Intergenerational Trauma Explained: The Role of Reflective Function and Mentalization in Healing Attachment

In this episode, we explore how intergenerational trauma shapes attachment patterns and how reflective function (RF) and mentalization can help break the cycle. Drawing on research from Fonagy, Slade, and Berthelot, we examine how trauma-specific reflective functioning influences disorganized attachment and how therapies such as Mentalization-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), and Minding the Baby (MTB) strengthen reflective capacity and promote secure attachment. Join Dr. David Puder and colleagues as they discuss the science of mentalization, attachment repair, and trauma healing, bringing together psychoanalytic, developmental, and biological perspectives to offer hope and clinical insight for patients, parents, and therapists alike. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-249-intergenerational-trauma-reflective-function-mentalization-attachment-healing Link to YouTube video https://youtu.be/2S9wXrEJOIY

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with three residents. We will be discussing an amazing paper called "Intergenerational Transmission of Attachment in Abused and Neglected Mothers: The Role of Trauma-Specific Reflective Functioning." We have an R2, Khaled Itani. We have an R3, Sharia Chirlo, and we have an R4, Fidel Shuman.

• 0:42Speaker 01

  Perfect pronunciation.

• 0:44David Puder?

  Oh.

• 0:44Speaker 01

  Nailed all three.

• 0:45Speaker 02

  Better than at graduation.

• 0:47David Puder?

  So, this is exciting. We are doing this live. There's no video of this. We are doing it live in Winter Park, Florida, and I'm excited to go through this paper with y'all.

• 0:56Speaker 01

  Yeah. Same. Thank you for having us. I was just telling Dr. Peter that, you know, when he first presented this article to me, it was kind of short in a way, but it's chock-full of information, so much lore. It's really, really dense with a lot of, you know, other studies that are, you know, interwoven in this, and I think this kind of ties it all together very nicely.

• 1:20David Puder?

  Yeah, we've talked about reflective function on this podcast. I had Dr. Steele on, who was part of the manual. I had Fonagi on, who's part of the manual. Reflective function is essentially the measurement of the adult attachment interview, in the adult attachment interview, of the mentalization that's going on in the adult attachment interview. And then, so this takes a step further, and it looks at mothers. And I just want to give that brief introduction. But I think the why is really important, like, why it's worth spending an hour, an hour and a half, talking about this article. Do you guys have a why? Do you imagine a why? Sharia?

• 1:59Speaker 02

  I definitely have a why. I think that it's really important to understand, like, intergenerational trauma and like, how it can lead into a child's life and how they function afterwards.

• 2:11David Puder?

  Yeah.

• 2:12Speaker 01

  Yeah, um, for me, the takeaway, the big why for me is like, a lot of mothers or people in the community are afraid that the trauma will be passed on automatically, but a deeper understanding of, you know, this reflective function, higher reflective function, it doesn't have to be that way every single time. So it's worth exploring for sure.

• 2:34David Puder?

  Yeah, and I don't think it's a hopeless message. If we know, if we can clearly say, this is the problem, here's the solution. And then as a culture, as a society, I'm hoping the more and more people understand this, the more and more we can create policies to actually reverse and help.

• 2:53David Puder?

  Go ahead, Khalid.

• 2:54Speaker 03

  So for me, you know, the mentalization process is really a love letter to like our future generations. Cause we're finding that, you know, we have like the therapeutic modes and we have some unresolved traumas. And if we go out of our way to, you know, address those, resolve those, this will show in the future generation and we're finding that in the infant, some of these attachment dysfunctions can develop very early on, sometimes as early as like four months. And so if more people were aware of this, they would, you know, pay more attention to how critical this early period is.

• 3:25David Puder?

  Absolutely. Yeah.

• 3:28David Puder?

  Yeah, I was, um, I was reading this stuff when my kids were born and I remember reading, um, like the still face experiment and like I was reading Ed Tronix book, which is like a thick research book while I'm bouncing her at night, you know, like I'm like for hours because she had colic. I'm like trying to understand this stuff and I think it made a huge difference. I think it made a huge difference. And it's not just mothers too. I think this study is specifically about mothers, but there are other studies about fathers. It's good to start with one study. I think this is a strong study. I think it was well done. So we're going to start with this one, but the impact on fathers and on infants is actually very important as well. And, uh, we may have time to mention some of those things.

• 4:12Speaker 01

  Absolutely.

• 4:13David Puder?

  So where, where do we want to begin?

• 4:16Speaker 03

  I think because it is a rather technical article, we can spend some time going into some of the very technical psychoanalytic terms that I think are foundational to kind of pursuing this text further.

• 4:29David Puder?

  I think, I think we should give like an abstract before we get there. Like an abstract is in like, this is, this is why it's important. If without any of the technical words, if possible.

• 4:44Speaker 03

  Yeah.

• 4:44David Puder?

  Okay.

• 4:45Speaker 03

  Yeah, yeah. Let's do that.

• 4:46David Puder?

  So, and then, and then let's get into the

• 4:49Speaker 03

  The nitty gritty.

• 4:49David Puder?

  The nitty gritty, because I feel like we're going to lose people if we jump into the, the kind of the, the fun stuff right away. Which I actually had one listener reach out to me recently and they were like, actually, when you say this is going to be really hard to understand, it actually inspires me to pay more attention, pull out a notebook. And so if this is hard for y'all, get the article, listen to this, try your best to understand it, then get the article, read it, and then maybe re-listen to it and you'll, you'll get it. Okay. So what's the abstract?

• 5:22Speaker 02

  I can talk about it in, I guess, simpler terms. So basically, this study is about how our patterns and trauma can reflect onto our children and how the ways in which you interact with your children can affect their well-being in terms of like, for example, how you react in a scenario, how you think of your thoughts versus a child's thoughts when something goes wrong, for example. And something really important with this study is that it's never too late. Like you can do this before you're pregnant, while you're pregnant, even after, and it still has lasting impact.

• 6:02David Puder?

  Absolutely, yeah.

• 6:03Speaker 03

  And it's kind of a bounce off Ria's point as well, something that this article kind of ends with. And it's almost like a point of optimism and a big takeaway that, you know, you have mothers who experience trauma. That experiencing of trauma is important, but their ability to mentalize that trauma, the ability to kind of process trauma is really what can make the big difference in their relationship with the infant later on. So if anything, I found this article in a sense rather hopeful in that it's kind of pointing to that very key fact.

• 6:34David Puder?

  Okay. Abstract.

• 6:37Speaker 01

  Yeah, I totally agree with those points and it kind of mirrors like the attachment styles that were highlighted in the article such as like, you know, disorganized attachment styles and how that's built early on and how you can potentially avoid or negate some of those attachment styles from building as an infant and then later manifesting as an adult if you have that mentalization, I guess, skill or understanding of your trauma.

• 7:04David Puder?

  Right, okay, so here's my attempt, okay?

• 7:08David Puder?

  So if you have had abuse and your high reflective function in the trauma itself, so if you were to talk about the trauma, you're able to speak about it fluidly, detailedly, without dissociating, without disavowed emotion, if you're able to do that, you have a very high likelihood that your child is going to have a secure attachment, an organized attachment, not a disorganized attachment style. And disorganized attachment style leads to future dissociation, is the simplest way. It's like a fear without solution.

