- I know all of you, I think you all know me.
I'm Carolyn du Bois, I'm the director of field work
here at the School for Social Work
and I welcome you to our annual field conference.
I'm absolutely thrilled that you're here,
I say it every single year to you,
we could not do this field program
or run this master's program, for that matter,
without the contributions of our field affiliates.
So we're thrilled that you're here,
thank you for all that you do all year.
I'd also like to thank my field team,
Maria del Mar Farina, our assistant director of field,
and Katelin Lewis-Kulin, our associate director of field,
both of whom are out running errands for me right now
but will be back, and we thank them.
It is my pleasure to introduce to you tonight Dr. Jon Allen,
who is this year's E. Diane Davis Memorial Lecturer.
I want to say a word first about Diane Davis,
who was a beloved and highly respected member
of our adjunct faculty who passed away
at an extremely young age in 1986.
This lecture is given each year in her memory
and in honor of her contributions to the field of
clinical social work, to psychodynamic practice
and to the Smith College School for Social Work.
And now I'd like to tell you a bit
about our distinguished speaker, Dr. Jon Allen,
an internationally-renowned expert in trauma treatment
about which he will speak this evening in a lecture entitled
"Trauma Treatment As Plain Old Therapy".
Dr. Allen is a senior psychologist at The Menninger Clinic
and professor in psychiatry in the Menninger Department
of Psychiatry at Baylor School of Medicine,
in addition to which he holds adjunct faculty appointments--
thank you-- at the Institute for Religion and Health
at Texas Medical Center,
and at the Center for Psychoanalytic Studies
in Houston, Texas.
Dr. Allen received his bachelor's degree
from the University of Connecticut,
his Ph.D from the University of Rochester in New York,
and completed a two-year post-doc fellowship
at the Menninger Clinic.
He is, as you know, an internationally-known scholar,
researcher and educator.
Dr. Allen has received numerous honors and awards
including the Scientific Achievement Award
of the Kansas Psychological Association
and the Arthur Marshall Distinguished Alumnus award
and the David Rapaport Award for Excellence in Teaching,
both at the Menninger Foundation.
He has held faculty appointments at
a number of academic institutions
and is a prolific author, having published 12 books,
numerous book reviews, editorials,
and 160 articles and book chapters.
I counted them up.
(laughter from crowd)
I just don't know how one person does that.
And then, furthermore, I learned at dinner
that he's a jazz pianist and has
almost 100 compositions to his name.
(chatter from crowd)
So I don't know what to begin to say.
(laughter from crowd)
The 160 articles and books' chapters cover topics
which include mentalization in clinical practice,
the treatment of trauma and dissociation,
psychosis and depression.
His book on traumatic relationships
and serious mental disorders has been used extensively
here at the School for Social Work
and has been extremely helpful to our students
as they prepare to serve the clients
with whom they work in the field.
Dr. Allen has served on the editorial and review panels
of numerous publications and has served as the editor
of The Bulletin of the Menninger Clinic,
the associate editor of the Journal of Trauma
and Dissociation, and as an editorial consultant
to the American Psychiatric Press.
He's the principal investigator of Menninger's
hospital-wide outcomes project
and has presented the research and scholarly work,
his research and scholarly work,
across an international range.
It's truly a gift to have him with us here tonight.
Please join me in welcoming Dr. Jon Allen.
(audience applauds)
- Thank you, Carolyn.
I don't know who that person is.
I'm gonna talk to you about plain old therapy.
Plain old presentation.
Okay. I am really thrilled that you asked me to come back.
I made a note that I was here in 2004.
Yeah, 2004, and I'm gonna give the same talk.
(audience laughs)
So probably if you were here, you don't remember it.
(audience laughs)
I hope. I didn't remember it. (laughs) So.
And that talk actually, Jerry Seamus and I
had spent quite a bit of time together,
and after the talk, I was,
I don't know if you know the word "whinging".
I think the Brits use it, and Peter Fonagy told me,
"'Whinging' is peevish complaining."
So when I was here in 2004,
I was whinging about science and its take
over the practice of psychotherapy.
And I had an interesting experience.
At the end of my talk,
and it was in this auditorium, I'm quite sure,
Laurie Pearlman, who some of you might know,
she was sitting about there and she said,
"Well, you know, it's interesting that you--",
she didn't say I was whinging, but she said,
"It's interesting that you were so critical of science
"and your whole talk was based on scientific research."
So, I actually, I'm still struggling with this
and I didn't know how much until Phebe Sessions
did a videotape interview of me this afternoon,
kind of a precedes of this talk,
and she says, "So tell me what's going on here.
"I've read your stuff, you review all this
"very complicated science and theory
"and you're telling me you're gonna talk about
"plain old therapy. How does this go together?"
So what I said is, and I realized it for the first time
in our talk, that I have mastered the art
of talking out of both sides of my mouth.
(audience laughs)
So I do think since 2004 I've got a bit better perspective
on this, and of course there's a ton of science
that has emerged pertinent to the treatment of trauma
since that time.
So I'm gonna aspire to present
maybe a bit more balanced view
of science and, as that paper said, art in therapy.
And I'll probably whinge because
I just whinge about stuff all the time.
So I'll probably do it here, too.
I do wanna say that there's a lot more material
on the slides and on your handout
than I'm gonna cover.
Having this in your handout frees me
to not go over it, but it's kind of a,
it'll give you a bit of a guide to the literature
and you should have also a bibliography
that you can use for more detail.
So I'm gonna hit the highlights,
and I'm kind of tethered to this computer here
since I don't have a clicker and the print's rather small,
so I'm gonna have to read it.
So I wanna talk about rethinking psychotherapy.
I think, to be very blunt,
the field of psychotherapy is nuts.
That's my diagnosis.
And so I wanna talk about that,
and I really think we do need plain old therapy.
We need more than that, but we certainly need that.
And I wanna talk about probably why you came
to attachment trauma and its treatment.
But I do think all of these things,
I hope, will hang together.
Now, this case material is not on your handouts.
It's disguised but I prefer not to circulate it.
But I wanna start, just to give you some feel
for how I work as a therapist,
and this patient illustrates something, I think,
very important about attachment.
So this patient--
by the way, this therapy was conducted,
twice-a-week psychotherapy in the context
of a several-week inpatient treatment.
So this is intensive hospital treatment
which includes group therapy, family therapy,
all kinds of therapies and psychotherapy,
individual psychotherapy which I was doing as part of it.
Okay, so rethinking psychotherapy.
I like this quote, and I'm very fond of philosophy
as you will see.
Now I was thinking, for this talk, I thought
"Okay, so how do I think about therapy?"
And this is the way I would think about it, basically.
And I'm talking about plain old therapy
and what's crucial in therapy,
making meaning of a person's life
in a trusting relationship, coming to know and understand
a person by means of engaging her or him
in self-understanding, engaging the person
in a reflective and empathic dialogue
about how best to live and the obstacles to doing so.
And there's one other thought I had as an afterthought,
but I'm convinced it's crucially important in therapy,
that we need to find a way of appreciating the person
that we're working with.
This is crucial. I'm not just talking about liking.
Doesn't quite get there. Appreciating the person.
And often this isn't hard,
but sometimes it is quite hard.
Some people, it's hard to appreciate.
What's hardest for me is people who are
pretty consistently...whinging, actually. (laughs)
Complaining, somewhat arrogant, and contempt.
A little vignette: I worked with a person
who was extremely angry.
She was very angry, and she had a battle
with her family and she came into the session
and she told me about how she cussed them out.
