Psychodynamic therapy: what is it and how can it benefit your mental health?


Published on:

We speak with integrative psychotherapist and counselor, Jeremy Sachs, to learn more about psychodynamic therapy, its benefits, and how to find out if it’s the right approach for you

Whether you’re struggling with a specific issue, or are looking for someone to talk things over with, there are many different reasons why you may reach out and start counselling. But did you know that there are a variety of different approaches out there that could help? Finding the right one that best suits your needs can feel overwhelming; that’s why it’s important to learn more about specific types and approaches.

What is psychodynamic therapy?

Also known as psychodynamic counseling, psychodynamic therapy is a therapeutic approach that embraces the work of all analytic therapies. In essence, psychodynamic therapy is based on the idea that our unconscious thoughts and perceptions develop throughout our childhood, affecting how we behave and think now.

A psychodynamic therapist is interested in your past, how you adapted to the people and environment in your past, and how these people and experiences shaped you. They believe how we relate to other people now is based on these beliefs/experiences from our childhood.

By working with a psychodynamic counselor, you can unravel these deep-rooted feelings, to resolve the painful memories that you have unconsciously been holding on to. They can help you see where you might need to unlearn, relearn, or change the ways you see the world.

Integrative psychotherapist and counselor, Jeremy Sachs, explains more: “Psychodynamic psychotherapy reflects on these key areas: the relationship between the client and therapist, the informative early experiences, and relationships of the client’s childhood, and their subconscious. The therapist will be interested in what the client believes about themselves, their relationships, and how they interact with the world as, often, these beliefs can be the source of psychological pain.”

What should I expect from psychodynamic therapy?

Using a variety of different techniques, at its core, psychodynamic therapy relies on the interactions between you and your therapist to reveal your unconscious. But what does that actually mean, and what can it help with?

Jeremy says: “Entering psychodynamic therapy, one could expect to examine past experiences that may feel particularly painful in the present. These could be losses, or instances that are traumatic. Alternatively, someone new to psychodynamic therapy may feel stuck, depressed, or anxious.

“Psychodynamic therapy can also be a useful mode of therapy for personality disorders. It is often called ‘deeper’ therapy, as it examines the root causes of pain, and is often long-term.”

What are the benefits?

Designed to help with a wide range of problems, it can be particularly effective in treating issues including anxietyeating disordersaddiction, and depression. It can also help those who feel like they have lost meaning in their lives, or are struggling to form or maintain personal relationships.

Who is psychodynamic therapy for?

Taking that first step towards therapy can be tough. So, how can you know if psychodynamic therapy is the ‘right’ kind of therapy for you?

“Data tells us that the type of therapy comes second to the relationship you have with your therapist,” Jeremy explains. “I could be the ‘best’ psychodynamic psychotherapist this side of the equator, but if you don’t feel safe and comfortable with me, it is unlikely the therapy will help. However, if you find yourself disproportionately affected by past events, traumas, or that present relationships are challenging, it might be worth considering psychodynamic psychotherapy.”

How long does it take?

While the number of sessions needed, and frequency, varies from person to person, typically someone who undertakes psychodynamic therapy may meet their therapist one or more times a week. Short-term, you may work with a therapist for 25–30 sessions over six to eight months, or one study suggested you could expect therapy to last around 50 sessions over the course of a year. The length of time depends on the individual, and your preferred frequency of sessions.

What techniques are used?

Drawing on techniques used throughout both psychoanalysis and psychoanalytic therapy, psychodynamic psychotherapists may use the following techniques to help them better understand how a patient’s mind works.

Free association

Where you talk freely to your therapist without shaping your ideas before saying them, and without using a linear story structure. This spontaneity is thought to allow your true thoughts and feelings to emerge without fear of how silly, illogical, or painful they may sound. This helps create an honest and open dialogue without fear of judgement.

Therapeutic transference

Transference can occur during psychodynamic therapy when you project your feelings about someone else (typically from your childhood) on to your therapist. This could be positive (e.g. you see them as caring and wise), negative (e.g. experiencing feelings of anger, resentment, or distrust towards them), or sexualised (e.g. experiencing romantic, intimate, or sexual feelings towards them).


Typically staying quiet throughout your session, your therapist may occasionally interject with thoughts or interpretations of the topics you are choosing to discuss. Your therapist can help you to learn new ways of behaving and thinking that promote personal growth and development, overcoming limitations your unconscious feelings may be causing.

Content vs process

What you say (content) is at a conscious level, and can be limited to what you understand. Whereas, how you present that information (the process) may give your therapist insight into your unconscious, and what you may be trying to communicate outside of your awareness. By observing your non-verbal cues, such as stumbling on certain words, changing topics, or even how much emotion you are putting into what you are saying, they can gain a deeper insight.

Should I try psychodynamic therapy?

When it comes to choosing a therapeutic approach, the most important aspect is to find the right type for you. There’s no right or wrong answer; it’s about finding a style (and a therapist) that you can connect with, and feel comfortable working with. Consider what you want to get out of therapy – do you have a specific problem you want help with, or a goal in mind? Don’t be afraid to try having sessions online, in-person, or even by telephone, until you find a method that works for you.

BGSP-NJ To Become ICPS – The Institute of Counseling and Psychoanalytic Studies

Boston Graduate School of Psychoanalysis’ New Jersey branch campus (BGSP-NJ) will be renamed The Institute of Counseling and Psychoanalytic Studies (ICPS) as of September 14, 2020. ICPS, formerly BGSP-NJ, represents a unique collaboration between Boston Graduate School of Psychoanalysis (BGSP) and the Academy of Clinical and Applied Psychoanalysis (ACAP) both virtually and in Livingston, New Jersey.

“We decided to rename our branch campus to alleviate the confusion that Boston Graduate School of Psychoanalysis in New Jersey was not in Boston, but instead located in New Jersey,” said Vicki Semel, ICPS/ACAP Program Director. “Our new name, The Institute of Counseling and Psychoanalytic Studies (ICPS), is significantly less confusing to our students while still reflective of our programs.”

The Academy of Clinical and Applied Psychoanalysis (ACAP) and ICPS continue to offer graduate, post-graduate, certificate and Continuing Education classes in Psychodynamic Studies and Mental Health Counseling at the Livingston, NJ campus and through distance learning. During COVID-19 ICPS, ACAP and all their programs are offered virtually. ACAP has been continuously, nationally accredited by ABAP, the American Board for Accreditation in Psychoanalysis, since 1990 and BGSP has been accredited by the New England Commission of Higher Education since 1996.

ACAP and ICPS offer alternative paths to mental health careers, as well as courses meeting Continuing Education requirements, to enhance clinical skills, or for personal growth for individuals in education, medicine, business, the clergy, parents and the arts, who seek something different from traditional programs in psychology, social work, counseling, or psychodynamic training.

ACAP is the only school in New Jersey to promote experiential learning from the very beginning, this accompanied with their small class sizes and emphasis on giving back to the communities in which their students came, make them one of a kind in New Jersey.

The North Jersey Consultation Center (NJCC) is ACAP’s clinical arm: a mental health treatment service where individuals and families of any age or diagnosis may receive expert care for as long as needed and at affordable fees. (For more information,

ACAP’s newest iStrive program is a Saturday program for young adults on the autism spectrum who are aging out of most services. It helps them continue growing toward independence, social relationships, emotional well-being, and career readiness, and gives ACAP/ICPS students an opportunity to work with this population. This program has been on hiatus over the summer and will resume on September 12, 2020. (For more information


During COVID-19 all programs and courses are offered virtually. NJCC is providing services either by phone or video conference.


Are Online Psychiatry And Psychotherapy The Next Frontier In Digital Health?