• 7:49David Puder?

  If, on the other hand, you have abuse and you have a low reflective function when discussing the trauma, meaning low ability to mentalize what was going on, the emotions, maybe you dissociate during discussing it, that leads to a much higher likelihood of having future disorganized attachment child. And so that's my abstract. Okay, now let's go into the details on each of the terms.

• 8:15Speaker 03

  So definitely to understand this article and kind of articles in a similar family, we need to know about mentalization as a term and reflective functioning. And the two terms work hand in hand because reflective functioning really is a measure of mentalization. So most texts, the way they tend to describe the mentalization is like the capacity to think about oneself and others, in this case, the infant, as a psychological being. In other words, more so reflective of how you interact, how you perceive the emotion, how you can kind of anticipate, how you can kind of relate, how you can respond. And mentalization is correlated typically to better psychological outcomes,

• 8:58Speaker 03

  because it's kind of related to, in a sense, how you process and how you kind of relay that back. Now, in the therapeutic practice from the literature that I was going through, there is a difference between mentalization and empathy. So, mentalization can help with empathy. And some authors even argue you need to mentalize and be able to empathize. I just thought that was a very interesting distinction that I came across.

• 9:22David Puder?

  Yeah, well, well put. So, the ability to mentalize is to understand your own and the other person's desires, emotions, experiences. It's, it's your ability to read a person accurately. Or accurately, but with a little bit of hesitancy that you're not able to really read them, right? So, we know that like when people with borderline precise disorder, for example, lose their ability to mentalize, they go into psychic equivalence mode, which is a fancy way of saying that their experience of the other person is reality, even if that other person is saying, "No, it's not reality." Okay?

• 10:04David Puder?

  So, to be able to mentalize the other is to be able to understand the other as a separate person. And so, there's a humility there that needs to be there. And then reflective function is, do you want to talk about reflective function now?

• 10:19Speaker 02

  I wanted to talk about like kind of the scale, like how it's determined what reflective function is in a way. So, it's scored on a 11-point scale from negative 1 to 9. Negative 1 is negative reflective functioning, which would mean totally barren or rejection of mentalization. For example, if someone asked you a serious question like, "What was your parenting style like when you were growing up?" If someone just said, "I didn't know," or they say... How would I know you're the psychologist? That would be a negative one.

• 10:48David Puder?

  Right, it's the rejection of the question itself. So you have a why question. Reflective function is really looking at the why questions. And then it's a rejection. I don't know. You tell me. You're the psychiatrist. You know, that kind of like grittiness or like, how dare you ask me? How dare you? That it's not just not reflecting. It's like the negation. So that's why they made it a negative one.

• 11:16Speaker 01

  Yeah. And then for me, I'm kind of like to bounce off that for reflective function relating to like a mother and a baby. Kind of want to look at examples of it. And, you know, if a baby's crying in front of you or like crying in front of the mother. A good like person with a high reflective function could could say. My baby's crying, triggers my memories, but that's mine and not his. I can still comfort him. Someone with like a low reflective function could like see the crying and freeze and lash out and dissociate. Like you were saying, but also, you know, in that relationship with the infant inadvertently sometimes.

• 11:56David Puder?

  Yeah, wow, okay. I actually have an example that it's kind of scary.

• 11:59Speaker 01

  Yeah.

• 12:00David Puder?

  We had these people over to our house. I'm pretty sure they're not listening. If they are, we love you guys.

• 12:06Speaker 01

  Good people.

• 12:06David Puder?

  But this was a scary moment, okay? So we're all around the jacuzzi and their kid falls in the jacuzzi. And the mom is like one foot away, sees the child fall in, freezes. Okay? My wife is like five feet away, sees this, goes over and grabs the child out of the pool from drowning. You know? And we like, we were like, what the heck? And I was like, she dissociated.

• 12:31Speaker 01

  Yeah.

• 12:32David Puder?

  And it was that fast. It was distress dissociation. So, you know, if you have a lot of unprocessed trauma and you dissociate very easily. You know, put a life vest on your child. Take, take, take, take the extra precaution, but you know, this is kind of like the extreme version of it, right?

• 12:50Speaker 02

  Yeah.

• 12:51David Puder?

  But it's that, but think about like if they're talking about their adult attachment interview and they're talking about the trauma in the adult attachment interview, then they may not, then they may dissociate during them talking about it. And so they're going to get a lower score there because they're not able to reflect on their own experience and the other person's experience. They're out, they're out of it.

• 13:14Speaker 02

  Yeah.

• 13:15David Puder?

  Okay, but I keep going. I want, I want you to go through the scores and what you learned.

• 13:19Speaker 02

  So then nine would be exceptional reflective functioning. So unusually complex and elaborated reasoning about mental states. So for example, if someone had asked during the adult attachment interview, did you ever feel rejected as a child? How would you think that someone would respond with a, with a nine?

• 13:37David Puder?

  Or the, the question would be, why did, when you felt rejected as a child during, usually it's like during a specific story, why did your parents reject you? Cause that's, that's, or I guess they could enter into a deep level of reflection without a demand question, but the demand questions are really like the why questions? And so.

• 14:01Speaker 02

  So there are predictive questions and then there's demand questions, so.

• 14:05David Puder?

  The, the demand ones, or the demand ones demand the person to reflect. Okay. And so, so, so Abraham Lincoln.

• 14:15Speaker 01

  Deep dive here.

• 14:16David Puder?

  Here we go.

• 14:17Speaker 01

  Going back in time.

• 14:19David Puder?

  I don't think I mentioned this on the podcast before, but I give, I give lectures on reflective function as some like grand rounds or whatnot. And this is, this is part of it. So he wrote a letter to John Stewart. This was after I think his, Anne died, who was, he was like his partner. And he said, for not giving you a general summary of news, you must pardon me. It is not in my power to do so. I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on earth. Whether I shall ever be better, I cannot tell.

• 15:01David Puder?

  I awfully forebode I shall not. To remain as I am is impossible. I must die or be better. It appears to me. The matter you speak of on my account, you may attend to as you say unless you shall hear of my condition forbidding it. I say this because I fear I shall be unable. Okay. So I give that a five. Negative one, negative one to nine. Okay. Now, I know a little bit about his life. And so now I'm gonna make it into a nine. Okay. This is my best. This is like, this is my best thing.

• 15:37Speaker 03

  I mean, it's dark, but he seems like he understands.

• 15:40David Puder?

  You can feel it. It's visceral, right? Maybe it's more visceral than mine.

• 15:44Speaker 02

  Very curious for the nine.

• 15:46David Puder?

  Anne's death has overwhelmed me, bringing to consciousness old feelings that I now recognize as anger. Anger I dared to admit as a boy when my father punished my scholarly ambitions, instead turning the rage inward and reshaping it into persistent guilt and self-blame. Likewise, now confronted with my helplessness to save Anne, the anger returns, but again finds no outlet, no target but myself, transforming once more into deep and paralyzing melancholy for which I see no escape.

• 16:19Speaker 03

  It's like textbook perfect.

• 16:20David Puder?

  You think so?