And I said, "Boy, that sounds nasty."
Now she was, I think rightly, feeling criticized
that I was, in a sense, saying,
"Boy, you were being nasty."
I think that message was pretty clear.
And she really objected.
She, basically, she said, "Well, this is PTSD,
"and I have trauma and anger is part of trauma
"and this is just part and parcel of being angry."
And so, okay, I didn't challenge it,
but I thought about it after the session,
and actually, what I understood,
anger was not the problem.
Now I was worried, because patients like this
get thrown out of our hospital, believe it or not, if it's
bad enough that it's just impossible to work with them.
I was worried about her treatment.
But I realized something that was very important
and I said it to her and she appreciated it.
The problem wasn't anger; it was contempt.
The cussing was contempt.
That's what bothers people.
I think anger is unpleasant, but contempt
is what really riles people up.
These, by the way, are, you could say it's moralizing.
These are not scientific interventions.
This is, you know, a way of thinking about people
that goes beyond science, but it has to do with
understanding people as people and how they affect people.
So that's a tip.
Think about contempt in the context of anger
and that's where the trouble is gonna lie.
So I wrote a paper with this title, long title,
and the first paragraph is one word: "No."
(audience laughs)
Beautiful book by Martha Nussbaum,
who's a University of Chicago contemporary philosopher,
and she, and the book is a tome,
but she goes back to the Hellenistic philosophers,
the stoics were examples, and actually,
she makes a case that they were doing psychotherapy.
This is post-Socrates, and they were doing psychother--
all the issues we deal with, they were dealing.
They were dealing with it in dialogue,
they were keenly aware of family issues, all these things.
This is old, old, old stuff.
This is the essence of therapy,
this is the essence of plain old therapy.
It's two millenia old.
This is venerable work that we're engaged in.
And there's a wonderful literature
from 2,000 years ago to today.
I started reading philosophy about 15 years ago,
ethics, and I realized that it really is more helpful to me
than a lot of what I read in the journals,
this old wonderful literature, and contemporary literature
of people who are thinking about what it is to be human
and to relate to other people as humans.
So now, here's how I get beyond whinging about science.
I think there's no reason to complain about science
and no reason for ambivalence about science.
We obviously have great reason to be
ambivalent about technology, no question about it.
We may destroy the earth, so that's one example
of something that relates to technology.
But science is, you know, we can distinguish between,
science generates knowledge, there's no reason
to be ambivalent about it.
The problem is that, I don't know if you're familiar
with the word scientism, is overvaluing science.
That's the problem, and I think the field of psychotherapy
is threatened by it.
I think I would say damaged by scientism.
And that's the problem.
We need to make lots of use of science,
but not only science, and this is what I want to emphasize
in the first part of this talk.
Another thing is that we need to rely on judgment.
And the therapy field is filled with manuals
of how to do therapy.
Now, at the extreme, the manuals are trying to provide
rules about how to behave, what to do,
and I think, to the exclusion of judgment.
We're looking for rules.
Tell me what to do, and judgment is difficult,
because judgment, there are no rules for judgment
because judgment is how to apply the rules
in specific cases, and there aren't any rules
for how to apply the rules.
And I think this is what we need to face.
Now, jazz. I wrote a blog post called,
"Psychotherapy Should Be Like Jazz,"
and the essence of the blog post
is that we need to be able to improvise.
And jazz has a lot of structure,
but we need to be able to improvise around the structure.
See, for me the formulation provides a structure,
some sense of what the problems are
and some sense about how to go forward,
but the rest is improvisation.
And this is the way relationships are.
Therapy is only a relationship, a good relationship.
It's not fundamentally different from any other,
a love relationship, a good friendship,
a parenting relationship, it's not fundamentally different.
This is what I mean by plain old therapy.
Now ethical thinking, I think, is crucial.
Here's the main stream: we need to do
evidence-based practice based on scientific knowledge
and, of course, a few hours a year we gotta go
to some place and get ethics credits.
(audience laughs)
I suppose that's probably true for you; it's true of us.
So I think we oughta turn this around, actually.
And that fundamentally, as it's been for 2,000 years,
if this is ethical work, in other words, how to live,
getting to know a person and so forth, as is parenting,
and that science is a part of it.
So I just want to flip the balance around.
Science is hugely important.
Now the idea of personal knowledge, there's a philosopher,
I really love his work, Michael Polanyi.
Basically, we all acquire personal knowledge.
Knowledge doesn't exist in Google or in encyclopedias,
it exists in persons.
And the question I have is, what personal knowledge
do we bring to the conduct of psychotherapy?
And this, he makes a distinction between tacit
or implicit knowledge, this is know-how.
Like riding a bike, playing a piano. Know-how.
A lot of what we do in relationships is tacit.
We don't know how we do it.
I remember, in thinking about talking to you tonight,
I remembered when I was a graduate student
we were really lucky.
We had a seminar with a very seasoned psychoanalyst.
And the unlucky bit was we had to bring in
tapes of our sessions and play them in the group.
And so, he would, you know, say, "Stop the tape.
"Okay, so what were you thinking when you said that?"
So one of my peers, he would come up with this
beautiful eloquent stuff about why he said what he did.
Pardon me; it was bullshit.
(audience laughs)
It was rationalization.
You don't-- you know, occasionally we will think,
"Gosh," you know, like I did about the contempt remark.
Sometimes we think, "Okay, I need to say this, okay."
And even sometimes if we're really quick,
we might even think in the session what we need to say.
But most of the time (audience laughs) we're not,
most of the time we're kind of responding,
and a ton of what goes on in the therapy, it's beyond words.
It's, you know, how to help a person feel safe.
But it's not something that you're talking about,
it's something in your bearing and your manner
and your affective state, and this is beyond control.
If you try to control it, you've got a total mess.
So there's something that needs to be natural and safe.
And of course it's not always gonna be like that,
by any means, you're gonna get tense,
you're gonna get frustrated, all of this stuff.
And it's out there.
But in general, so there's a ton of this stuff.
It's like the tip of the iceberg, is the language
and the narrative.
This thing that I read, this is the tip of the iceberg.
It's a big tip, but it's still the tip of the iceberg.
Most of what we know in living is not explicit,
and there's a wealth of knowledge,
and a lot of it is culture and so forth.
So the explicit is what we're focusing our attention on,
but it's a small part of the process.
I like this.
This is a comment about enlightenment, actually,
focusing exclusively on science
as the exclusive knowledge needed to conduct therapy
as a form of scientism, and what Polanyi says,
"which fetters thought as cruelly as ever
"the churches had done. It offers no scope
"for our most vital beliefs, and it forces us
"to disguise them in farcically inadequate terms."
How about that.
Okay, so here's my thought about the kind of knowledge,
personal knowledge, what we know as individuals,
highly individual, that might go
into how to conduct psychotherapy.
And science, yes, is a part of it,
and a pretty important part of it.
But I don't know what the proportions are,
and they're gonna vary.
For me it's probably quite important
because I'm OCPD and I like science and all that stuff.
But this is only a piece of it.
And I think you could do quite well as a psychotherapist
without knowing much science at all, frankly.
Some people just have a knack,
a natural knack for psychotherapy.
By the way, one of the things I like about
the idea of plain old therapy is that
you do not need to be gifted as a therapist
to do good therapy.
We can't have psychotherapy that
requires gifted people to do it.
We need people, ordinary people need to
be able to do it using their ordinary human skills.