Post written by James Wantuck


In 2017, the World Health Organization declared that mental health disorders are the leading cause of disability worldwide. However, there are not enough professionals to reach the huge number of people affected, and the shortage of treatment options is only getting worse. One solution is to move mental health treatment online.

My company recently introduced telepsychiatry and therapy services to our patients. The demand has been overwhelming, and we are working on rolling it out across the country. According to a Frost and Sullivan report, telemental health is expected to grow by 22.5% annually through 2021.

So let’s take a look at some data that shows why online mental health treatment may be a growing trend over the next few years.

1. Online psychotherapy is as effective as in-person treatment

People receiving treatment for depression showed the same results, whether they saw an online or in-person psychiatrist, according to this study. They also had the same treatment satisfaction ratings.

There is very little clinical downside to patients having online appointments, particularly for relatively straightforward cases of stress and anxiety, depression, relationship issues and workplace conflicts.

Of course, there are cases when a patient’s mental health calls for in-person treatment, but for the average person struggling with a mental health disorder, online services are just as good as, if not better than, traditional psychiatry and psychotherapy.

Effectiveness alone is one reason to increase access to mental healthcare online.

2. People tend to be more adherent to their medication

For a variety of reasons, people with mental illnesses often struggle with medication management. The symptoms of these conditions — like mental slowness, physical lethargy or a false belief that they don’t need medication — make adherence difficult. According to this study, other sociodemographic factors seem to be common in cases of bad adherence, including low income, low socio-educational status, the severity of depression and difficult access to physicians or to medication.

Medication noncompliance across all health issues reduces treatment efficacy and costs the United States up to $300 billion per year. Any improvement in mental health medication compliance can improve patient outcomes and reduce expenses associated with noncompliance.

The ability to get antidepressants and other psychiatric medications online can help patients to be more compliant with their treatment regimen. For this reason and others, I believe we’ll continue to see psychiatric medication maintenance moving online.

3. It’s more cost-efficient

One in six Americans has been diagnosed with depression at some point, and the rate is almost twice as high for low-income earners, according to this Gallup survey. Unfortunately, this means that the people most in need of mental health services are the people who can least afford it.

Virtual mental health services have the capacity to change this. Because of lower overhead — no office space and a distributed workforce — virtual providers can pass on cost savings to consumers. In many cases, this means the consumer pays the same or less for online services than they would in person.

Moreover, even if online solutions have the same insurance copay, travel time and expenses related to travel and childcare can add up. Virtual visits eliminate those unnecessary expenses, as evidenced by one such case study of a telehealth program.

4. It’s more time-efficient

Online psychiatry/psychotherapy is definitely much more convenient than traditional in-person appointments. As internet and smartphone access continues to proliferate and comfort with virtual medicine grows, I expect that adoption will accelerate.

With no travel time, virtual therapy and psychiatry takes less time than traditional appointments. There’s no need to leave work early to dash across town. Patients can have an online appointment on their phone during their lunch break. Patients also avoid wait times and experience a higher level of privacy when seeing a mental health professional from home.

For some people, particularly for those with anxiety disorders, the comfort of having a psychotherapy or psychiatry visit from home is very advantageous. The act of leaving home can be stressful for some, so the small comfort of having an appointment at home is a convenience in and of itself.

With virtual appointments, patients can allocate only the time needed to speak with their therapist or psychiatrist, nothing more.

Online psychiatry/psychotherapy improves access to care

More than half the counties in the United States lack a practicing psychiatrist. That alone presents a challenge for many patients to receive psychiatric care.

Even for people who do have access to a local psychiatrist, getting to an appointment can be difficult. Older adults, patients with chronic illnesses and people with agoraphobia or severe depression may struggle to get to appointments.

There’s no denying that more people will have access to care if they can receive online psychiatric services. I’m optimistic about the continued growth of virtual mental health, and I’m excited to be a part of providing greater access to mental healthcare.

Mary Robinson, ACAP’s Board President, has been nominated by CNN as a CNN Hero.

Mary Robinson, ACAP’s Board President, has been nominated by CNN as a CNN Hero.

People can vote ten times a day!

Cast your vote here:

Mary L. Robinson, MA, CT

ACAP President Board of Trustees

Imagine Executive Director and Founder


Mary Robinson, MA, CT, is the Executive Director of Imagine, A Center for Coping with Loss located in Mountainside, NJ and the Founder and former Executive Director of Good Grief located in Morristown. She has over 35 years of business, management, technical, and training expertise in both the corporate and nonprofit sectors. Leaving the corporate world in 1997 to volunteer and work full-time in the field of children’s grief support, Ms. Robinson is committed to creating communities where children coping with loss get the support they need to thrive, be resilient and grow up emotionally healthy.  Working and volunteering in the field of children’s grief support grew out of Mary’s own personal experience of loss as a child. Her commitment is to ensure that no child grieves alone and that children in grief grow up emotional healthy, resilient and able to lead meaningful and productive lives.

Mary has a BA in English, an MA in Applied Psychoanalysis and is a Certified Thanatologist. She is a member of the Association for Death Education and Counseling and the National Alliance for Grieving Children, and serves as President of the Board of the Academy of Clinical and Applied Psychoanalysis.

Prior to working in the field of children’s grief support Mary spent 14 years at Prudential Financial, first as a System Analyst and then for five years worked in Corporate Community Relations where she managed the company’s volunteer programs and helped give away money to nonprofits.

How the right song can help you manage anxiety

Maya Benattar is a licensed psychotherapist in New York City. Her office looks like the typical therapist’s office — calm and quiet, comfortable seating, soothing lighting. The perfect place to work through difficult feelings of anxiety and depression.

But a few items might catch your eye: a piano, drums, a guitar, and various other music-making tools. Not things you’d typically expect to see in a therapy setting.

That’s because Benattar — in addition to her credentials as a psychotherapist — is also a board-certified music therapist.

When it comes to coping tools, it’s hard to find something more universally loved and leaned on than music. Music therapy takes that to the next level, using music as an evidence-based tool for reaching clinical goals, with applications ranging from physical rehabilitation to mental health treatment.

But just because music is the primary tool doesn’t mean you need to be a skilled musician to benefit. Though the people she sees often have an emotional connection to music, Benattar stresses that musical skill or experience is not required. “Humans are naturally rhythmic. Our breath, our heartbeats, our schedules all have a rhythm,” she explains. “The beautiful thing about music therapy is that it incorporates the mind, body, and spirit into the therapy process, at a visceral, sensory level.”

Music has been used by humans throughout history for both mental and physical wellness, but music therapy as an organized therapeutic medium came around in the 1940s, when doctors and nurses in hospitals noticed the effects music had on soldiers coping with PTSD after the second World War. Today, there are over 5,000 board-certified music therapists in the United States, each having completed an accredited degree program, clinical training, and board examination.

The basis for using music as a therapeutic tool extends beyond anecdotal evidence — there’s hard science behind the melodies. Music therapy interventions have been shown in peer-reviewed studies to reduce stress levels, facilitate emotional release, and decrease anxiety in a variety of mental health settings.

But how does music therapy differ from simply throwing on some headphones and listening to your favorite album?

Benattar says it all comes down to having a guide through the process. “Often times, our instinct when feeling anxious or depressed is to try and shift our moods with music by only listening to ‘happy’ music, which is only masking those issues,” she says. “Something I work on my clients with is using music to tolerate or understand these feelings instead of just shifting them.“

“I want to help my clients use music listening in an intentional manner. To not just disconnect, but to understand and process their emotions.”

Jennifer Townsend — a board-certified music therapist based in Houston — takes a similar approach with her clients. Townsend works on an acute psychiatric facility, where patients are experiencing severe mental health crises. Yet the foundation is the same.

“Something I do with some of my clients is to help them with the process of really identifying anxiety and peace,” says Townsend. “Having them list out the words that describe both their anxiety and their ultimate goal, and using music as a vehicle to discuss those states of being.”