• 16:21Speaker 03

  Because, I mean, even like the phrase like bringing into my consciousness really speaks to that reflective process that's occurring.

• 16:29David Puder?

  So I think it's a higher score. And I love, I love his own quote. I mean, I think viscerally his own quote grabs me.

• 16:35Speaker 03

  Yeah.

• 16:36David Puder?

  But specifically, I think this is high reflective function because he's connecting the past to the present.

• 16:43Speaker 03

  Abuse.

• 16:44David Puder?

  The, um, the, the impact of his father and the powerlessness there with the powerless currently. So the connectedness of those, the, the understanding of the, the internalization of anger into his depressive personality. He had a depressive personality style. So he kind of like the understanding of his psychodynamics, right? And then the, um,

• 17:10David Puder?

  The realization of why the anger is so hard to because anger is usually you're moving towards a goal. And there's an obstacle and then you get angry because you feel thwarted towards your goal. And then the anger helps you overcome the obstacle to move towards your goal. Okay. Tell me one example of anger that it's not that. And I would be very surprised. It's always that, okay, in my mind. At this point, that could be a very low reflective function statement, by the way. Kind of an all or nothing, but in general, that's what I see.

• 17:41Speaker 02

  Should we score that a three?

• 17:42David Puder?

  We could score that. If someone can prove me wrong, then it would score lower. But right now it's a nine. And then that egocentric scoring of myself as a nine also brings me down lower, though. So that hurts it. Okay.

• 17:56Speaker 03

  So what about two right now?

• 17:57David Puder?

  So I'm like digging myself a hole.

• 18:00Speaker 01

  No, you just went back up to a nine by calling it egocentric in a way.

• 18:04David Puder?

  But I recognize I'm doing this to humor you guys. So that actually raises my score.

• 18:09Speaker 03

  There you go. Well, humor is like the highest cognitive faculty, right?

• 18:12David Puder?

  No, because I'm

• 18:13Speaker 02

  Back at a nine.

• 18:14David Puder?

  Because I'm interpersonally aware of your responses and then tailoring my response to that, which also increases your reflective function. Okay. You can see how you can play this game. It's fun.

• 18:25Speaker 02

  So in the RF manual, there's like different sorts of types. Like basically, this is an example of like how somebody would score. So like, for example, like there's like self-serving RF. There's disavowal RF. So there's like different things.

• 18:36David Puder?

  So that exactly like, so if I say too many self-serving comments.

• 18:40Speaker 02

  Yeah.

• 18:40David Puder?

  You know, like, you know, people that always drop these like, I'm great. You know how great I am. That's actually a lower RF. So people with more narcissistic traits score in the threes more commonly.

• 18:53Speaker 02

  Yeah.

• 18:53David Puder?

  Okay. BPD 2.7, eating disorders 2.7, impatient around there. Prison across different prison studies, like one to low twos. So actually, prison is lower, which kind of makes sense because they they're moving instead of in words, they're moving in actions. Right?

• 19:15Speaker 02

  Yeah. Something was brought up in one of the articles we read that there was a lot of scores in the high-risk population from one to two. And maybe there's there's need for a little bit more scoring like within those categories because there's so many different types of high-risk population that you can't really score well.

• 19:33David Puder?

  Um, yeah. So, explain that.

• 19:35Speaker 02

  Basically, there, there was an article saying that there's like high-risk populations, for example, like in the prison, that everyone would get a one or a two. How do you differentiate it? So there needed to be a little bit more of like 1.5, 1.7. Like, there needed to be more to that, to that scoring schedule that they needed to figure out.

• 19:51David Puder?

  Yeah, maybe. I, I think if they're scoring in a one or two range, those are people that, that are, are pretty, they're, they're not really mentalizing. They're like, it's like pre-mentalizing. Um, and th- these are people that have a hard time naming their own emotions or what other people's emotions are, right? These are, these are people that like, um, like, you know, have a really hard time imagining another person's mind separate from their mind. Which, if you're very, so we have to also realize not everyone will imagine your mind in the same way that you imagine their mind.

• 20:32Speaker 01

  Yeah.

• 20:32David Puder?

  When you're talking to them.

• 20:33Speaker 01

  What does a negative one look like?

• 20:35David Puder?

  A negative one is, is just the disavowal. So it's like you, you ask any question and then they get hostile towards you. So this is like the person withdrawing off of methamphetamines, who like, you're like, what, what brought you in here? Get the f- out of my room! How many times do I have to tell you? Get out, get out! And you're like, sir, I just need to know your medical history. I said, get out! And I would actually say like, document that, okay? Get some, get some notes from the nurses on what's going on. Get some, you know, look at all the chart.

• 21:11Speaker 01

  Collateral.

• 21:13David Puder?

  Collateral, yep.

• 21:13Speaker 01

  All you can do at that point.

• 21:14David Puder?

  That's what you can do. Don't, don't spend an hour talking to that patient. It's probably gonna get worse, right?

• 21:20Speaker 02

  So wait for the RF to increase a little bit?

• 21:22David Puder?

  No, no, no. Let, let the, let the meth get out of their system further, right? So, okay, yeah, and then, um, so we talked about the scores a little bit. Okay, and I think that's, that's important to understand. And, and so I teach these cohorts now and we actually, like, once a week, we'll go through RF questions, talk about, um, they'll write something. And I'm not scoring them, like, I'm not saying that's a two, you know, that kind of thing. We're, we're trying to create a space for everyone to kind of develop and grow and expand their RF. So whoever their starting point is. All right, let's, uh, what's the next one? Are we talking about the other measures?

• 22:06Speaker 03

  Yeah. We can, but just before we wrap up on RF, there's just one tab I wanted to put in it. This article did something rather interesting. It did make a distinguishing of RFT, so reflective function as it relates to trauma in specific. And this was a very intentional move and they did comment on it. And the purpose for this is that deficiencies in reflective functioning as it relates to trauma does not necessarily indicate global deficits of other, you know, RF as it comes to other things. So I thought that was, that was something interesting to, to mention as well.

• 22:42David Puder?

  Yeah, really cool. I think it was needed to separate those and I think they found a really cool link between specifically RF in the trauma narrative, which is what I've found as well as I've started checking my patients, doing adult attachment stuff. They'll be low RF in one part of their story.

• 23:03Speaker 03

  Yeah.

• 23:03David Puder?

  But higher RF, higher RF in other parts.

• 23:06Speaker 03

  Yeah.

• 23:07David Puder?

  And they'll have this one portion of their life or their childhood that where their significant trauma occurred. And there'll be a lot of disavowed emotion around that specific thing. And so it's, it's like, it gives me language to understand it. The other thing that was, that's kind of linked in my mind, but a little bit different, is in cognitive processing therapy or, um, CPT.

• 23:33David Puder?

  Cognitive processing therapy.

• 23:35Speaker 01

  Yeah.

• 23:36David Puder?

  They will look for guilt in the trauma. And I think about how like if you are blaming yourself for something that you were the victim of, that's a lower RF sign. But in that type of therapy, that would actually be something that they would laser in on and try to decrease the guilt. If you can decrease the guilt, you can actually help them work through the trauma. And so just, just having a score is, is like one thing, but then knowing how to do the work is, I think, another thing. How do you reduce the shame and reduce the internal self hatred and loathing of them in the midst of their trauma? That's, I think that's where the magic of psychotherapy happens.