And for better or for worse, I did make a statement
in a recent book that, actually, therapy requires
skill in being human, which is kind of daunting,
(audience laughs)
but you can't get it from science.
But I think the benefit of science is
that it-- this is, I'm anticipating myself.
But basically the benefit of science is
that it shows, I think quite conclusively,
that plain old therapy is actually helpful to people.
And it helps us understand why it is helpful to people.
And a bit about how to do it.
So we have a technology.
I like better than the term "art", I think, "craft".
Jeremy Holmes, who's a British psychoanalyst,
said he likes the word "craft,"
that doing therapy is a craft,
it's something that you learn through apprenticeship.
And certainly there's a lot of art in any craft.
But I think craft is the right word, better than art.
But we have, you know, the technology, the manuals,
therapy techniques and so forth,
and we have structured clinical interviews
which I actually find very helpful.
So we need some technology.
Here's my grandiose sense of what,
the scholarly resources, which is only a part
of what we need to know,
but this is what I think is pertinent to doing therapy,
and that's a bundle.
So why do we need plain old therapy?
When I wrote that paper in Smith Studies,
the art of therapy, it came back to mind
an experience I had as an undergraduate,
and I've written about this and talked about it since
because it was so instructive.
So believe it or not, when I was a senior
I was in my final semester as a senior,
I was gonna go to graduate school.
I'd taken a couple graduate courses
in clinical psychology, and my supervisor said, "Well,
"why don't you see a patient in the psychology clinic?"
I don't think anybody would do this today.
But this was a while ago.
Okay, so I said "Okay."
And the thing that made it not crazy was
that I was gonna do systematic desensitization
with somebody who had a phobia.
And that's pretty easy; you develop a hierarchy
of things that are scary and the person relaxes,
you teach them how to relax, and they imagine
all these situations while they're feeling relaxed.
And it works, which is pretty amazing in itself.
So this was fine, I did it, it went fine.
But something, the insidious bit was
that the guy actually wanted to talk to me.
(audience chuckles)
And I finally realized that he wanted to talk to me.
And then I was screwed.
(audience laughs)
How do you talk to somebody
to help them with their problems?
I had no manual for that.
So it was funny that came back to me,
and it's sort of, you can see,
I'm still trying to work through that experience.
(audience laughs)
So here's, I was teaching a patient education group
as I've done lots of them, and this woman who was
brilliant and quite psychotic, came up to me
and she handed me this little slip of paper
at the end of the session.
And it was a quote from Chekhov's play "The Cherry Orchard"
and she had paraphrased it, but the gist of it is this:
If many remedies are prescribed for an illness,
you may be certain that the illness has no cure.
Now this is a very wise statement, right?
It's, to me, it's logical.
So Peter Fonagy counted, very carefully,
the number of current therapies
and he's convinced that this is an underestimate.
This is why I said earlier,
the field of psychotherapy is nuts.
There's something crazy going on here.
And I'm gonna amplify that bit.
(audience laughs)
So one thing you may have noticed,
that if you don't have an acronym
you are nobody. (audience laughs)
Enough said.
(audience continues to laugh)
So, in preparation for this talk
I reread that paper published in the Smith Studies,
and I thought that I had come up with plain old therapy
when I wrote this blog post.
But actually, then I discovered, lo and behold,
it was in that paper.
And I like this.
We now have guidelines, manuals, algorithms.
I find one facet of this development
to be immensely perplexing: why is plain old psychotherapy
not considered to be an evidence-based treatment?
(audience applauds)
This is what I mean about re-thinking psychotherapy.
If you stand back from this, the thing is,
it's nuts that we've got all this going on.
What are we doing here?
Frankly, I think it's narcissism because
you've gotta have your own thing,
and you know, Freud said, what was it?
The narcissism of small differences or something,
you know, you gotta be...everybody's gotta have--
and I got my own acronym,
so I'm guilty of the same old thing. Okay.
So, just a little bit about Menninger.
The challenge of this, we moved
from Topeka to Houston in 2003.
We had, it was part of managed care
that, you know, we used to do very long-term
inpatient treatment, which frankly didn't really
make total sense, but anyway, we did it for a long time.
So we moved to, quote, short-term,
but four to eight weeks is luxuriously long
in hospital psychiatry.
So we have, I think the luxury here is
we can do what I call psychotherapeutic hospital treatment.
That we can really do psychotherapeutic work,
individual, family, group therapy,
in the context of hospital treatment
which is a great luxury.
We have a very heterogenous patient population
and very eclectic interventions, see,
because we used to be a psychoanalytic hospital
and, you know, we've modernized like everybody else.
We've got CBT and DBT and all the other things going.
We have a lot of educational groups
and I've done, for many years with various colleagues,
groups focused on attachment and mentalizing
which we'll talk about, basically as a way
to try to get some coherent framework.
And actually we try to help
the patients understand the treatment,
cause the treatment is wildly complicated
with all these acronym therapies we've got going,
so you have to try to help the patients understand,
okay, but bottom line, what's helpful here?
And that the point is the therapeutic community
and relationships.
Attachment theory is a really good theory, I think,
for kind of plain old therapy,
although you could do others.
Now, with allegiance to research, we also have done
a ton of outcomes research,
so we have demonstrated to our satisfaction
that our treatment is very effective,
and, you know, the place wouldn't exist
if the treatment weren't effective,
but we have very, very good solid data
and some recent follow-up data
that it's also durable,
so I'm not for a moment dismissing the importance
of having evidence for the effectiveness of treatment.
I just don't think the horse races
of one brand against another make any sense.
This is amazing to me, this is prescient.
50 years ago.
This was before we had a ton of research
that has demonstrated this point quite convincingly.
So we gotta figure out what's going on
that is helpful in psychotherapy.
And I think we do bring science to bear on that.
Now what I want to say to put this in balance,
this is one thing.
Actually, it's very hard to demonstrate.
By the way, same is true with medicines.
That any one antidepressant is any more effective
than any other, extremely hard.
They have different side effect profiles.
But the effectiveness and the new medicines
are mainly, not more effective, they're mainly more benign.
But there's not, it's very hard to demonstrate that any
therapy is more effective than any other good therapy,
where it's very easy to demonstrate that
relationship factors have a major impact on the outcome.
Now there is some evidence for brand specificity,
and this is the point I really wanna make.
I think about the state of the art in therapy.
See, we've had the battles forever
between the academics and the clinicians, right?
We're all aware of that?
The academics do their research and they have
sort of, relatively pure cases and so forth,
and the clinicians are out there in the trenches
trying to work with a whole bunch of different people,
different kinds of problems and complicated problems,
and there's this battle between the two.
And the academics say, "What you're doing is
"not scientific and not good scientism,"
and the clinicians say, "Yeah, but you're in
"your ivory tower, and you know, you're doing
"all this fine research and you oughta come out
"and work in the trenches."
So that battle's been going on.
Another version of that battle is psychoanalysis
and psychodynamic therapy versus
the other acronym therapies.
And I don't think that's the best way
to draw the battle lines.
I think a better way to draw the battle lines
is the specialists and the generalists.
And see, the specialists have procedures
for dealing with symptoms.
And these are great.
They are studied, they are careful, and they work.
The trouble is us generalists,
like the GPs of psychotherapy,
are out there dealing with people who have
complicated life problems, multiple symptoms,
complicated diagnosis, and you can't just say,
"Great, well let's work on this one symptom here."
Well, maybe you could, and if it were a terrible symptom,
do it, by all means, or refer somebody.