Townsend stresses that music is more than just lyrical content as well. The actual music — tempo, rhythm, melody, harmony, and timbre — can have a physiological effect on our bodies. Our heart rate and breathing can speed up or slow down to match the rhythm of a song, a phenomenon known as entrainment, and affect our physiological state as a result.

“We can use this to help move people into a more alert or calm state, depending on their need,” says Townsend. “We can match someone’s heart rate and emotion, and as the music changes, we can speed up or slow down that heart rate or mood. We entrain together, resulting in a physical change in the person.”

Besides addressing long-term therapeutic goals, Townsend also finds herself helping clients survive challenging “in-the-moment” mental health crises, using music to support things like progressive muscle relaxation to help manage an oncoming anxiety attack and teaching symptom management beyond the therapy room.

“The music therapist’s role is to build a relationship and observe while listening to or making music,” she says. “I want to see what nonverbal and verbal responses happen, and work through those responses to assist the healing process.”

While clinical music therapy requires the assistance of a trained and certified music therapist, both Townsend and Benattar stress the importance of empowering people to use music effectively on their own. “I never want to discount how people use music for their own self care. That’s very important,” says Benattar. “But I encourage people to use music listening in an intentional manner. Can you create a playlist for when you feel anxious? Or that lets you feel sad? That intentionality is important, rather than just masking what’s there.”

Reposted from Ladders

My Life As a Psychopath

science of us

The word “psychopath,” like many words associated with mental and personality disorders, is used broadly, and often incorrectly — colloquially, we might call someone who lies a lot a psychopath, just as we might call someone who texts us more frequently than we want “crazy.” The word “psychopath” is also routinely used to describe serial killers, though not all serial/mass murderers have psychopathic personalities. And while “sociopath” is sometimes (mistakenly) used interchangeably with psychopath, only the latter is rigorously defined and clinically accepted, says Craig Neumann, a professor of Clinical Psychology at the University of North Texas whose singular research focus has been the psychopathic personality and its traits.

According to Neumann, the true definition of “psychopath” is actually pretty narrow: “Broadly speaking, psychopathy refers to a pathological personality style that is interpersonally deceptive, affectively cold, behaviorally reckless, and often overtly antisocial,” he writes. To qualify, he says, a person must possess traits pertaining to each of four “domains”: Interpersonal, Affective, Lifestyle, and Antisocial. The corresponding traits are as follows:

Interpersonal: They’re manipulative, deceitful, and/or narcissistic.
Affective: They lack remorse, are callous, and may take pleasure in hurting others.
Lifestyle: They’re impulsive, may use illegal substances, and may have disregard for the consequences of their actions.
Antisocial: They are physically aggressive and may have a history of or tendency toward criminal behavior.

Importantly, Neumann notes, psychopathy is a scale. “It’s not that you’re either a psychopath or not,” he says. “In the same way someone can have severe depression but it’s also possible for someone to have mild or moderate depression.” Neumann uses the example of professional poker players: they might be deceitful, and narcissistic, but they’re (probably) not psychopaths. Similarly, he takes issue with neuroscientist James Fallon’s calling himself a psychopath because his brain imaging profile matched that of psychopathic individuals.

“Just because the amygdala shows hypoactivation does not make you a psychopath,” says Neumann. “This is a characteristic that’s associated with psychopathy, but biology is not destiny. We believe that the syndrome, the personality disorder, is a coming together of these four major domains.” While certain people may possess a few, or even most of the psychopathic characteristics (like superficial charm, sexual promiscuity, and early behavioral problems, to name a few) listed on the Psychopathy Checklist (the PCL-R) — another tool used in the diagnostic process — unless they fulfill each of the four domains, Neumann doesn’t consider them truly psychopathic.

“The max score on the PCL-R is a 40, but to reach 30 is really going to be up there,” he says. (Most people score between a 1 and a 3, he adds.) “But the point I’m trying to make here is that even people who are 25, 26, they don’t quite reach the diagnostic threshold. Even people who are 16, 17, 18 on the PCL-R are nasty sons of bitches. Do they meet the diagnostic threshold of what we would call meeting a diagnosis of psychopathy? No.”

Neumann hasn’t met or spoken to the subject of the following interview, but he did offer some potential disclaimers when I described the nature of our conversation. “These people dissimulate, they lie quite regularly, so it’s a challenging interview to do,” he says. “And most individuals at very high levels of psychopathy are not going to submit to an interview.” He’s also insistent that psychopaths are inherently and evidently unpleasant to be around. “One of the essences of personality pathology is you usually feel it in your gut first. Would I get in a car with this person and drive across the United States? And if you say ‘Oh, hell no,’ that gives you a clue that there’s something off in terms of personality,” he says.

The woman I spoke to, who will remain anonymous, says she was diagnosed as a psychopath in her mid-20s, and the diagnostic process she describes appears to be in line with what Neumann says is required. That said, our conversation was under an hour, and I am not a psychologist. That conversation, which has been edited for length, is below.

When were you diagnosed as a psychopath?
From age 26 to 27. I went through the whole diagnostic process over several months. There were a certain number of doctors that were involved, and a lot of testing: neuropsych testing, personality testing, brain scans, a lot of different interviews and going through the history of my childhood. It wasn’t a quick snap diagnosis. It was something that was arrived at over a decent period of time.

What precipitated that decision to start looking into a diagnosis? 
Well, when I was younger I had some youthful indiscretions that I don’t go into. But I had gotten [an evaluation] as a teenager, and had no idea what the result of that was. But when I got a little older, it just — I’d always known my whole life I was quite different in how I trust people, how I thought about things, how I experience the world. I actually ended up contacting the same doctor who did the first workup. And he remembered me, which I thought was interesting. He said, “Well, let’s just start from scratch,” which I was actually interested in doing. I wanted to know: why is my experience so different? Why do I not comprehend the basic interactions that, for other people, it just seems to be natural for them?

I had no idea what it was going to evolve into. I didn’t know it was going to be months of testing. I think there were a few times where I was ready to not care anymore, but I kept with it for some reason. At the end of it, he was a very smart person. I think he’d probably known someone else that was on the psychopathy spectrum, so he wasn’t immediately judgmental. He didn’t automatically give me the rundown of criminals, or what a lot of people assume psychopathy to be. He was able to actually talk to me about it. Once he explained it to me, it was: oh! Oh, all right. That makes sense.

Let’s talk about what people get wrong about psychopaths, in your view. Especially now, when there’s this huge cultural true-crime obsession, I think we have this very particular understanding of what a psychopath means, and it’s almost universally someone who’s very violent.
It’s actually not an unreasonable thing — not because it’s true, but because of what they’re presented with. Most studies done on psychopaths are done [on men] in prison or in forensic hospitals, so everything you’re going to hear is going to come from a criminal. It’s always going to be painted against the backdrop of someone who has committed crimes. They’re only out for themselves, they don’t care about anyone else. If you interviewed any walk of people, and based their entire profile based on [the institutionalized] version of that person, like neurotypicals or autistic people, bipolar people, you get a very different picture than if you interviewed them in their general lives.

There is also this mistaken thinking that all serial killers are psychopaths, which is just not even remotely true. It’s just a myth that won’t die. There’s a phrase: “Not all psychopaths are serial killers, but all serial killers are psychopaths.” It’s just incorrect. But people hear this, and they associate [us with] serial killers. For some reason, people think we want to kill people. And I think that probably comes from the lack of empathy. People believe that if you have a lack of empathy, that automatically opens a floodgate of antisocial behavior. That’s not really how it works. I may not care, I may not have an emotional reaction to someone’s pain, but that doesn’t mean that I’m going out of my way to cause pain. It just means that I don’t have that emotional response.