• 24:18Speaker 01

  Yeah, I don't even want to know what my RF is. I don't know what that says about me, but.

• 24:25David Puder?

  Well, that says, uh, that says that there's a healthy amount of concern.

• 24:32Speaker 01

  Yeah, so we could probably score that.

• 24:34Speaker 02

  Yeah, we actually could help you with that.

• 24:36Speaker 01

  Unhealthy avoidance of the mentalization.

• 24:39David Puder?

  Well, because I haven't asked you a question yet on your, that would, that would be like a demand question. I'm not going to score that one. It's a negative one.

• 24:46Speaker 01

  Okay, thank you so much.

• 24:48David Puder?

  Okay. No, I, I think there's a little bit of trepidation. Actually, I heard this from one of the, um.

• 24:53Speaker 01

  Well, if I'm uncomfortable with it, I can only imagine what patients feel, you know?

• 24:59David Puder?

  So they were.

• 24:59Speaker 01

  Do they even want to go there?

• 25:01David Puder?

  You know, most of my patients that I've like, uh, asked them to, to go through something like this, it's like they're, they just want to get better. So if this is like something where you can pinpoint like, hey, this is an area that we can get an idea of how you're doing in certain parts of your story, then we can try to, try to deepen it, you know? I think it's really good.

• 25:24Speaker 01

  Listeners embrace it. That's what I say.

• 25:27David Puder?

  But, you know, so I've created, um, I haven't released it yet. Maybe like in a couple of months I'll release it, but I'm creating like a reflective function journal, which takes people through the process of how to increase their RF.

• 25:39Speaker 01

  Okay.

• 25:40David Puder?

  So this will be the first like, this will be the first hint of that, but I'm excited to get that out there. Okay, so we talked about RF. We talked about that there was a separate RF trauma scale. So they gave these mothers the adult attachment interview. They scored their RF, they scored their attachment style. They looked at passages where they spoke about trauma, near-death experiences, lots of fear, right? And then they scored those separately and gave that a number as well. And what else do we want to cover in terms of the particulars here?

• 26:16Speaker 03

  So we can kind of do a brief overview of what the disorganized attachment is then. In other words, like what we're looking for. I mean, we did speak about it earlier. We do tend to correlate this disorganized attachment to dissociative states. And then we did also mention earlier as well that, you know, it kind of, it's almost like a third space, a loss of better words, in the schema of how we kind of regard the attachment styles. So attachment styles, when they were first described, it was organized, and then the disorganized ones. And even among the organized ones, you had like the secure and the non-secure. And then aside from that, we had the disorganized. So not all the organized ones are functional, a loss of better words. They're not all secure in that, you know, like, for example,

• 27:01Speaker 03

  avoidant simplification, but tends to come from like rejecting parenting, or anxious can come from inconsistent responses. But then when we have secure, right? That's also following like a set predictable pattern. Hence, it's an organized response. But when we get to disorganized, it's almost as if, you know, you have two conflicting responses at play at the same time. And the way you had described originally, it was like the fear without solution. And, you know, manifestation, again, being dissociative states, and above all, a paradoxical pattern. And so there was, you know, some talk on what does that look like? And I think Dr. Peter, maybe you can speak more to that on like what that looks like in real practice. I mean, there's like a classic example they give in the text.

• 27:44Speaker 03

  It's like the toddler that may walk towards their mom, but with their head down or like turning where they may briefly be very angry and then, you know, go back to normal. Sometimes this is crabbed as like a momentary response, but.

• 27:56David Puder?

  Like they may start to move back towards mom, but then dissociate and like freeze, like flop on the ground. And then go the other direction or go to mom, right? There's no organized way of reconnecting to mom. So in the, um, in the attachment interview, it's done about a year and a half of life. The mother leaves the room, comes back into the room. And then what does the child do when the mother leaves and the mother comes back in the room? Right. And then they're scoring that. It's very consistent statistically. And a lot of people don't even know that disorganized attachment style is a thing. Like, have you guys ever heard of that before this?

• 28:36Speaker 02

  I have a psychology degree, so I do, I have heard of that.

• 28:39David Puder?

  You have heard of that in psychology? Great. I mean, there's a lot of like, you know, when you're a new parent, you read these like attachment parenting books, they won't mention that at all. Like, it's like, they don't really understand a lot of the research. And so it's disorganized attachment. I did two episodes on that, me and Annabelle Kuhn did a great job digging into that. And I want to do more on, on it in the future because it really helps explain a lot of things. So essentially, when the infant sees the mom, the mom comes back into the room. Secure attachment, cries, goes to mom, 30 seconds, goes back in place.

• 29:23David Puder?

  Okay. So like the bounce back to joy is pretty quick. And, um, the, uh, the anxious attachment may go back to mom. And then they're distressed for like a lot longer. They may be like hitting on mom a little bit. They're like upset at mom and that it's like they're really upset. And then the avoidant attachment, which in the adult attachment interview becomes dismissing. Same thing dismissing is because they're dismissing of attachment words. Avoidant because they're, the behavior is avoided. So when the, when the infant comes into the, the infant is in the room.

• 30:04David Puder?

  Mom comes back in the room and the infant just continues to play. But salivary cortisol is going to be elevated. The, the child is stressed out. And so you see these kind of dyads in adult relationships where you'll classically have one of the partners who's more avoidant or dismissing like attachment stuff.

• 30:26David Puder?

  You know, and they've been programmed from a very young age when they're distressed to hide their distress. It's safest to hide the distress for whatever reason. And the more anxious preoccupied partner will be more verbal, more angry, more trying to connect, more distressed, right? They're verbally worried more about their relationship. And they're both, they both can believe in their heart of hearts that the most important person in the world is their partner. They both, they both usually believe that.

• 31:08David Puder?

  This is, this is the, how EFT works magic, you know, because emotionally focused therapy like helps them find that, you know, and find them, find the emotion and express it in a way that's helpful, not unhelpful. Okay. So with, you have the anxious, you have the avoidant, and then on top of those things, you can be disorganized. And so the disorganized, you can be secure and disorganized, or you can be insecure. Usually it's insecure. And it's, it's kind of like this thing that they found where it's like they did these things that didn't make sense, where it seemed as if the child didn't have an organized way of reconnecting with mom.

• 31:52David Puder?

  So they start to move back towards mom and then they freeze, right? That could, that's the classic one. So the, the, the main thing that the study found was that mothers with low reflective function in their trauma were 3.4, three times more likely to have infants with attachment disorganization than were mothers with a history of trauma. But high reflective function trauma.

• 32:23David Puder?

  So, go ahead.

• 32:24Speaker 02

  I think it's like whenever you maybe you're talking with clients, they're wondering, like, why is this happening? For example, like, did I do something so like largely of a failure? Or did I really lack that much empathy with my child? Why are they reacting this way? But I think it's important to note, I think there was an article by Beeb in 2010 that said that it's not like a global failure of empathy or engagement, but it's like specific failures when the infant is like manifesting a distress. So.

• 32:56Speaker 03

  Yeah, she had like this concept of like the momentary failure.