But I think we need a way of thinking about therapy
for the generalists, and that they need not be defensive
about what they're doing because it works.
Tons of research over a half century have demonstrated
that good therapies work.
And it's very hard to demonstrate
that any one is better than any other.
This was a careful review of this sort of
symptom-focused treatment versus the other treatments,
and actually they found there was a slight advantage
for the symptom-focused, the CBT, et cetera,
with regard to the outcome of the symptom.
Which makes sense.
Even then, the advantage wasn't huge.
But if you're a person with a symptom,
and there's a bit of an advantage,
you should do the thing that has a bit of an advantage.
And I think we need specialists.
It's just like medicine.
But we need generalists, and the generalists
have plenty of evidence behind what they're doing,
it just doesn't come from the horse races
and there's definitely no Triple Crown winner.
The other thing is, there's this broad spectrum.
We have, you know, hundreds of psychiatric diagnoses,
but the fact is running through all these diagnosis
is a broad spectrum of severity,
and it is very interesting to me
that this severity factor reflects commonality
in etiology including family history of illness,
genetic risk, childhood maltreatment,
and compromised brain function.
This is a pattern that goes together.
And childhood trauma is a major contributor
to the severity of disturbance, which we all know.
So in a sense, this is, see, for the generalist,
I mean, this is the package that we're working with
with severe psychopathology for which
there's not a rule-based treatment.
So this is basically a summary.
So the bottom line there, generalists should use
specialized treatments or refer patients
for specific symptoms, and there's no reason why
this can't go together, plain old therapy
with specialized treatment.
But see, what I discovered as an undergraduate,
I'm convinced that even if you used manualized treatment,
it's very important to be good at POT,
because you're gonna need to talk to the person.
And you might need to get to know them, actually.
This would be a good thing.
Because this is the context in which anybody,
a physician, anybody working in the healing professions
needs to develop a therapeutic relationship with the person
for that intervention, whether you're prescribing medicine
or providing general medical care or doing psychotherapy.
Or doing some symptom-focused therapy.
So if you can't do POT you really can't do specialized work.
And this is a point that we make
in teaching our patients about treatment.
It's really important that the,
a lot of our treatments, if you go back
to this first patient I talked about,
see, a lot of the treatments promote self-regulation
of emotional distress. CBT, mindfulness.
A lot of things, they're what you can do
to decrease your distress.
This is fine, and it's perfect for avoidant attachment.
Right? This is what is learned in the first year of life,
is, "Okay, I need to manage on my own."
Well, welcome to psychotherapy.
We'll help you do that.
But see, this is not what's powerfully important.
It's interpersonal regulation of distress
is the most powerful way to regulate distress.
And if you look at the first year of life,
self-regulation comes into play in the infant
when the interpersonal regulation fails.
When there's a failure of connection
and a disruption in the attachment,
then the infant turns to self-regulation.
This is like a back-up strategy.
There's a beautiful concept of self-dependence,
quote unquote, this is Joseph Lichtenberg
using attachment theory, he says,
"Self-dependence is the capacity
"to bridge the gap between separation and reunion."
This has it perfect.
Because we have to manage emotional distress
on our own a fair amount of the time,
because we can't always be connected with somebody
in a trusting, safe relationship.
But there's no substitute, ultimately,
for that trusting, safe relationship
as the best way to regulate distress
from the first to the last year of life.
So I think this is a kind of a c-chain,
and our patients are kind of shocked when we say,
"You know, it is really good to
"depend on other people emotionally."
This is what attachment theory demonstrates
throughout the lifespan; it is really good.
And in fact, if you want to be independent,
autonomous, successful and so forth,
being able to depend on other people emotionally
is exactly what you need.
When you need it, you need it.
And this was, this patient I talked about,
this was the problem.
The avoidance strategy works until it doesn't.
And when it doesn't, you need to depend on other people.
What really is, this is where people get suicidal.
They are suffering, they're in terrible pain,
and they're out there trying to manage it on their own.
They cannot rely on other people
and they can't rely on themselves,
and you can see this, sadly, in the first year of life.
In attachment research.
So, this wonderful book by Sidney Blatt,
Polarities of Experience, and this is
fairly straightforward attachment theory,
just very briefly, secure attachment,
there's a balance between relatedness and autonomy.
It's in balance.
The secure base of attachment is,
when you can count on the attachment figure's
availability and responsiveness, then you can be autonomous.
Cause you know when it hits the fan
you can do something about it.
If you don't have that confidence in attachment,
you're on shaky ground.
If it doesn't work, you can, the ambivalent strategy
is basically, "Okay, I need to make more of a fuss.
"I'm not getting my needs met, turn the dial up."
And you do it by, you know, protesting,
angry whinging if you will.
You can do it by alarming people and so forth,
that's the ambivalent strategy.
And it's a good strategy because
it's trying to get the connection to work.
The avoidance strategy, a lot of our patients,
we have a program, Professionals in Crisis.
This is like people like us, and they're
masters at avoidant attachment.
But they run into trouble.
And one thing, of course, if you can't rely on people,
what's a great substance...substitute?
I said it. Substance abuse.
(audience laughs)
It's just, you know, this works on the same brain circuits
as attachment does, and so no wonder they get--
I didn't do this. (audience chuckles)
Okay, so, avoidant-- but the trouble,
and this again, all these strategies,
the amazing thing is, infants,
by the time they're one year of age,
they've figured out which strategy works
in a given relationship.
By one year of age, before they can talk.
These are strategies to do the best you can
in a particular relationship.
So you know, if you need to make
more of a fuss in the relationship
to get your needs met, go for it.
If you need to keep distance in order to
maintain the relationship, go for it.
And ideally, you know, you can make use
of the relationship when you're suffering.
The disorganized attachment pattern
is not an effective strategy.
That these infants, they're in a daze,
they're profoundly ambivalent,
they just can't work out a way
of relating to the caregiver that is effective
in reducing suffering; again, evident.
Now I'm gonna throw in just a little bit of ethics here.
I love this idea.
This is from Kant, who was writing around
the end of the 18th century, and he said
there are two great opposing moral forces,
I love this: love and respect.
Love is obvious, coming close,
but he said respect is keeping your distance.
Now if you think about attachment, this is perfect.
Because it involves a balance of love and respect,
closeness and distance.
Cause the way things go wrong,
and I'm talking about, this is a clear in infant research,
too much intrusiveness, too much connection,
kind of hypervigilance in the attachment relationship,
does not make for security.
What you need to do is allow for distance,
allow for disconnection, and then establish reconnection.
That's what promotes resilience.
Is being able to manage disconnection and reconnect.
I hope with that patient that I talked about
there's an example of that, disconnect, reconnect.
That's what makes for effective learning
about how to deal with conflict in relationships,
which is absolutely universal.
Gosh, the computer didn't like that slide
but I really like it.
(audience laughs)
So if you think about relationships,
really this is just so simple and it is really wonderful.
So you see, the thing that we were talking about
in the video today, that I have all this complicated stuff,
but there's some basic, simple stuff
that I think, really, is what I really gravitate toward
to keep us anchored and with some sense of what we're doing.
And we use this concept of mentalizing.
This comes from the work of Peter Fonagy,
and it is an enormously helpful idea,
and basically mentalizing is a sense of connection
psychologically with what's going on
inside the other person and yourself.
Attachment-- mentalizing is like the glue of attachment.
Because the infant is not gonna attach to somebody
who's not psychologically connected
with what's going on with the infant.
It just doesn't make sense.
They're not gonna attach securely.