In a day to day sense, or in your interpersonal relationships with people, is empathy or attempted empathy something you’ve had to teach yourself in order to relate to other people? How does that work?
Well, we have cognitive empathy. So if your mother died, I can look at you, I can see that you are in pain. I may not feel the same pain, but I can understand you feel pain, and that series of behaviors usually warrants a certain response: comfort or interaction, engagement. And so it’s a matter of honing that over time, and also making sure that I can continually consider that my reaction to things is not how other people experience things. Which is hard, because you sort of go through life with the assumption that everybody experiences it like you do.

Do you ever feel afraid?
We don’t feel fear. We get adrenal responses. When you have adrenaline responses to a car accident, or bungee jumping, or what have you, we’ll still get that, but for us, we don’t feel the fear, which can be obviously dangerous if you’re a little kid, and you don’t know you’re supposed to be afraid of stuff. We don’t process the emotion of fear. It doesn’t occur to us. And we can’t understand it, either. I mean, we get that you feel something, but we don’t get it.

How do you perceive it when you hear someone expressing their fear of mortality, or says they’re afraid to die someday? That always baffles me, because I can’t comprehend why it matters. For me, life is very much in this immediate moment. This moment is all you have, and the fear of it going away is just nonsensical. This is a huge disconnect for me. People explain it in ways that they very much understand: they’re afraid of dying, they’re afraid of not being important, they’re afraid of being forgotten. And none of those things are important to me, so it’s sort of like saying I’m afraid of not being the color blue.

In your romantic relationship, does that present a challenge as far as talking about values, or knowing what to do when someone wants sympathy from you? 
Certainly. I’ve been with my partner for 19 years, and he’s been with me through the whole diagnostic process, and it’s definitely been a learning curve. He’s probably one of the most patient people you will ever meet on the planet. He reads people and he understands people on a level I simply don’t. Through learning from him, I actually can apply that back to him, and understand what his needs are. It’s always a conscious effort. I know that for a lot of people, their significant other is more important to them than themselves. They think of them first, that sort of thing. That will never be natural for me. I always have to make sure I am manually considering him. There are certainly things that I miss, and it requires me to have to do bimonthly maintenance. Am I hitting all the marks for you? Do I need to do anything differently? Where am I not fulfilling what you need? And usually he’s like “eh, it’s fine.”

To be honest, that sounds like a wise practice for most people. I think a lot of people take it for granted that the other person knows where they’re at.
I agree with you. I call it cognitive love. And it’s investment. You have to make that investment, you have to make the time, you have to take the other person into consideration all the time. It’s important. His needs are on the same level as mine — which, if you knew me, you would know that that’s very, very rare.

When you say cognitive love, does that mean you don’t feel that sort of romantic roller coaster feeling that other people describe to you?
Well, no, I don’t. Certainly attraction. I feel attraction, and he’s very attractive. But psychopaths don’t process oxytocin like neurotypicals do. What oxytocin contributes to in your brain is chemical love, so that feeling of a roller coaster. Bonding is another one we don’t have. You bond to your significant other, you bond to your children, you bond to your pets. There’s also trust, which is a weird one, because I didn’t know oxytocin had anything to do with trust. Most people feel trust as an actual emotion. I never knew that. To me, trust was always: You show me how you’re going to behave, and I will determine whether or not I want you around. I always knew I didn’t trust people, and I always had a disconnect, because I didn’t know it was a chemical reaction for most people. I didn’t have an explanation as to why I didn’t trust people, but then I started digging into oxytocin. It made sense.

A lot of people think of psychopaths as having a very flat emotional affect, and I know we haven’t talked for long, but that’s not my impression of you. You obviously have a personality, and a distinctive way of speaking, and so I wonder what your experience is with that perception. 
People think we have no emotion, which is absolutely not true. We just feel them way turned down. If most people feel an emotion between seven and eight on a dial of ten, I feel it between zero and two. Negative emotions are background noise. We can’t tune into that frequency because our brains just don’t process enough information for them to ever be loud enough to feel or direct behavior. We enjoy things, get excited about things, like adrenaline — that’s great. I laugh with people, I enjoy intellectual discussions. A lower functioning psychopath probably wouldn’t enjoy intellectual conversation. They’d rather go and rob a liquor store. But that’s why they spend most of their lives in prison.

Do you feel at all that your psychopathy is an advantage to you? Do you feel lucky in any sense? 
No. It’s not an advantage, because all neurotypes come with limitations, don’t they? With psychopathy I constantly have to figure out people, and why they do what they do, and how to respond to them. Normal people have to deal with grief and loss and pain and heartbreak, but they also have things to make them happy. I think people are pretty wired the way they’re meant to be. I don’t know that it’s necessarily an advantage or disadvantage, it’s just what you make of it. I could easily take psychopathy and make it a terribly negative thing for both me and the world, because I could make bad choices, and do terrible things. I could do that, but that’s not who I have any interest in being. Anyone can make bad choices for themselves.

Do you still see the doctor who diagnosed you, or do you sort of have any regular treatment that you do?
It’s completely self managed at this point. There’s really nothing to manage. I learn about it by reading studies. I haven’t spoken to [that doctor] since back when I got the diagnosis. It was pretty much, “Thank you very much,” and that was the end of that. We never spoke again.

And you don’t take any medication for it, right?
No. It’s just a variant brain structure. And actually we respond very differently to medications as well, because our chemistry is different, so you can expect strange medication reactions. I’ve been dealing with that. Whenever a doctor prescribes the medication, I can pretty well expect it to not work as intended.

Does that apply to something as innocuous as a cold medication? 
Yeah. Sometimes cold medicines work for things like decongestants, but things like pain medication, I’ve never experienced the high that other people get. I have no comprehension of why people enjoy opioids. We also can’t get addicted to things because of the way our brain works. There are psychopaths that use drugs, but you can cut them off cold turkey and they will not have any withdrawal. They don’t have any cravings, and they can just go on with their day like it was nothing. That’s another weird chemical processing. So we just lack certain normal cues that other people have.

Online you’re very out as far as being a psychopath but is it something that a lot of people in your personal life know? Or your family?
No. They have no idea, and I’m going to keep it that way.

Do you have a relationship with your parents?
Yeah. They’re great people. They don’t know. They had a really difficult child to raise in me, and I’ve gotten older, and to them, I’ve matured into the daughter that they always wanted. I don’t really see a need to change their perceptions of things. They know me for what they need to know me for. Trying to explain psychopathy to people, especially older people, is really difficult.

With a lot of diagnoses I think the assumption would be that the more information your parents or your family or whoever has, the better they will be able to understand you, but obviously you don’t feel that way. 
Well, sure, but then you’d have to have them dive into neurology, biology, understanding the wiring of the brain. And the word has so much negative stigma. Most of the time when you say “psychopath,” people immediately have a very specific reaction, and they shut down. They have absolutely no interest in hearing past evil, dangerous, killer, malicious, out to get you. The things people assume about psychopathy are crazy. Trying to explain that to someone when you’re their daughter, and they think of you as someone they know, they love, they trust, that’s going to upset their entire perception. And you may never get it back. It’s a huge risk and not one I really have any interest in taking.

When you meet new people, whether professionally or personally or whatever context, do you present them with the version of yourself that fits the situation? 
Absolutely. Why tell them anything that they don’t need to know? They just need to know what they can expect of me.

Do you think it’s something that people suspect about you? Or do you think people’s perceptions are so off that they wouldn’t really know what psychopathy looks like? 
No. Psychopaths use what we call a ‘mask.’ It’s basically an entire affectation of being like everyone else. We learn at a really young age that if we respond to things the way that we naturally respond to things, people don’t like that. So you just learn how to affect the behavior and how to appear like everyone else, and that’s just what you have to do.