• 32:58Speaker 02

  Yeah.

• 33:00David Puder?

  So Beatrice Beebe, 2010, it's a hundred page paper, maybe, maybe more. Tried to get Beatrice Beebe on my, on my podcast multiple times. If you're hearing this, please come. If you know her, please email me and help me get connected with her. Or, or anyone that worked on that paper. I would have anyone, actually. I should, I should, we should, we should search them down. So it's a great, it's a great paper. And basically Beatrice Beebe videotaped four month old infants and their mothers interacting. And it was the dyadic interaction and what was going on between them that predicted disorganized attachment later on. So if they were disconnected, like baby's smiling, mama's got a grimace,

• 33:45David Puder?

  baby's trying to move away from mother, mother looms in. So there's like, there's a, there's like, when the, there's not a back and forth attunement, a playfulness, right?

• 33:59Speaker 02

  Confusion.

• 34:00David Puder?

  Some confusion. Yeah.

• 34:01Speaker 01

  The source of my fear is also the source of my safety. So that's the confusion there on the infant's side.

• 34:08David Puder?

  Right. The source of my fear is also the source of my safety. It's very confusing. Yep. And, and I will say as well, like even, even with kids with great childhoods, you'll get somewhat disorganized attachment style. And, and that, that's because there's lots of things that are contributing. And also attachment changes too. So it's not like fixed in stone. Like you're more likely to become the attachment of the people you spend like. You know, the decade following the first two years of life, right? So you you can change. It's not like, once you're like this, always like this.

• 34:54David Puder?

  Reflective function can grow too. Okay. And so I I think of it as like a lifelong journey, more than like a six month project.

• 35:06David Puder?

  But but I what I'm realizing, though, is like, we have to, we have to create the pathway. The pathway needs to be like, if you know where you're going, you're more likely to get there. Right? So these are, these are goals, right? Okay, we want to grow in these. We want to grow in reflective function. We want to grow in our ability to hold people's distress.

• 35:28Speaker 02

  Speaking about, I guess, meeting our heroes. While I was looking through these articles, I had run into Dr. Slade's work on programs for specifically her MTB program, which is like minding the baby programs.

• 35:42David Puder?

  Okay.

• 35:43Speaker 02

  That were from, like, they go from two months of age all the way to two years later. And they kind of follow high risk populations. And she actually emailed me back within 12 hours, which is wonderful. And she provided me with her latest article in her book, which she wrote in 2023, which kind of does a good summary of that timeline between the start to like all the way to two years out.

• 36:08David Puder?

  Okay. And what did you learn from?

• 36:11Speaker 02

  Yeah, I can go into that for sure.

• 36:15Speaker 02

  This program provided intensive home visiting services for first time mothers, babies and their families, beginning in second trimester of pregnancy. And they're visited weekly through pregnancy, labor and delivery, the child's first year, and then bi weekly until the child turns two. They were following the level of parental reflective functioning, the dyadic communication, the quality of attachment. And then they looked into like postpartum depression as well. They did screenings for those and post traumatic stress disorder.

• 36:45Speaker 02

  They kind of found that in part, there was an involvement of there being a social worker and a nurse along with this population that did help with, for example, increasing their rate of pediatric immunizations by one year, just by being involved with the social worker and being, having access to, for example, like necessities like diapers. And that also kept this relationship going till two years. They had two phases of this, of the study, a phase one cohort and a phase two. And they found that the MTB group reported significantly fewer externalizing behavior problems than did the control mothers when children were between three and five. So it goes all the way out to those time periods.

• 37:24David Puder?

  So, so less externalizing behaviors, so less aggression?

• 37:28Speaker 02

  Mm-hmm.

• 37:29David Puder?

  Right. So, yeah, and kids with more disorganized attachment actually have higher aggression in like the age six, five, six, like that age. Okay, go on.

• 37:38Speaker 02

  Yeah. And so the examination of the odds ratios with this study found that infants in the MTB intervention were 2.69 times more likely to be classified as organized than their control group peers, and 2.59 times more likely to be classified as secure than their controlled group peers. Pretty significant.

• 37:59David Puder?

  This is where we need to have intervention.

• 38:02Speaker 02

  Yeah.

• 38:03David Puder?

  Like, this is, this is the level that's going to make an impact, you know? And so great. Put me in, send her my email.

• 38:11Speaker 02

  Definitely will.

• 38:12David Puder?

  Or connect us over email. I'd love to have her on.

• 38:14Speaker 03

  It's interesting too, because, um, so Bebe has a YouTube channel. And on the YouTube channel, there's actually, um, some videos. It's like, there's like an hour-long one, like a 30-minute one.

• 38:25David Puder?

  Yeah.

• 38:25Speaker 03

  That actually shows her sitting down with the mom and going through the, um, the interaction with the infant, picture by picture. And that process itself of just looking at the infant's reaction had some therapeutic benefit as well. And it's formed some basis of the education. So, yeah, we have like the, you know, more formalized model that Steele and others are developing. But I think if it just comes into people's conscious, the interest will naturally spark itself.

• 38:49David Puder?

  Is it Steele?

• 38:51Speaker 02

  It's Layne.

• 38:51David Puder?

  Layne?

• 38:52Speaker 02

  Ariana Layne, Dr. Ariana Layne at Yale.

• 38:54David Puder?

  Okay, want to get that right, yeah. I mentioned Steele earlier. So, okay, that was actually helpful for me, too. When, when I was studying this was right before my kids were born.

• 39:06David Puder?

  And so I was like really into BB and I was like really studying this stuff. And it gave me an incredible meaning for what I was about to go through too. And I felt like any other training was very superficial. It's very like it seemed, and I also have to thank Dr. Tar because Dr. Tar was so into this stuff. The attunement, the moment to moment connectedness. There's a video I have of my daughter and I was singing to her and she was singing back at me at seven weeks old.

• 39:38Speaker 01

  Wow.

• 39:39David Puder?

  And I think it came from that like practice of attunement for that for seven weeks, you know, that I would, she would mimic me. And so.

• 39:50Speaker 01

  It's a crucial period, you know, infants kind of, you know, earlier on, they mirror all of your behaviors. So if they see a stranger, right, earlier on, they have stranger anxiety. They are going to look to your reaction first. And if you're smiling at the stranger, they're like, oh, okay, like this is fine. But if you have like some kind of like weird interaction with them, they're going to adapt that too. So, you know, that's something to definitely keep an eye on as a parent. Like that, those few weeks and months are just crucial. Like what you're saying, the attunement and the mirroring.

• 40:25David Puder?

  Yeah, absolutely. The mimicry, right? There's a lot of mimicry that goes on and they need bidirectional mimicry towards them too. Like they get, like when, when you see them doing something that they're excited, they need you to get excited with them. Or when they're venturing out and having a little adventure, it's like to kind of join them in that little adventure. And it's like, you know, probably the most, the biggest risk thing we have in our day and age is what?

• 40:56Speaker 01

  Devices.

• 40:57David Puder?

  Devices.

• 40:58Speaker 01

  Yep.

• 40:58Speaker 03

  Not being present.

• 40:59David Puder?