So awkward as the word mentalizing is,
it's essential because it's the psychological attunement
to the other person and to yourself.
So we have, as I was saying earlier,
we have a few basic domains here
that a lot of this stuff is going on non-verbally.
And it's beyond words and it's beyond control.
And it has a profound influence on our relationships.
This is what's going on in the baby world.
This is all nonverbal, but babies are
very sophisticated socially, and as I said,
they're very sophisticated with regard
to attachment cause they figure out how
to relate individual by individual
depending on the way they're responded to.
Then what we do consciously in therapy
is mentalizing reflectively, and this is where
Socrates and his followers come in.
This is thousands of years we have been trying to figure out
using reflection, and I don't wanna downplay it
for a moment, I mean, this narrative,
we all appreciate the importance
of this coherent narrative.
It's crucial, and so that's the reflective part,
again, that is venerable.
But what we emphasize very explicitly
is from an ethical stance,
because mentalizing without the ethical stance,
none of this is worth anything.
I mean, psychopaths, in their own way
are very effective mentalizers.
This is not what we're talking about.
We mentalize for all kinds of reasons.
We mentalize to compete with other people.
This is not what we're talking about with attachment.
So we have this ethical frame,
and I think we should be very explicit about it
and that our values are hugely important here,
and that the best we can do is own up to them
and be as explicit as we can about our values.
And I'll say to people, "Well, I can tell you
"from my value system..." x.
So I will just say it.
Here's what I, I made an intervention.
You might find this a little weird.
But you might find me a little weird.
(audience chuckles)
So anyway, I was working with this patient,
this was a person who was hard to appreciate
because, as I was talking about,
she was among the ilk of people who really
are quite arrogant and quite contemptuous and devaluing.
And she was challenging to appreciate.
But I said to her at one point,
I was very frustrated and I said to her,
"You know, I find myself appealing to your self-interest."
And I said, "I don't like it. I would rather
"appeal to your goodwill."
Cause, see, I was trying to work with her
around treating people more decently.
And it was crucial for her treatment,
she was gonna wreck her treatment.
And I was trying to, you know, go for prudence.
"Well, it would be in your own interest,"
that, you know, you'd get what you want.
And I realized that and I said I didn't like it, actually.
I mean, I was doing it and I, you know,
and this really hit home.
She came back to that concept.
And actually I discovered in the course of the work
that she could be very caring and empathic,
and I could appreciate that.
But, you know, this was hard for her
to get to that stance.
So I'm just very explicit about this.
And I've learned a lot about people by reading philosophers.
It's a, gosh, I'll tell ya, here's a great example.
We say you should be nonjudgmental.
Right? Well, that's a complicated idea.
Because we're always making judgments about people.
Always!
We're not remotely without making judgments,
moral judgments, I would say, judgments about character,
judgments about what's right and wrong, good and bad.
We're doing it all the time!
We couldn't relate to people, including our patients
if we weren't engaged in that evaluative process.
So, nonjudgmental, I read, this is Christine Swanton,
a New Zealand philosopher, wrote about nonjudgmental.
She said, "Being nonjudgmental is like
"not being too quick to find fault.
"And moreover, looking for the good in a person."
See, this is a beautiful idea.
It's like Kant. These are beautiful ideas.
That's the best thing I ever read about being nonjudgmental.
And so when patients say,
"Well, you should stop talking about nonjudgmental.
"Don't we criticize and we need to criticize?"
Yes, we do. But it's not fault-finding.
And I think that some of us are trained
to be pathology hunters.
And that really, if we were trained to look for the good,
this would be better to work from there.
And I think that's what Swanton is saying.
Just read the personality disorder criteria in the DSM,
you're gonna find this language throughout.
This is clearly evaluative language.
And I've been using it. Arrogant, contemptuous and so forth.
So we have said, if mentalizing is the most common
and fundamental common factor in therapy,
which it is, it's also gotta be the least novel.
And it clearly goes back 2,000 years.
So it is not novel.
Peter Fonagy said, he backpedaled a little bit there.
May contain traces of originality but those are byproducts.
(audience members laugh)
So, I'd like the mentalizing approach to therapy,
I think of it as a style of therapy.
And there's one word there: transparency.
This is really important, and if you take the stereotype,
and it is a stereotype of psychoanalysis, you know,
where you're not even looking at the person
much less saying anything or responding.
So, that's a stereotype, but it's more true
of some than others.
But this is the opposite end of that continuum.
Being transparent.
And see, this is crucial if you look at the infant research.
Is the transparency, the responsiveness, the spontaneity.
Again, this is just allowing yourself to be with the person,
to respond to the person.
So if somebody said something that I think is nuts,
I would just look...what? You know, why not?
"This doesn't make sense."
I have even done, got out of my chair.
(audience laughs)
I don't do it all the time.
(laughing) One of my, I really like this intervention.
This young man I was working with,
he was really, he sort of gradually let me know
you know, how out-there his behavior was,
and I said, "You know, I've got a diagnosis
for what you're doing."
I said, "It's crazy shit."
(audience laughs and applauds)
He loved it. He loved it.
But you see, if you're gonna do that kind of stuff,
you have to have demonstrated in spades
to that person that you really appreciate them as a person.
You care about 'em, you're tryin' to help 'em,
and if you don't have that going in the relationship
and you do something like that,
it's just gonna, you know, they're gonna walk out
and they are not gonna come back
and they should not come back.
So you really, you've got to have that frame.
But once you do have that frame, I think
being upfront, facially, vocally, in your posture
and in what you say to people,
they need...the beauty of this approach,
and this really comes from Bateman and Fonagy,
is that you share your mind with the patient.
And it's not like you're coming from a dogmatic stance,
like, "Let me tell you, now, I've figured you out."
Now you might think that this is a bit like this,
but this is collaborative.
This is simply explicating what you've understood
together with the patient.
So you're not coming as the expert from on high,
but you're saying, "Let me tell you what I'm thinking."
If you just preface what you say by,
"Let me tell you what I'm thinking,"
it's not declaring some truth from on high,
you're simply making what your experiencing
available to them, for their consideration,
and that's exactly what you want them to do with you.
It's sharing.
And this is, if you look at what's going on
on the nonverbal level, in these very early relationships
where attachment gets established,
it's that transparent connection that is crucial.
So the baby knows what the caregiver is feeling,
and the caregiver knows what the baby is feeling.
When this goes wrong, either the caregiver is shut down
or the baby is shut down, and then
there's no way of influencing the relationship.
And another thing, I think, that is--
I'm just preaching now, so.
(audience laughs)
Another thing that I think is crucial
is we therapists, we need to trust our patients.
Because to be transparent and spontaneous,
you need to trust that that other person
is not gonna respond to you by jumping down your throat,
treating you with contempt and so forth.
Otherwise you can't do this.
So you need to feel safe with them.
Which is hugely important, and not always really easy.
And if you don't, you're just constrictive
and you're not doing very good work.
So, okay.
Now here's this, I keep coming back to attachment theory,
which just seems to me like if you're gonna use science,
this is good stuff.
And you know, there are thousands of experiments here.
This is just really robust knowledge in our field.
So, anyway.
So here's the amazing bit.
Peter Fonagy did this study.
It followed work done by Mary Main,
but he took it to another level.
So what he did, nobody in their right mind
would try to do this study, but he did it, thankfully.
So you interview the parent for an hour.
This was moms, and it's been done with dads,
but he started with moms who were
pregnant with their first child.