There’s a very different version of me that goes out of the house and interacts with the world from the person who’s home with people who know how I actually am. And even with the people who do know me, and do know how I actually am, there still has to be a mask. If somebody’s spending time with me in a room, I won’t give them the impression that they’re welcome. They might say something to me, and I’ll answer them back, but I’m not going to look at them, there’s no feeling of being welcome. But to me, unless I tell you to leave, you’re completely welcome.

I have a friend who will feel like I resent her spending time with me. She’ll be like, “I’m bothering you.” You’re not bothering me. Why do you think you’re bothering me? She’s like, “Well, I just get the impression you don’t want me here.” Did I tell you to leave? “No, but are we okay?” We’re fine! You’re fine. I have to make that connection. So if I don’t do that, people feel like there’s something profoundly lacking, and they feel uncomfortable. It’s very disquieting to them.

Does that friend know what your diagnosis is? 
Yes, she knows, and she tries very hard. She makes adjustments for me, I make adjustments for her. That’s the sort of mutual investment in the friendship.

I think most people are so used to feeling like they have to be people pleasers, and that everyone else should be that for them, I can imagine why it would be unsettling to be around someone who, while they’re maybe not doing you any harm, they’re not going out of their way to practice those social pleasantries, either.
Exactly. And if I was completely mask off, and something tragic happened to them, if she was lost a parental figure and came to tell me about it, I would just look at her with a flat look of, “Okay.” It wouldn’t be “Are you okay? What can I do for you?” It would just be, “Alright.” And that’s not a good response to have when someone’s having a grieving process. You have to engage. I learned very early on that there are responses that are required for people to not be very uncomfortable.

Is that something that gets easier with time, or is it something you’re always working on? 
No. It’s always, always, always a pain in the butt.

You’ve said you get a lot of death threats online when you post about your experiences as a psychopathic in forums. Why do you think some people respond that way to you? Do you have any idea? 
I think it comes from a visceral fear of the unknown, or fear of evil. Hollywood has desperately pushed this narrative of psychopathy. And when you’re taking away the villain, which is really what psychopaths are in movies, people get very upset about it. I don’t know if you’ve seen sites like Love Fraud or Psychopath Free, on and on and on, but there are all these sites where people go when they’re convinced their ex is a psychopath, when really their ex was just a toxic, awful person. There are millions of those, and they’re everywhere, and they come from every neurotype.

Is there anything that you feel that I left out, that you would like to add?
It’s a lot more complex than people realize. I think it’s important to hold people responsible for their actions, not brain formation. People make choices. Psychopathy is not an excuse, and it’s definitely not a reason why someone does bad things. People do bad things because they make bad choices. So instead of looking at psychopathy as this constellation of things that represent evil, just look at it as a different way of experiencing the world, and what a person chooses to do with that is on that person. 

Sigmund Freud and 21st Century Social Media: Id, Ego & SuperEgo as Social Media Platforms

Posted on July 1, 2018, Written on June 13, 2018 By Chris Broyles

You walk up to Berggasse 19 in Vienna, Austria, and enter a dimly lit room filled with thousands of books, odd antiquities and hear the dull tick of an unseen clock. You see an oddly familiar face of a slight older man with a silver-grey beard, cigar delicately balanced between his fingers, and he asks you to sit down. After a measured beat, the famed neurologist and founder of psychoanalysis Sigmund Freud leans in and gently asks:

“Tell me about your Twitter…”

So that might not be *exactly* what he would have said back in the late 1800s and the early 1900s during the rise of psychiatry. But given the progression of some of his famed theories including the belief that the human psyche is structured into three parts; the Id, the Ego, and the SuperEgo, he might have had a field day equating these systems to the way individuals seem to approach modern day social media.

As Sigmund Freud’s model of the psyche – or personality – lays it out, these three components can be viewed like an iceberg – the tip of the iceberg above water represents conscious awareness (Ego), while the larger mass of the iceberg below the surface represents the unconscious mind (Id), where the innate desires, urges, needs are met, and the ‘pleasure principle’ initiates the human need for instant gratification. As you grow older, your personality develops, and you grow to control these ‘Id’ based urges, and your true self (your ‘Ego’) matures. All the while, resting both above and below the surface, you strive to reach your own ideal (‘SuperEgo’) by controlling the Id, and balancing your Ego, and who you actually are as a person.

What’s the correlation to social media? Well, as we’ve seen in the three major social networks, the instantaneous nature of Twitter – or our “social Id” – lends itself to both real-time moments of delight, humor and shared event-driven experiences, but also gives voice to regrettable bursts and limited character shots of insults, sexism, racism, and other streams of consciousness that might have better been left unsaid (or at least, unwritten).

Facebook, with its shared connections, photos, posts and ‘likes’ between friends, family, schools, businesses and our everyday lives, is a reflection of our self (our “social Ego”) …demonstrating on a near daily basis who we actually are as a person and member of society or defined group.

LinkedIn on the other hand, is a platform where we define who we are professionally, but also enables the user to carefully construct who they want others (more often than not, strangers vs. friends or colleagues) to see who we want to believe we are: a “social SuperEgo” that symbolizes our ideal self.

What makes it so hard for people to control their pleasure principle, or “social Id” on Twitter? Sigmund Freud himself wrote: “The first human who hurled an insult instead of a stone was the founder of civilization.” It took ABC mere hours to respond to Roseanne Barr’s racist and Islamophobic tweet about Valerie Jarrett by firing her and canceling the recent Roseanne reboot. “Roseanne’s Twitter statement is abhorrent, repugnant and inconsistent with our values, and we have decided to cancel her show,” ABC Entertainment president Channing Dungey wrote in a statement. There have been many other moments where jobs have been lost, lives altered and online “angry mobs” formed as a result of what was tweeted. Jon Ronson gave a TEDTalk a few years back on how ‘one tweet can ruin your life,’ despite the fact that the platform initially gave voice to the voiceless, but was now growing into a steady stream of epithets and dehumanizing colloquy. The talk featured the now infamous 2013 story of Justine Sacco, the PR exec, who as she was leaving for an 11 hour flight to South Africa from London, tweeted ‘Going to Africa. Hope I don’t get AIDS. Just kidding, I’m white!” The fallout was as swift and punishing as you might imagine with this kind of exercise in ‘social Id.’ And there isn’t room in this piece to discuss how our current President utilizes his primal need to use the social platform.

Facebook addressed the societal impact it has in a blog post late last year. David Ginsberg, Facebook’s Director of Research, and Moira Burke, Research Scientist at Facebook, wrote about the critical question about whether spending time on social media was “bad for us.” While they candidly talked about the ‘bad’ that can come with passively scrolling and consuming social media, they also addressed the research that describes the positives that come with actively interacting with one another. The research netted out that separating good from bad comes down to how you use the technology.

CEO Mark Zuckerberg said:

“…it’s important to remember that Facebook is about bringing people closer together and enabling meaningful social interactions; it’s not primarily about passively consuming content. Research shows that interacting with friends and family on social media tends to be more meaningful and can be good for our well-being, and that’s time well spent. But when we just passively consume content, that may be less true.”

Facebook’s platform allows for us to have those meaningful relationships and engagement, and as the age of its user grows older, the sharing of photos, videos, graduation announcements, trips, dinners and entertainment becomes even more a part of the sharing of “self.”

Now that we’ve talked about our Id and our Ego, what about our “social SuperEgo?” If the SuperEgo is “the component of personality composed of our internalized ideals that we have acquired from our parents and society,” working to suppress the pleasure principle of the Id and at the same time striving to make the Ego stay in line, how does LinkedIn play its role? In our world, it’s a business tool. And as professionals, we strive to present ourselves in our ‘ideal form’ to others.