  Not, not being present. Yeah. And I would say depending on like the severe, the severity of the household dynamic, right? But for most of the people who are probably listening, it's, it's devices. And that, that's going to cause an interesting impact as well on people long-term.

• 41:14Speaker 03

  Cause kids are so smart. Cause they know even though you're physically there, but if you're in your phone, they know emotionally you're not there. They can pick up on that, even from a very young age.

• 41:23David Puder?

  Yeah. Yeah.

• 41:25Speaker 02

  Something I notice that sometimes at bedside at Namors Hospital is maybe one parent doesn't know how to interact with the child, like when they're born. So I think this is all important to like communicate to parents that it matters, your interactions with your child. It matters like how your facial expressions go. Like everything is being watched even from birth.

• 41:48David Puder?

  Yeah. Yeah. I think we need, I think we need to convince people who think, oh, communication doesn't really start until they start saying words. It's like, no, no, no.

• 41:57Speaker 03

  Exactly.

• 41:58David Puder?

  No, that's not, that's not how it works. Yeah.

• 42:03Speaker 03

  You know, part of it too, at no point, like, does anyone ever get any formal instruction or really like an overview of what mirroring is? Like, parents don't know that, okay, it's not just some cute thing that you do and you just kind of pick up just, you know, by virtue of being human, but it's actually something that has actual tangible benefit from like day one.

• 42:21Speaker 01

  Yeah. And taking the way the device from the kid because you're like, ah, they're getting addicted to it or something like that. That's not going to solve the problem. You have to detox your own.

• 42:30David Puder?

  No, you have to take it away from yourself.

• 42:32Speaker 01

  Exactly.

• 42:33David Puder?

  They're not going to want to be on a device if you aren't also on a device.

• 42:36Speaker 01

  Yeah.

• 42:37David Puder?

  That being said, I'm not perfect by any means. Like, don't.

• 42:40Speaker 01

  I'm terrible at it.

• 42:41Speaker 03

  Nobody is perfect.

• 42:42Speaker 01

  I still got time though.

• 42:43David Puder?

  But, you know, with, with my kids, we have quality time and we've chosen to not have a TV in at my house, actually.

• 42:51Speaker 01

  No TVs in your whole house?

• 42:52David Puder?

  No TVs in the whole house.

• 42:54Speaker 01

  Okay.

• 42:55David Puder?

  Yeah, we're serious. We're serious. But, you know, if they, if they really want to watch something, they can watch it on YouTube.

• 43:01Speaker 01

  So Fireplace is nice, probably.

• 43:04David Puder?

  Fireplace, uh, we do a lot of trampoline. Walks. I'll, I'll play Minecraft with them. We'll do Minecraft together. That's fine. Chess, me and my son. I'll play chess a couple hours a day.

• 43:15Speaker 01

  Meaningful time.

• 43:15David Puder?

  He's getting good.

• 43:17Speaker 01

  Meaningful time together.

• 43:18David Puder?

  Okay.

• 43:18Speaker 01

  Has he beaten you yet?

• 43:19David Puder?

  Oh, he can beat me, fair and square.

• 43:21Speaker 01

  Wow.

• 43:22David Puder?

  But not every time.

• 43:24Speaker 01

  That's an ego blow right there.

• 43:25David Puder?

  No, not really.

• 43:26Speaker 01

  How old is he?

• 43:27David Puder?

  Are you kidding? I'm excited for, I'm so proud of him. When he does it, I'm like, oh, man, he really got me. He's like, did you, did you let me do that? He's, he's nine.

• 43:37Speaker 01

  He's nine, okay.

• 43:39David Puder?

  So, yeah, he'll be, he'll be better than I'll ever be in a couple of years.

• 43:43Speaker 01

  That's what you want as a father, right?

• 43:44David Puder?

  Yeah.

• 43:45Speaker 01

  You want him to be better, better than you.

• 43:47David Puder?

  Yeah.

• 43:47Speaker 01

  Ultimately.

• 43:48David Puder?

  Yeah, I think it's pathological to actually have envy. It's, it's, it's, you know, a little bit pathological. A lot. It's, it's a little bit pathological if you're envious of your child advancing farther than you. Like, that should be like the goal, right? So, yeah. Well, okay, let's, let's, uh, let's go through and kind of make sure we cover all the things we wanted to cover.

• 44:16Speaker 01

  Yeah.

• 44:16David Puder?

  What else, what else haven't we covered that we want to talk about?

• 44:19Speaker 01

  I guess we can get into the nitty gritty of some of the findings of the actual paper, if you guys want to do that.

• 44:25David Puder?

  Yeah.

• 44:26Speaker 01

  So, you know, through the findings, they found that in a his, in mothers with a history of abuse, with a high RF, reflective function, the infant's organization was 63% organized and 37% disorganized. So they have this history of abuse, but they have a high RF, and that's what the proportion was. Most of them, 63% were organized, the infants.

• 44:52David Puder?

  So just think two thirds organized.

• 44:54Speaker 01

  Two thirds organized.

• 44:55David Puder?

  Two thirds. If if they had higher RF, but these are very, they picked an abused population. This is not a normal population of of mothers, by the way.

• 45:04Speaker 03

  It was like primarily Caucasian, and I think they were like mainly like middle class as well.

• 45:08Speaker 01

  Socioeconomic status.

• 45:10David Puder?

  There was some low, there was some low. I don't think socioeconomic status actually made that much of an impact.

• 45:16Speaker 03

  They did comment on that as well. Like it was a little surprising in the sense, I believe that they, I think it was anticipated that lower SES would contribute to like perhaps like more rates of like generating disorganized attachment. But again, like the big thing that they found that made all the difference was just that mentalizing process itself, irrespective of demographic, it sounds like.

• 45:33David Puder?

  That's right. Yep.

• 45:34Speaker 01

  And then in the mothers that were abused with a low reflective function, two thirds of the infants had a disorganized attachment style compared to a third of organized. So you know, kind of like the exact opposite mirroring effect here.

• 45:51David Puder?

  Yeah, and that's that's a substantial shift. Like that's, that's, that's not, I mean, you know, I'm so tired of studies that are like the correlation was point two. You know, this is not a point two correlation. This is a, this is a big impact.

• 46:03Speaker 01

  This is a nice pie chart.

• 46:04David Puder?

  This is a nice pie chart. They did, you know, three point four fold difference, right? Which is, which is substantial. The beta, do you want to talk about the the beta on that? The risk of mothers being classified as unresolved increased with a number of different types of maltreatment that a mother had been exposed to during childhood. The beta was 1.14. This is specifically talking about unresolved as in like the adult attachment interview, their attachment style was unresolved. And then it goes on, suggesting a dose response relationship between early adversity and unresolved attachment status. However,

• 46:49David Puder?

  there was no association between dose of maltreatment, the level of the mother's reflective function trauma score.

• 46:59David Puder?

  So it's not like, it's not like the women who are more severely abused, as scored by, by the way, a very accurate dialogue between an interviewer and the interviewee. It wasn't that the severity decreased reflective function in the trauma. Or, and then it goes on, and there was no association between the dose of maltreatment or infant attachment disorganization. That also was really fascinating to me.

• 47:35Speaker 01

  So worst possible abuse was possible at the time, but with a high RF, it was kind of protective in that sense for infant organization.