So an hour interview about their attachment history,
and from this interview, very sophisticated,
developed by Mary Main, you can actually
gauge the quality of the parent's attachment
and their valuing of attachment.
So whether they're secure or preoccupied,
ambivalent, avoidant, or disorganized,
flummoxed and kind of traumatized.
Now, what he discovered is that this,
again, before the baby is born,
this predicts a year after the baby is born
in a 20-minute laboratory situation,
whether the infant will be securely attached to the parent.
This is amazing.
From a one hour interview you predict
to 18 months later to a 20-minute lab situation.
So the question is, okay, so how do you get
from the parent's sense of security
to the baby's reaching out to the parent?
This is called the transmission gap.
What's happening in this gap?
Well, thankfully, there is an answer.
Mentalizing interactions.
In other words, again, what's happening
in these interim months since the baby was born is that
the parent is psychologically engaged with the infant.
This does not mean perfect attunement.
This doesn't happen.
If you look at secure attachment,
good relationships, synchrony, being in sync
is going on about a third of the time.
But what's going on about 70% of the time
is the repair of disruptions.
In sync, out of sync, back in sync, out of sync,
back in sync, that's what going on in these secure--
and they have to do with allow-- this is the respect bit.
Allowing the distance, allowing the baby to disengage,
or the mother to disengage, and then reconnecting.
That's what establishes the confidence,
that you can reconnect.
And this requires a sense of communication
that the infant is expressing a state,
the mom is responding to that state.
Whether it's the wish to engage,
the wish to disengage, the response to protest, all of this
is going on in what turns out to be a secure attachment.
And the icing on the cake is that
these securely attached infants turn out to be
more empathic, better at peer relationships,
and actually function better in a host of domains.
Now this is common sense.
Think about it from a learning perspective.
Okay, so the parents had a good attachment history;
this doesn't mean that everything
went well in the parent's life by any means.
But the parent has come to terms with it
so can value attachment, seek attachment
and establish attachment even with a trauma history.
Now how does that happen? Through mentalizing.
Through a good relationship.
It's the same thing for the parent.
But if you think about it, it's very common-sensical.
Why would this, infant secure attachment
means that the infant is distressed,
the lab situation is that the mom leaves the playroom
and comes back, you look at the reunion.
The infant's distressed by it and reaches out to the mom
and communicates the distress and they reconnect.
So you've got the repair of the disruption.
This is logical.
Why would the infant confidently go to a parent
who is not psychologically connected?
There's no mystery here.
But see, this is my idea about psychotherapy.
Mentalizing begets mentalizing.
So this is the way we get people connected,
is to try to provide that kind of relationship.
Quite belatedly, actually, in individual psychotherapy.
So I'm not gonna go through this,
but this is just some of the work
that goes into clarifying that transmission gap,
and I emphasize Beatrice Beebe's work,
this brilliant work, and again
I'm not gonna go through this,
but basically she's looking at the nonverbal bit.
This is four months old.
This has to do with watching videotapes
about how they're interacting; none of this is verbal.
The mom might be talking to the infant,
but the infant is not understanding the words.
But more that's a marker of the mom's connection.
So this transmission gap is getting filled
with really great research, and of course
we've got the counterpart here
to the secure attachment, this is the
disorganized end of the spectrum
where you have a history of insecurity in attachment,
non-mentalizing interactions, disorganized attachment,
and then this is actually predictive
of later psychopathology.
So, lemme see, I think I'm gonna go on to another.
See, actually what I discovered in this interview with Phebe
is I like simple stuff, but I like a lot of it.
(audience laughs)
So this is the simple idea I have about trauma.
It is the recurrent experience in a relationship
of feeling disconnected and invisible.
And the patients who come to us
are out there in these states where
they are in unbearable emotional pain.
And they just feel like they're alien,
and nobody gets it, and they've withdrawn, they're passive.
And again, the thing that's really disturbing,
you can see this at four months, six months of age
in an attachment relationship that's really going badly.
Kind of withdrawn, passive, and literally dissociative,
if you read these descriptions, they're dissociative states.
The infants are not connected with the caregiver,
and they're not connected with the environment.
They're not connected with toys, objects,
they are literally glazed, spacey,
sometimes literally walking around the lab in a daze.
And I think our patients, a lot of them
are akin to that, where they're just out there.
And the one word, I could summarize the whole talk
with one word, or my total understanding of trauma,
is "invisible".
And you'll actually hear patients use that word
or words like it.
It's the feeling of invisibility in pain
that is what's traumatizing.
And again, we're not talking about
an isolated experience, we're talking about
recurrent experiences that establish
a fairly predictable sense that, you know,
"If I'm hurting, I'm on my own
"and I can't deal with it."
And that's where people get suicidal.
So we have the counterpart, and this is
a very rich research, meticulous research.
And again, maybe this is impressive because
she looked at, I think it was 20,000 seconds of videotape.
20,000 seconds analyzed meticulously.
So pretty compelling data.
And essentially what she found
is the essence of these relationships,
let me get to-- you can look, you've got the slides,
thankfully, but here's the point I want to make.
She says that these mothers are not generally less empathic.
But something very specific, when the infant
is in a state of distress, they disconnect.
So a simple way of thinking about this
if you take the intergenerational perspective,
again, this is very simple:
if the parent has been traumatized
in her or his attachment relationship,
when the infant is distressed and needs her or him,
this is distressing to the parent.
It's like a reminder of trauma.
"Oh my god, I'm needed. I'm needed.
"I need to respond."
And then the parent has not had that experience
so this is like a reminder of trauma
that causes a lot of distress in the parent
and so they avoid re-experiencing that distress
by turning away from that pain.
Now to some degree I think most of us
are liable to turn away from pain.
This is not, and we're faced with a lot of it,
and it's hard to keep focused on it.
But this is our job.
So I will read through this,
this is Beebe putting into words
what the infant might experience
in the context of disorganized attachment.
"I'm so upset you're not helping me.
"I'm smiling and whimpering.
"Don't you see I want you to love me?
"When I'm upset you smile or close up or look away.
"You make me feel worse.
"I feel confused about what I feel
"and about what you feel. I can't predict you.
"I don't know what's going on.
"What am I supposed to do?
"I feel helpless to affect you."
This is the crucial thing.
Think about efficacy, or agency, whatever you wanna call it.
Really, I mean, great, it's great that we can
build stuff and make stuff and of course
we blow up stuff, too, but...
so that's a kind of efficacy.
But the most important kind of efficacy
is influencing another person.
And especially when you think about the baby,
being able to communicate distress
in a way that evokes some responsiveness,
reasonable responsiveness, that's the efficacy
that really matters.
So I think that I should highlight that,
"I feel helpless to affect you."
This is what leads to learned helplessness,
passivity, depression, suicidality and so forth.
"And I feel helpless to help myself."
Cause these babies are not good at self-comforting, either.
So they're not getting comforting,
they're not doing the things that babies do
to comfort themselves when that comforting
isn't responsive, "and I feel frantic,"
and I think that summarizes a lot of people
before they come to see us.
Now you might say, "So what's all this stuff with babies?"
Well, actually, there's really good literature,
and this is a terrifically good book,
recent, by Beebe and Lachman,
where they're explicating the connections
between all this wonderful research.
And Beebe's one of many.
Daniel Stern's work is just absolutely brilliant.
And Stern and his colleagues have
applied this to adult therapy,
but basically, this nonverbal communication,
this stuff that's going on with babies
goes on with us all the time
and it certainly goes on in the therapy relationship.