AdWeek wrote an article last fall about how LinkedIn has gone from questionable Microsoft acquisition to one of the most influential social media platforms for businesses and professionals. “People are more careful about what they say on LinkedIn, because it’s essentially their default resume,” says M. Scott Havens, global head of digital for Bloomberg Media. “We see a much cleaner conversation that’s supportive, positive and actually useful.” LinkedIn has grown to be a platform where ‘civil discourse’ and B2B engagement runs supreme.

While Sigmund Freud may not have lived to see 21st century social media, he believed that “the voice of the intellect is a soft one, but it does not rest until it has gained a hearing.” He invariably would have had a lot of business lining people up and laying them down on the couch to analyze their online profiles. At the end of the day, social media platforms have now become inescapably woven into the fabric of our society. Whether exercising our pleasure principle on Twitter, sharing photos of our latest family outing on Facebook, or posting recent thought leadership from our company on LinkedIn, it’s interesting to see how our personalities naturally fall into this “tripartite” theory.

Digital Illustration by: Ben DeRosa

Reprinted from:

Mission to Mars: What psychosocial challenges would astronauts face on an epic journey to the red planet?

By Kirsten Weir

June 2018, Vol 49, No. 6

Posted from here (APA)

Even at their closest, when Earth and Mars are approaching one another in their oblong orbits, there are 35 million miles between our blue orb and the red planet. But that distance hasn’t stopped NASA and other space agencies from setting their sights on a human mission to Mars, which would require astronauts to live in space for at least two and a half years. NASA has been working toward the goal of delivering astronauts to Mars by the early 2030s, says Thomas Williams, PhD, a psychologist and chief scientist of human factors and behavioral performance at NASA’s Johnson Space Center in Houston, Texas. In December, President Donald J. Trump signed a space policy directive instructing the space agency to return astronauts to the moon. It’s been nearly 46 years since astronauts last traveled beyond Earth’s orbit, and a fresh moon mission would serve as a pock-marked steppingstone toward a subsequent human mission to Mars.

Getting there requires not only rocket science, but also human science—which can be even more daunting than perfecting propulsion systems and landing gear.

NASA doesn’t take these challenges lightly, Williams says. Scientists are carefully assessing the physiological, psychological and social factors associated with a journey to Mars, with NASA conducting research independently as well as in partnership with experts outside of the agency. “We are concerned about the risks behavioral health and performance would pose to a Mars mission within our current understanding, but we have cutting-edge researchers to help us answer these questions,” he says. “None of this we consider insurmountable.”

Far from home

Scientists have been studying the effects of living in space for decades. Since 1971, astronauts (and their Russian counterparts, cosmonauts) have spent weeks or months inhabiting a series of space stations orbiting Earth. The current iteration, the International Space Station (ISS), welcomed its first crew in 2000 and has been occupied ever since.

Research from the space station has provided useful information about how astronauts respond to the challenges of space, such as microgravity, confinement and isolation, says Nick Kanas, MD, emeritus professor of psychiatry at the University of California, San Francisco, who has long studied space psychology. But interplanetary travel is another story, he says. “Mars is a long way away, and the extreme distance has psychological ramifications.”

Pictured here are crew members (left to right): Dr. Ross Lockwood, Dr. Tiffany Swarmer and neuropsychologist Dr. Ron Williams at the Hawai’i Space Exploration Analog and Simulation habitat.Currently, astronauts spend about six months at a time on the ISS. So far, the longest consecutive period spent in space is 437 days, a record set by cosmonaut Valeri Polyakov aboard the Russian station Mir. A multiyear journey is uncharted territory—and a long time to spend in tight quarters with just three or four other people. “It will be hard to have the kind of social novelty we crave,” Kanas says. And because a Mars expedition would probably be a collaborative effort among countries, those astronauts will have to overcome cultural differences to live and work together.

What’s more, communication between Earth and a Mars-bound ship will be delayed up to 20 minutes each way. If an astronaut asked a question, 40 minutes could pass before he or she received a reply. “We know the ability to talk in real time with family and with the people on mission control is very important to astronauts,” Kanas says. “When you take that away, it creates a real conflict.”

The difficulty of speaking with family members on the ground could contribute to loneliness and psychological problems such as anxiety or depression. Astronauts will also have to be much more autonomous and prepared to handle emergencies on their own, since they won’t be able to rely on real-time advice from mission control. “The communication delay will lead to crews having to take care of their own problems, including medical or psychological emergencies,” Kanas says.

Another concern is how astronauts might react to the experience of being so far from Earth. Many ISS astronauts report that gazing at and photographing the Earth from above is a favorite pastime that can reduce stress and even inspire spiritual or transcendental experiences, as Kanas described in a review of the psychosocial issues related to long-distance space travel (Acta Astronautica, Vol. 103, No. 1, 2014). But that perk won’t be available from 35 million miles away. “Nobody knows the effect of seeing the Earth as a dot in the heavens,” he says. “Maybe it won’t have any effect—but maybe it will.”

Floating questions

The physical challenges of living in space can also have implications for psychological well-being. One top concern is how space radiation will affect the body. Beyond the protective bubble of Earth’s atmosphere, space radiation poses a significant threat to human DNA, cells and tissues. “It can impact the central nervous system and can alter the structure and function of the brain,” says Williams.

In animal studies, NASA scientists are exploring how chronic radiation exposure might affect brain function. Recently, Charles Limoli, PhD, at the University of California, Irvine, and colleagues exposed mice to charged particles that simulated cosmic radiation. They found structural changes in the mice’s brains such as reduced complexity of dendrites, the extensions that branch from neurons. What’s more, the mice also showed behavioral changes, including memory deficits, increased anxiety and deficits in executive function (Science Reports, Vol. 6, No. 1, 2016).

Researchers are also studying factors that might compound or minimize those effects, Williams says. For example, scientists are exploring the concept of cognitive reserve, which posits that education and experience can help protect the brain against physical damage (such as the pathological changes associated with Alzheimer’s disease). NASA scientists are investigating whether cognitive reserve can also protect against radiation in space.

The effect of altered gravity is another active area for space scientists. Floating weightless might look like fun, but it can lead to physical problems including motion sickness, muscle wasting and changes in visual perception. Those changes could have downstream effects on psychological well-being, Williams notes. Getting regular exercise, for instance, is a lot trickier when your feet don’t touch the ground—and physical activity is known to promote positive mental health.

Weightlessness can also contribute to psychological problems in surprising ways. For example, kidney stones are more common in altered gravity environments, and stones can raise the risk of urinary tract infections, Williams says. In some cases, undiagnosed UTIs can trigger confusion or delirium, which could be mistaken for a psychiatric disorder. Researchers’ work to connect the dots among these possible risks is essential for preparing astronauts for life in space. “It’s important to be alert to what medical conditions could occur as a result of these altered environments,” Williams says. “If someone has a medical condition, we don’t want to treat it as a psychological problem.”

Mental health on mars

Prolonged weightlessness is hard to study on Earth, where it’s impossible to cancel out the effects of our planet’s gravity. But many other features of an extended space mission can be recreated in so-called space analog studies conducted in confined and isolated environments.

U.S. Air Force Reserve Officer Casey Stedman served as commander for the second mission of the Hawai’i Space Exploration Analog and Simulation project.The largest such study to date was the Mars500 project, led by the Institute of Biomedical Problems of the Russian Academy of Sciences in 2010–11. For 520 days, six healthy male participants from several countries lived inside an enclosed module in Russia designed to mimic the feel and function of a Mars shuttle. Crew members had military and engineering backgrounds, similar to the traditional backgrounds of astronauts and cosmonauts. During the simulation, the crew members performed routine maintenance and scientific experiments, were isolated from Earth’s light-dark cycles and experienced communication delays just as they would on a flight to Mars.