• 47:44David Puder?

  Yep. So it wasn't just the dose of the maltreatment that led to the more disorganized kids. I think that's a very important thing.

• 47:52Speaker 01

  Hmm.

• 47:54David Puder?

  Okay, so it's hopeful because if, if the mother can do the work before, like if you're listening to this and you want to have children and you've never done therapy, this is a good reason to consider doing therapy on some of the traumas of your childhood. Okay.

• 48:11Speaker 03

  And I think this also points to like the resilience of people, you know, they can undergo these traumas and then, you know, if we put in the work, we, we can have these positive outcomes. And it also reminded me a little bit of like the statistics that say that most people who experience trauma don't develop PTSD. And I thought that was an interesting parallel.

• 48:31David Puder?

  It depends on the severity of the trauma. It depends on the history of their own trauma. It depends on the personality type. It depends on, they can, they can develop manifestations, physical manifestations that aren't PTSD diagnosed in the DSM. So they can develop sequelae, you know, like I've had a lot of patients with trauma that develop all sorts of like.

• 48:57David Puder?

  Very, you know, unique things that are not PTSD exactly, but they're still suffering. So they can still suffer in different ways. There, I think also it's different between childhood and adult, right? Childhood trauma, like in this study, they're mostly looking at childhood trauma in these women, like physical, sexual, emotional neglect. They're looking at the, at the impact of those things.

• 49:24Speaker 01

  The percent of that was higher in mothers compared to fathers in the study.

• 49:30David Puder?

  Which one are we looking at here?

• 49:33Speaker 02

  Is that the one where they had like singled out fathers from the father and the mothers impact on the child and they still saw that it was reflective of the, the mothers?

• 49:45Speaker 01

  I mean, there was a slight difference, but like it said, among those who experienced neglect by primary caregivers, 89% identified their mother and 82% their father as neglectful. Among those who experienced parental antipathy, 79% reported antipathy from their mother and a slightly lower in their father.

• 50:03David Puder?

  But it's almost the same percentage.

• 50:05Speaker 01

  Yeah.

• 50:06David Puder?

  Were you surprised by that? Is that what you're saying? Like the, so basically what that, what this is reporting on is they were abused by either their mother or their father, right? And most, the neglect was from both mother and father, about the same?

• 50:26Speaker 01

  About the same, but like slightly higher in mothers. I wonder if there's anything there.

• 50:31David Puder?

  No, I mean, these are small percentages. I mean, it's a small group and it's just, I think that this is just more helpful in reporting the, like, this is what they found in the, in this specific group of people.

• 50:45Speaker 02

  I think they found, to go back to Dr. Slade's article with MTB, they actually decided to organize it based on depression and PTSD as well, but they didn't see any differences among having the diagnosis or not, but it was mainly focused on if they had RF or not, like the level of RF.

• 51:06David Puder?

  Okay.

• 51:07Speaker 02

  So I think that kind of provides evidence behind the idea that like a diagnosis of PTSD, like someone who was diagnosed with PTSD but has a high RF would be less likely to have a childhood with disorganized attachment than someone.

• 51:22David Puder?

  Yeah, exactly.

• 51:23Speaker 02

  Yeah.

• 51:24David Puder?

  And I think that's what this study is showing, right? It's not if they're having a mental health crisis. It's like if they have a good RF, then they can get through it. If it's not going to ripple into their kids as much. Now, that being said, if your parent is schizophrenic, bipolar, untreated, unmedicated, and currently psychotic, unable to take care of themselves, like that's going to be a rough childhood for that kid, you know? So I think there's caveats to those, you know, like what is the severity of the depression? If it's super severe postpartum depression, it's going to impact the kid.

• 52:06David Puder?

  Still face the experiment, it's different for a depressed mother, for a non-depressed mother, higher rates of insecure attachment with postpartum depression, stuff like that. Which is why, you know, we should be passionate about helping people in that, in that group. Okay.

• 52:25Speaker 02

  I have some point kind of on caveats.

• 52:27David Puder?

  Okay.

• 52:28Speaker 02

  I was looking a little bit into like epigenetic programming, like from, like in utero. So for example, like we have half of our genetic material formed five months in utero in your grandmother's womb, in your mother's ovaries, and does that have an effect? There's some studies that kind of correlate maternal, early life, sexual and physical abuse in both the maternal and infant like cortisol levels. And they showed that children with the history of trauma in their mothers have significantly lower baseline cortisols, but they tend to peak faster. This is interesting to think about, along with other studies, but it does, there are studies coming out.

• 53:10David Puder?

  But here's the thing, I'm looking, I'm looking at this graph.

• 53:13Speaker 02

  Yeah.

• 53:13David Puder?

  In the paper.

• 53:14Speaker 02

  It's about the same, yeah.

• 53:15David Puder?

  It's about the same.

• 53:15Speaker 02

  At the end.

• 53:16David Puder?

  And this is where I think, like,

• 53:20David Puder?

  I would be more interested in, now this cortisol response to a stressful situation? Or to what?

• 53:28Speaker 02

  It was a stressful situation, so they made like a loud noise and this is what it's been response to, but what I was getting to the point of is that there are articles coming out soon, I think it's Corden who's coming out with them, that is showing that these have lower important factors compared to like the reflective functioning.

• 53:44David Puder?

  Right.

• 53:44Speaker 02

  Part of this.

• 53:45David Puder?

  I mean, I think if, if you're in a stressful, if you're talking about something stressful or going through something stressful and you have an inability to reflect on it, it's going to be registering more stressful in your, in your body, you're going to have more stress hormones. That makes sense to me. But I think what we're, what with the mind, it's so complex, the biological stuff is just giving us a signal of something very complex. And so the question then is, how do you treat this very complex organ that we have, right? And is it just with biological means or is it with connect, human connection, exercise,

• 54:29David Puder?

  diet, lifestyle? You know, so, okay. What, any other things from this?

• 54:36Speaker 03

  One concept, Dr. Peter, that I do want to hear kind of your insights about, and that they brought it up in the discussion, is a term that they themselves coined, and I suppose us being in October with the Halloween theme, this is appropriate. The concept of the alien self. So in their, in their article, they, they, you know, brought up this term and they described it as the formation of an unmentalized alien core in the infant as a result of a failure of the mother's mirroring response. So it's also described in other words as an internalization of maternal absence, or like a formation of an incoherent sense of self due to an unmetabolized distress.

• 55:17Speaker 03

  The way I kind of rationalized it in my mind is almost, lost of better words, one becomes emotionally naked or emotionally vulnerable, and then they feel like they're just left out in the open, and then there's almost like a micro shock or like a micro embarrassment that occurs and causes someone to overcompensate and then being exclusively withdrawn and less trusting. I thought that was interesting that they kind of, they kind of brought that up.

• 55:44David Puder?

  You know, when you, when you mention this and I think about this, it's like I'm thinking about many patients, you know, and specifically some that I've walked with for years doing therapy. And what their childhood was like, was like a vacuum or like this kind of abyss, you know? And it's like, when the emotion starts to come out, it comes out so raw because it's been disavowed their whole life. It's like they've had no place for disgust, for anger, for any of these emotions, you know? And you can go through residency and you can still have that be your reality.