And so we can use this to become a bit more aware.
But where is this, "It is not," the second to bottom line,
"It's not to our advantage to become self-conscious."
The paradox is that it has to be natural.
So if I command you, "be natural,"
I mean, this is all, this is paradoxical.
You can't, this is beyond your control.
But we might become somewhat aware of it,
and we might, you know, if you're sitting there like this,
or if you're having trouble looking at the patient,
or whatever, you know, you might become aware of it
in a way that you can detect, "Wait a minute,
"something's going awry here."
But you can't try to regulate it all that much.
And again, the bottom line,
"High levels of coordination are not optimal."
The mid-range is optimal, and I think it's interesting
that that fits with what Kant said.
So...
Here's a good idea.
One of many coming from Peter Fonagy.
So he and Mary Target in '97 published
a terrific paper on trauma, and they said
there's a dual liability.
And this is again one of these many, many, many
simple ideas, that the trouble,
if you take maltreatment as an extreme case,
but if you look at the research
we're not talking about blatant maltreatment,
we're talking about something much more subtle,
and that is this disconnection.
But the dual liability is pretty simple,
that if you're, say, abusing and neglecting a child,
you are evoking distress and you are
undermining the development of the
capacity to regulate that distress.
So this is the dual liability.
Now Peter has an idea that he and George Gergely
have latched on to.
This is also from philosophical literature,
and it's another mouthful, "epistemic trust".
But the idea is extremely important.
Epistemic trust is that the patient needs to,
we all need to in close relationships,
they need to trust that you are a source
of valuable information about them,
about relationships and about living in the world.
They have to trust you as credible.
And I think this is really important.
And what happens in disorganized attachment
is that you get not only the distrust
that you don't feel safe with the person,
but the distrust that, "I can't learn something from people.
"I can't trust people to lead me in the right direction."
So it's the closing off to influence.
Giving up on people.
"I can't get anything out of relationships,
"I can't benefit from relationships."
And so they're closed off.
I think a good formulation actually does go
a way toward establishing epistemic trust,
that you have some valuable knowledge about them.
Even, ironically, if it's all come straight from them.
But something about articulating it.
A patient said to me recently, this was very wonderful,
she said, she read it, she said,
"You're listening to me."
And she said, "Also, you see as important
"what I haven't seen as important."
And this was very valuable, actually.
Nothing, there's nothing in this
that we hadn't talked about, but explicating it
is often quite helpful.
So...this is just a summary slide
of what I was saying a bit ago.
I like Bowlby's, this is from a 1990,
1988 book, which is, you know,
Bowlby wrote these big three-volume,
this three-volume set?
Well, I came across by luck, this short book.
(audience chuckles)
A Secure Base. 1988.
And I read it, and I thought,
"Wow." It was like, oh my god, attachment, this is it.
So that was my introduction,
and then I read the long ones,
but you start with the short one.
But this is wonderful,
basically that you explore the various unhappy
and painful aspects of his life, this is of course
written enough ago so that it shouldn't say
his or hers, but anyway,
past and present, many of which
he finds it difficult or perhaps impossible to think about
without a trusted companion.
I mean, this is a statement about plain old therapy.
This is the statements I made about
the personal conception of psychotherapy, that's it.
I said in a trauma group one day,
"The mind can be a scary place,"
and the patient said,
"Yes, and you wouldn't wanna go in there alone."
Now this statement that she made,
this is the best idea about therapy,
trauma therapy, certainly, this is in one,
this was a young woman who made this statement,
this is it.
So this is the idea.
This is what psychotherapy is about.
You see, and the infant research is very consistent.
You don't wanna be in those states alone.
And this is where attachment goes badly awry,
when consistently you're in those states alone.
So she nailed it, and, this is as good as it gets.
(audience laughs)
I'm gonna give you one other clinical example here
that's not in your...
I think I'm gonna stop there
so we have a bit of time for discussion,
comments, questions, disagreements.
(audience applauds) Thank you.
Free for all.
Just don't throw things.
- [Voiceover] Hey there.
This is the most fabulous thing ever.
(audience laughs)
(mumbles) I'm a doctoral student here
and I'm working on issues of philosophy
and the philosophy of social work,
so hearing you talk about this
I'm wondering what your thoughts are
about why it feels so hard to get
therapists on the philosophical bandwagon.
(mumbles)
- Um, I think, let me th-- I don't know,
first of all, it's a huge project.
If I say, "Go read Martha Nussbaum."
Okay, Martha Nussbaum is great.
But she's gonna be referring to all these
philosophers who you're not gonna have a clue
who she's talking about, how this fits into the history,
so this is something, it's a huge project,
really, to get even a kind of modest acquaintance
with the literature.
But I think there's a historical problem here
that, really, I can whinge now about this,
that philosophy-- now I'm not talking about
social work, so forgive me, cause I'm a psychologist,
but philosophy and psychology split up a century ago.
The psychologists said, "Oh, we don't want this
"armchair stuff, we want empirical research,"
the philosophers said, "Look, we're interested
"in logic, don't try to turn us into psychologists,"
and they divorced each other.
I think this was a disaster.
Because then the psychologists turned to science
and they close off.
The reason I like philosophy, I mean,
we've got literature, we've got art,
there's a lot to learn.
Tons of information about life.
But I like philosophy because it's systematic,
and in that sense it's parallel to science.
And the two were one up 'til a century ago.
So I think that it's a symptom of the divorce,
and I think scientism may be the answer.
That, you know, we think,
"Well, philosophy, that's soft, armchair stuff,
"There's nothing substantial in it."
And it's ignorant.
But so it's a combination of the cultural attitude
and the so-called culture wars.
It's, I mean, the whole of the humanities,
I think, should be of massive interest to psychotherapists.
But it's not part of the culture.
But the effort is ridiculous, frankly.
But, I mean, it's true, our knowledge is so specialized.
The infant research. It's a huge project,
to learn about that stuff. Attachment theory.
I mean, so, effort.
But if you just pick up philosophy
sort of without knowing what you should look at
it also can be profoundly boring.
(audience chuckles)
See, what I discovered is that
if you read philosophy that's really good,
it is immediately relevant and the writing is fabulous.
Fabulous writers in philosophy.
But there's a whole huge boring tradition
of contemporary, or recent, modern philosophy
that's just obsessive.
So that's some thoughts.
Good luck to you.
(audience laughs)
Yes.
- [Voiceover] I really loved what you said
about ethics and what you were talking about
really reminded me of Ivan Boszormenyi-Nagy,
who was a very early family therapist
who invented what's called contextual therapy,
and he talks about giving or receiving
and this personal, this kind of philosophical
dimension in relationships.
And I think you were seeing it and relating it
very much to attachment,
which is kind of the intrapsychic dimension.
But I don't think it's really being taught
in social work school anymore, but he was
a very profound influence on me,
and I think it is something that's not necessarily
just philosophical (mumbles),
but it's something that clinicians
can easily grasp and can actually use in treatment.
- Yes, well, good, thank you,
so we're on the same wavelength in that.
It is useful, that's the thing.
It is immediately applicable, I find.
But you've mentioned something
that I really neglected, and Phebe and I
talked about it in the interview this afternoon.
Family work.
See, I think if you go into the attachment literature
what you realize is that
the current attachment relationships
are where the action is.
And so, really, the work that I think frankly
is most important is family work.
And in our clinic, this is the blessing,
I have as an individual therapist,
is that we have fantastic social workers who are doing
what I think is the most difficult work in the clinic,
although other people might disagree.
