it's helpful to learn that you shouldn't. The psychodynamics and, and good therapy isn't what people like dramatize and think of it as in terms of, you know,
- [56:53]
A
these, these deep insights that clever statements, theory. It's this stuff fundamentally. Yeah.
- [57:01]
B
And that's. Patients want that they want. You know, a lot of times I have patients that say like, I just want someone who gives me good advice or I want someone who, who, who, who really helps me to kind of get my business going. And that's, that's not, that's not the meat.
- [57:14]
A
Yeah. It's contrary to the process. And of course, this also touches on the common social media complaint from people who don't do therapy because they. I can't find therapists smarter than me. Well, that's really actually not terribly important.
- [57:27]
B
That's the problem.
- [57:28]
A
Yeah, that's the problem.
- [57:30]
B
That's a problem. Not why you think.
- [57:31]
A
Well, until next time.
- [57:34]
B
All right, take care. Thanks for listening. If you want to support the show, check out my very practical antidepressant course. If you want to check that out, go to Psycho Farm. Farm. If you prefer to read, you can go to Amazon.com you can just search my name. Gregory G R E G O R Y Malzberg. M A L Z B E R G. And the book is Psychopharm's Guide to Treating Depression. It's a nice, easy, readable, practical guide to medications, depression,