That experiment raised some concerns, says David Dinges, PhD, a psychologist at the University of Pennsylvania who researches chronobiology and has studied astronauts on the ISS and in space analog environments. He and his colleagues recorded psychological and behavioral changes among the Mars500 participants. One crew member experienced mild to moderate symptoms of depression during most of his time in confinement, they found. Two others experienced abnormal sleep-wake cycles, while another reported insomnia and physical exhaustion (PLOS One, Vol. 9, No. 3, 2014).

In the same study, he and his colleagues also found that the two crew members who had the highest rates of stress and exhaustion were involved in 85 percent of the perceived conflicts with other crew members and mission control. A single stressed-out astronaut, in other words, might cause problems that affect the entire mission.

In a different study, Dinges and colleagues looked more closely at the sleep and activity habits of the Mars500 crew. They found that as the months stretched on, crew members became increasingly sedentary when awake. They also spent more time sleeping and resting, which the researchers characterized as a kind of behavioral “torpor” to conserve energy. Four of the six crew members experienced sleep problems during their 520 days in pseudospace, including disrupted sleep-wake schedules, reduced sleep quality, a shift to more daytime sleep and performance deficits related to chronic sleep loss (PNAS, Vol. 110, No. 7, 2013).

Some of those problems can be addressed by optimizing lighting to more accurately mimic the 24-hour cycle and UV spectrum of sunlight on Earth, Dinges says. “We are a circadian species, and if you don’t have the proper lighting to maintain that chronobiology, it can create significant problems for crew members,” he explains. Other elements, such as stress or operational factors related to crew work schedules, might also be to blame, he says. But more research is needed to fully understand those factors.

Coping skills

Dinges is among a large team of scientists working to understand and prevent psychosocial problems that might arise in space. In a new NASA-supported project, he and colleagues at institutions across the country are looking for biological indicators that offer clues about a person’s emotional, social and cognitive resilience. “We know there are substantial individual differences in how people cope with different kinds of stressors, but we don’t understand why that is—and more importantly, how to identify ahead of time how people might cope, or how to help them do it,” he says.

NASA already employs a comprehensive physical and psychological screening process to identify astronauts likely to thrive under the stressful conditions of spaceflight. Biomarkers of resilience could add a new dimension to that evaluation. However, selecting biologically superior astronauts isn’t necessarily the goal, says Dinges. Instead, he envisions such biomarkers being used in research to identify and test medications or behavioral strategies that could boost resilience.

“Biomarkers could be used to determine how to maximize those countermeasures,” he says. “Behavioral issues are serious, and the challenge isn’t just to figure out who can optimally cope, but also how to provide help for those who need it.”

It’s too soon to say whether scientists will succeed in finding a blood test to measure resilience. But with or without such a test, a Mars mission requires a strategy to help astronauts manage stress and maintain emotional well-being.

Raphael Rose, PhD, a psychologist at the University of California, Los Angeles, is among the scientists contributing to that effort. He has studied a stress management program among participants in the Hawai’i Space Exploration Analog and Simulation (HI-SEAS) project, a study led by the University of Hawai’i at Mānoa. During the fifth installment of the project in 2017, six men and women spent eight months living and working in an isolated compound on the rocky, otherworldly landscape of Mauna Loa.

During that project, participants used Rose’s program, the Stress Management and Resilience Training for Optimal Performance (SMART-OP). The program involves a variety of self-guided modules, such as video demonstrations of conflict-resolution strategies and a biofeedback game that helps the user practice regulating his or her breathing and heart rate. Rose says NASA is reviewing the findings, which have not yet been released to the public. But he’s optimistic the program shows promise. “The participants found the program really useful and helpful, which is a good sign that it’s something people would actually use, and something that could be integrated into future trainings or missions.”

“These crews contain rather remarkable people who are already quite resilient to start with,” Rose says. “But we can lower the risk of any behavioral health concerns by addressing things in advance through training and providing people with an avenue to address any issues that come up.”

Studies such as Mars500 and HI-SEAS are important, but can’t answer all of the questions about life in space. Sample sizes are tiny. And participants know they’re not actually hurtling through the void of space. Of course, there’s that pesky thing called gravity.

Yet while a true trip to Mars might have unique stressors, it is also likely to be filled with excitement and wonder. For people who have long dreamed of exploring the next frontier, those benefits are likely to outweigh the potential risks. “The reality is it would be pretty exciting for astronauts to actually be the first to walk on Mars,” Williams says.

The Art of Not Trying Too Hard

Steven Shapiro • 5/4/2018

Q: I’m sometimes unable to form an alliance with “difficult” clients, and therapy fizzles out before it’s gotten started. How can I reach these hard sells?

A: As you’ve undoubtedly discovered, when we genuinely connect with clients, therapy usually goes smoothly and effectively, and the work is rewarding. We tend to ascribe our successes to our clinical skills and our clients’ motivation. Like¬wise, when things don’t go so well—when we sit with passive, sullen, unengaged, unforthcoming clients for session after session—we often think it’s because we lack the necessary skills, or the clients are unmotivated or resistant. We may even begin to resent such clients for putting up barriers against our best efforts to help them.

What stands in the way of connecting effectively? I’ve found that the major difficulty stems, paradoxically enough, from trying too hard! Many clients, even if they’re highly motivated to get into therapy, have only limited tolerance for emotional connection, interpersonal closeness, and sympathetic concern—actions that most therapists assume are central to the alliance and to therapy itself. The harder you try to reassure such clients and show how much you care, the more fearful, defensive, and withdrawn they become.

What’s happening here is a failure to match our self-presentation and efforts to connect with our clients’ emotional capacity to respond. To put it bluntly, our song hurts their ears, and the more they express their discomfort, the louder we sing. What we need to do instead is work on matching our personal style and way of connecting to theirs, making it easier for them to accept our attention and clinical focus.

Here are three guidelines that may help you form a solid alliance with your hard-to-reach clients.

1. Instead of assuming that withdrawn, distancing, sullen, un-forthcoming clients are being “resistant,” consider the possibility that emotional experience of any kind makes them uncomfortable and anxious. Or: it’s not about you.

Clients’ emotional distance may have nothing to do with your skills, but may reflect longstanding personal difficulties and family-of-origin issues. The emotional chilliness may be interesting in itself. Go with the flow! Engage your own curiosity about this dynamic without im¬plicitly shaming clients for being “resistant” or “self-defeating.” Explore clients’ behavior with questions about its origins. Is the discomfort more related to issues of trust, feelings of vulnerability, rejection, or a need to be independent and in control? What does this say about their upbringing, previous relationships, or prior therapy? Your tone should be casual, respectful, and curious. “What’s it like to have nothing in particular to say?” you might ask. “Does this happen in other areas of your life?” “What impact does it have on you?”

2. Carefully observe clients’ reactions to your manner of relating and respond accordingly.

This may seem obvious. Aren’t we all on the alert for our clients’ emotional reactions to the ongoing process of therapy? But here I’m talking about looking for delicate, usually nonverbal, cues about the “temperature” of the session—largely an intuitive process.

Joseph was a young man referred because of his serious substance abuse, depression, and suicidal thinking. As we talked, he described a lifelong history of feeling that he’d had “difficulty fitting in,” along with tirades about the evils of “society”: people were “sheep,” who allowed themselves to be herded around by venal, self-serving politicians; people selfishly thought about meeting their own needs, with little concern for the greater good. My attempts to search for personal connections consistently met with argumentation. It was too painful for Joseph to acknowledge that his childhood with insensitive parents didn’t reflect the whole of society. I’d ask him in what way these “social” issues personally impacted or reflected his life, only to be assaulted with his criticism that my question proved his point—that I wasn’t concerned with the overall good of others, but was only selfishly interested in the individual. Whenever I spoke of my concern that just engaging in tit-for-tat dialogue made it difficult for me to help him, or said anything that indicated I cared for him, Joseph became visibly uncomfortable and responded with cynical and sarcastic remarks.