But working with very difficult families,
and so when the treatment really goes well,
the individual therapy is kind of helping the patient
make use of the therapeutic community
and especially the family work.
And when the individual therapy
and the family therapy are in sync,
I think that's when the treatment goes best.
I realize now, I'm, you know, pretty much done
with my career; well, not totally
but I've still got another 10 minutes, but,
(audience laughs)
I mean, really, individual therapy is not
the most potent thing to be doing.
But it's easier than doing family work.
So I don't totally regret it.
But I think the family work is really the crucial thing,
and this was Murray Bowen, I think, really said this,
work with the current attachment relationships
and try to get them going, and there's
a lot of wonderful work there.
Sue Johnson is somebody who's doing,
really using this theory,
but the other thing is the most hopeful
intervention literature in the field,
in the psychosocial realm, I think,
is the early attachment work,
where they're working with moms and babies,
they work with moms in groups,
they videotape, they sort of, they look at
each other's interactions with the babies
and then they, they actually get help,
you know, connecting and reestablishing connection.
- [Voiceover] People can now see (mumbles),
you can just Google it on YouTube and see it.
- Yeah. Circle of Security is another thing to Google.
They're doing just wonderful work.
So I'm really glad, too, that you brought up
the family dimensions. That's crucial.
- [Voiceover] Hi, Jon.
- Yes.
- [Voiceover] Thank you so much.
I really appreciated your presentation.
You made a comment though, early on
that you saw people with avoidant styles
being excellent at self-regulating?
- Yes.
- [Voiceover] And it's been my experience
working with people with that kind of style
that they're often more dissociating
(mumbles) experiencing (mumbles).
And I guess I'm curious to hear
your thoughts about that.
- Yes, when you're...yeah, see,
when you're in there,
you can think of two different patterns of avoidance.
The avoidant attachment in infancy,
is the infant is managing fairly decently.
It's stressful, but they're managing
without relying too much on
close, comforting contact with the attachment figure.
Disorganized attachment is the extreme of avoidance,
where they are no longer able to manage.
And I think dissociation would be a clear
indication that you're at least likely
to be in the realm of disorganized attachment.
Where there's no reasonable way of regulating emotion.
So that's how I would think about that problem.
So this is quite straightforward with our patients,
they're very effective, they handle a lot of stress,
but they move from, in effect, the avoidant,
where they can manage on their own,
they move into the disorganized state
where they're at sea and adrift.
So that's how I'd think about it.
And it's a gray area between the relatively successful
avoidant strategy and disorganization.
And in the infant literature,
and for that matter in the adult attachment interview,
the disorganization is something that's not pervasive.
It's sort of, you see it in bursts.
But when you see it in bursts,
it's an indication of some very serious trouble.
And dissociation is the clearest example of it, actually.
We got a few more minutes. Please.
Sorry, what...okay, up there.
- [Voiceover] When you were talking about
the intergenerational (mumbles) of (mumbles) attachment,
I think you were talking about (mumbles) mentalization,
you made one comment about the dangers of overattunement,
and I wonder if you can clarify where,
what overattunement is, kind of like,
is that over-mentalization?
- Yeah. There's a term for this
that Bateman and Fonagy use, actually,
they call it hypermentalizing.
Hyperment-- too much of a good thing.
So we have a term that actually
my daughter came up with,
which is "excrementalizing".
(audience laughs)
I couldn't refrain from that.
And if you Google "excrementalizing",
a friend of my son's who's a guitarist in New York actually
performed a piece which she titled Excrementalizing.
She was looking for a title, anyway,
that's a little bit off topic, but it is connected.
And in our book, one of 'em,
yes, I think it's a book on plain old therapy,
well, anyway, excrementalizing is in there.
Excrementalizing means that you're mentalizing
but you're doing a crappy job of it.
(audience chuckles)
So the hypermentalizing, the way this gets going
is that you're so, it's hypervigilant.
See, you're so worried about what's going on
in the other person's mind that it's like
you're glued to them and you're making
all kinds of inferences about what's going on with them.
So it's like too much and distorted.
The too much is the "hyper,"
and the excrementalizing is the distorted part.
But see, what that doesn't do,
an example in the infant literature
is that the infant turns away from the mom.
Now let's say the mom is very insecure about her mothering.
So the infant turning away from her is threatening to her.
It may threaten her sense of herself as a mother.
So what does she do? She looms in.
She follows the infant.
And then the infant doesn't have--
see, a big part of how we regulate in interactions
is turning away, looking away.
Just stare at another person for a long time;
it'll drive you nuts!
And so, you know, we gotta regulate
by turning away and withdrawing and then coming back.
So that hyperattunement or hypermentalizing,
whatever you want to call it, interferes.
That's the failure of respect,
that's why I love that,
to give the other person space.
It's a kind of possessive way,
and it's possessing the person's mind, in a way,
just not letting 'em have their space.
Yes.
- [Voiceover] I guess I'm curious
what the term "mentalizing" is referring to
mental and then mind and then brain,
which feels a little bit dissociated
from the more somatic way that I
experience an attunement, you know?
And so I'm wondering if you would speak to
the choice of that word and how
that's a somatic experience in connection with (mumbles).
- Yeah, that's why in that slide
I have the sort of nonverbal part,
which is, and then reflective mentalizing.
And I think, and Peter Fonagy and I agree about this,
you need all three of these going.
And to only focus on the reflective mentalizing
is to miss a ton.
And the word "mentalizing", the problem with it is
it's too intellectual, it's too mental.
People hear "mental".
Well, what about emotion?
This whole, everything I've been talking about
is about emotion, and so that's a problem
with that word, it's kind of dehumanizing.
And now since you mention the brain,
I'm gonna plug one other, this is one last whinge, okay?
Is about biomania.
See, if you take the technological approach
where you got manualized things and rules
and procedures and all of this,
and then you get into the biological psychiatry,
which I'm not complaining about,
we need it, there's no question about it.
But exclusive focus on the brain, I think,
is the far end of that scientism continuum,
where you literally lose the person.
And the life of the person is just not in your purview.
And I mean, this is a caricature, but it's out there.
Where, really, you've lost the mind
and, you know, you're just totally fascinated
with the brain and the images and the medicines
and the neurostimulation and all of this stuff.
And so I think this, it is a problem
that the humanism in our field,
which is the guts of it, you know, fades from view,
and guts, of course, is what you're talking about.
Yes.
- [Voiceover] Most people who perform therapy these days
seems to focus strongly on the body.
I'm wondering how you integrate those ideas
with plain old psychotherapy.
- Yeah, well, I think it, what this shows
is that plain old therapy is not all we need.
I think plain old therapy is really important,
I think we're gonna need it forever
no matter how many other therapies
and medicines we have, but I think
work on the body is really helpful.
I mean, we're lucky, we have going at the clinic
trauma-informed yoga,
which is helping people in a very safe way
who are, you know, they live from the neck up.
And, you know, helping them get more in touch
with what's going on in their body.
So I don't mean for a moment to say
well, all we need in the therapies is plain old therapy.
There are lots of reasons for other things that we do.
I just want to, what my goal is,
people who are out there just muddling through,
trying to help patients by talking to 'em,
that they shouldn't be made defensive by,
"Well, you're not doing evidence-based practice."
I think the whole attachment field
has generated a half-century of fabulous evidence
for what we do.
That's basically what I'm saying.
Not that that's the only thing.
(audience applauds)
Okay, enough. Thank you. Thank you. Thank you.