I used these reactions as a cue to search for a different way of relating, hoping to connect with a less defensive aspect of his character. Given his low tolerance for emotional experience, I turned down the heat on anything remotely emotional and changed my language from comments about “my concerns” and “his potential” to concrete remarks about keeping a “productive focus” and “meeting established goals”—less like therapy and more like a motivational business meeting.

I noted a reduction in tension and resistance almost immediately. The less effort I made to connect personally, the more Joseph relaxed and allowed connection. By going slower, we arrived faster. Eventually, Joseph became comfortable enough that I could gently confront him with the need to make a choice between “having fun”—engaging me in argumentative banter—or actually meeting his goals for therapy.

3. Closely monitor your clients’ anxiety level.

The best barometer of therapeutic responsiveness is clients’ anxiety level. Anxiety is like the tip of an iceberg. We may not know what lies below the surface, but sensitively monitoring clients’ discomfort will provide a guide for how to proceed. Alter your approach as needed to keep anxiety in an optimal range: too little and clients aren’t motivated; too much and they get overwhelmed and defensive.

Sue, a middle-aged woman with a long history of self-defeating behavior, suffered from severe depression and feelings of inadequacy. As a child, she’d been physically abused and devalued. My personality and training led me to maintain a more distant relationship, offering little of my personal self. Thus, when Sue would sink into helplessness and hopelessness, I’d explore, dispassionately, the related internal dynamics and conflicts. These explorations proved fruitless, and I noticed an increasing anxiety, frustration, and even confusion on her part. As I experimented by offering more personal reactions, I noted a reduction in anxiety and a deepening of rapport. Expressions of compassion for her suffering and admiration for her courage in addressing such difficult childhood experiences seemed to compensate for her inability to offer these feelings to herself. Unlike Joseph, who needed less therapeutic emotion, Sue needed more emotional connection than I’d been giving. She didn’t need to hide or guard herself: she needed to be understood explicitly and validated in a deeply emotional way.
In one therapy session, she reported a significant accomplishment, but was unable to experience any sense of pride or success in it. When I encouraged this well-deserved feeling, she became increasingly anxious. How¬ever, when I openly and warmly told her how proud I felt about her achievement, her discomfort immediately decreased. As I transitioned to a more affirming, explicitly validating, approach and “gave” this experience to Sue, she demonstrated steady improvement and increasing ability to experience healthy pride herself.

The more you develop a broad range of skills, comfort zones, and flexibility, the more you’ll be able to tailor your approach to the needs and styles of a variety of clients. You’ll be a master actor, able to adapt to a broad range of roles, rather than a character actor, who plays essentially the same part in every script.

Being an effective clinician means letting go of preconceived ideas about how to respond, and paying attention to your clients’ moment-to-moment needs. This attitude requires comfort with the unknown and faith in the therapeutic process. When you have no idea what to say until after the client has responded, you’ll know you’re getting the hang of it.


Article Reprinted

The Best Kept Psychotherapy Secrets

How to get help with today’s “problems of living.”

Posted Apr 23, 2018

Psychology Today

Keeping secrets is a central tenet in my line of work as a psychiatrist and psychoanalyst.   I am intimately involved with the most private experiences, behaviors, fantasies, thoughts, and desires of my patients. Keeping secrets is vital in developing and maintaining a trusting and nurturing alliance with my patients. As treatment proceeds and trust deepens, my patients reveal more, and eventually, they come to understand even the “secrets” they have kept from themselves.  Or as one of my patients frequently liked to remind me, “You are only as sick as your secrets.”

But the profession of psychoanalysis has often had a tendency to prescribe itself too much of its own medicine.  We have been so good at keeping secrets that the public does not really know who psychoanalysts are, what we do, what we treat, or how to find us!

Who are we?  

We are psychiatrists, psychologists, social workers, or academicians who have 5 to 10 years of extra training beyond our professional degrees. Psychoanalysts are educated to become experts in the “basic sciences” of talk therapy and difficulties encompassing relationships, love, and work.  These difficulties can lead to a variety of “problems of living”

This education is intense!  It involves four to five years of classroom work and weekly presentations of clinical material from several cases to different senior psychoanalysts. But the most central part of the training, and what distinguishes it from all other psychotherapy education, is that we become patients in our own personal psychoanalysis.  This is important because it offers the beginning psychoanalyst an opportunity to:

1.     Gain a better understanding of their inner psychological life

2.     Work out their personal emotional difficulties

3.     Resolve therapeutic “blind-spots” when working closely with patients

4.     Gain an empathic understanding of the vulnerability of being a patient

What do we do?

We listen in a specific manner, utilizing well-honed skills from our specialized training.  We also invite our patients to listen and observe their inner emotional life.  In a sense, it would be like looking at an X-ray of your body with a radiologist.  The radiologist’s expert training can help them identify problems that may be right in front of your nose but are not readily apparent.  You might share discomfort in your body and the radiologist could help you correlate this with the X-ray and vis-versa.  Over time, you could learn from each other and develop a good idea of what is going on inside.

What do we treat? 

We treat “problems of living.”  Although these struggles are ubiquitous, and an aspect of being human, sometimes the stresses and strains of everyday life, traumatic events, or other “triggers” tip the scales away from normal health. This can result in anxiety, depression, inhibitions, and symptoms.  Some examples of symptoms are anger, irritability, low self-worth, somatic preoccupation, lack of confidence, sexual dysfunction, problems with relationships, obsessive thoughts, avoidance behaviors, insecurity, not being able to reach one’s academic, or professional potential.

Developmentally, problems of living often first appear in adolescence or early adulthood as life gets more stressful with increased adult responsibilities such as independent living, marriage, children, careers, and other commitments.  These struggles tend to become more entrenched, tenacious, and intricate as life goes on, potentially causing angst in an otherwise good life. As a result, I advise younger people in college, graduate school, or as young professionals to consider and address their problems of living early on and in a serious manner.

In this fast-paced Twitter age, many people seek a quick fix. Who could argue or disagree with wanting more for less when it is effective? But with problems of living, short-term treatments may temporarily ease acute discomfort and symptoms but are only nibbling around the edges of more extensive workable difficulties. Unfortunately, unless effectively treated, these problems will likely repeat themselves over and over within a lifetime.

What else is important to know?

It is important to note that the profession of psychoanalysis has changed and is evolving with the times.

Psychoanalysts are all races and ethnicities.  We are men and women. We are straight, gay, liberal, conservative, and everything in between – just like our patients.

Psychoanalysts are radical!  In our fast, action-packed, social-media driven, instant gratification culture, psychoanalysts offer the radical approach of slowing things down in a private, quiet, and completely confidential setting. We help you explore and redesign your interior emotional world, yielding freedom from inner shackles.

Psychoanalysts are “all natural” with few additives! We conduct our work through the natural use of language and a close, meaningful relationship.  This is basic to being human and connects us to our humanity in such a seemingly simple yet extraordinarily complex way.  By using the freedom of talk, and listening in a particular way with a well-trained ear, we help work out personal vulnerabilities and bolster strengths.  One occasional “additive” is the use of medication, when necessary, along with talk therapy.

Psychoanalysts are a rainbow coalition, offering a psychological pot of gold for those who are motivated, courageous and have the determination and grit to take the audacious step to explore their inner life to free themselves from their restricting anxieties, depression, inhibitions, and symptoms.

Most of all, psychoanalysts care and are here to help.

About the Author: Bruce J. Levin, M.D., is a Training Analyst at the Psychoanalytic Center of Philadelphia and at the Institute for Psychoanalytic Education (IPE) affiliated with the NYU School of Medicine. He is Distinguished Fellow and Life Member of the American Psychiatric Association. He practices in Plymouth Meeting, Pennsylvania a suburb of Philadelphia.