• 56:28David Puder?

  That's the crazy thing that I've found. Like you can function in life very high. You could be a lawyer, you could be a physician, but you could still have this like total, this total disavowal of a lot of your core, a lot of experiences, like anger, disgust, you know, all these things that like, for whatever reason, they were never attuned to, they were not allowed, they were not mirrored, right? Maybe there was so much going on in the family that there was no space for this. And so when they come out, they come out very raw, they come out very big, right? Sometimes they're pointed at me, that's transference.

• 57:08David Puder?

  And so actually, transference focused therapy is probably the therapy type that has shown to increase reflective function the most. But they've also done the most studies on it. The DBT didn't do very much for it, where transference focused therapy actually increased it from like, in one study, it was like 2.7 to I think 4.3 point.

• 57:34Speaker 02

  3.1. It was 2.75 to 3.31.

• 57:37David Puder?

  3.31. So one study, I mean, that's a big jump in a short amount of time. I think you have to think about this as like a journey.

• 57:45David Puder?

  So, yeah, I don't know if the alien self or like this kind of like this, there's a foreign part of myself. Yeah, for some people, I think they can resonate with that. They also talked in here about sometimes because the infant has not had the ability to get an experience represented from another, they will project it onto you, the therapist, and then you will identify with it. That's projective identification. And then you start reacting differently to them. And so this kind of like, this is where like, therapy gets both complex and I would

• 58:27David Puder?

  say incredibly interesting because these things, like enactments, when enactments, it's another way, it's like they're playing out the distress. Because a lot of these things happen in a pre-verbal way, right? And so they're, it's like the human is trying to, the human species, we have a verbal ability, but when the trauma is pre-verbal, how do you play that out? But by through kind of a more visceral means, like, so especially if a patient feels like the provider cannot understand them, they will find a way for the provider to

• 59:11David Puder?

  feel with them. And so a lot of that feeling with them will be you starting to feel very distressed, either towards them or with them, or like, it'll be very painful to share space, right? So it can come out in a number of ways. And I've had people feel all sorts of things towards me that I don't think I fully, it's like, no one really prepared me for that. No one, no one said, you are signing up for psychiatry. Patients will feel everything towards you. But I think they do that in other specialties, too. We just don't talk to them about it. It's like the patient's just enacted and you're like, oh, can't work with that person.

• 59:56David Puder?

  Where it's like, we're like, no, we're like continuing to work with each other.

• 59:59Speaker 01

  Yeah.

• 1:00:00David Puder?

  Yeah.

• 1:00:00Speaker 01

  So you say transfers focus their psychotherapy is good and has, you know, scientific backing for improving relative functioning?

• 1:00:10David Puder?

  Reflective function.

• 1:00:11Speaker 01

  Reflective functioning.

• 1:00:12David Puder?

  Specifically, I would say anything where there's the interpersonal going on and there's a good frame, you need, you need a, you know, you need some boundaries, right? Some boundary.

• 1:00:21Speaker 01

  Yeah.

• 1:00:22David Puder?

  Empathic attunement with an understanding of the interpersonal with, with mentalizing, I would, I would say.

• 1:00:29Speaker 01

  So what does that, what does that look like? Like, is it more narrative based?

• 1:00:33David Puder?

  Uh, you're, you're going to talk about what's going on between us, right? So the, um, if the, both the, the positive and the negative, you know, so like, uh, like, what is the space between us like, the interpersonal? Between sessions, what, did you have any thoughts that came to your mind about what are, what is going on between us? So, so with one of the people that specifically had a very dissociated childhood, it's like, you know, she always was fearing that I was going to be angry at her between sessions. During sessions, she could feel that I wasn't angry at her,

• 1:01:14David Puder?

  but once I left, she would imagine me as being angry and that was like distressing, right? So we check in on that, like, as you're coming in today, like, how, what was the space like between us this last week? And then, um, we, there were, there were periods of differing emotional states that were felt over the course of treatment. And there was a long phase of I, complete dissociation from what she could feel between us, and that was very distressing to her.

• 1:01:47Speaker 01

  Interesting.

• 1:01:48David Puder?

  So you kind of, it's, it's, it's a journey. I would say it's very different for different people.

• 1:01:54David Puder?

  But the interesting thing on what leads to good outcomes in psychotherapy is having high reflective function yourself. Right? So in one study, that was like 70.5% of what made. Better therapists, better therapists. I mean, that's pretty incredible. So that, that is like, okay, so how do we grow in that? Right? And this is kind of the quest I'm on. It's like, how do, how do we grow our reflective function? Like, it's not going to be, it's not going to be rejecting everyone with a different viewpoint than your own. I'll tell you that for sure.

• 1:02:34David Puder?

  Like, one thing Nancy McWilliam talks about in her book Psychoanalytic Psychotherapy is the best preparation for therapists is to read broadly of different cultures, of different societies. Right? To read, "You ought to be a great reader and become acquainted with literature of many countries and cultures. In the great literary figures, you will find people who know at least as much about the human nature as psychiatrists and psychologists try to do." She's quoting someone here. Okay, this was Heinz Kohut, once, once encouraged a 14-year-old son of a colleague to write Anna Freud about his interest in becoming a psychoanalyst.

• 1:03:19David Puder?

  And this is what she responded to him. Okay, that's cool.

• 1:03:22Speaker 03

  Beautiful.

• 1:03:23David Puder?

  So, um, so, yeah, you, it's like, it's like a lifelong journey. Right? And so, think about how we can increase our reflective function, conversations in multiple domains of life. By the way, this is, it's energy intensive to increase this. Right? It's kind of fun to root for only your team. Okay? Look no further than politics. Look no further than sports teams. Right? This is what the majority of people enjoy yelling about.

• 1:03:51Speaker 03

  Two fields with very high amounts of splitting.

• 1:03:55David Puder?

  Idealization, devaluation, right? It's fun to, it's fun to have parts of our life where we're a little bit idealizing and devaluing. Right?

• 1:04:03Speaker 03

  Mentally, it's less work too, to be honest.

• 1:04:05David Puder?

  It's, it's much less work. Yeah, let's just do confirmation bias all day long. Right? I'm right, you're wrong. But if you tell someone that, then they'll be like, how dare you tell me that I have confirmation bias? What is that one? What's the score? How dare you?

• 1:04:22Speaker 02

  Negative one.

• 1:04:23David Puder?

  Negative one, right?

• 1:04:23Speaker 02

  Hundred percent.

• 1:04:24David Puder?

  Yeah. It's like, no curiosity into my mind and how I got to that point of thinking in the, in the complexity of that. Right?

• 1:04:34Speaker 02

  An immediate rejection.

• 1:04:35David Puder?

  Immediate rejection, no, no conversation, right? Uh, labeling people something, right? If, if you're, if your way of labeling past exes is just a diagnosis, that's actually a three in reflective function. So it's easier to just, you know, everyone I dated was a narcissist. Maybe they were, but when you say narcissist, you also have to, to be high reflective function that you have to describe what that means. The why, right? So it's not enough to just put a label on someone, but that's also thinking about how we talk about our own patients as well. Right? It could be, a, a label can help us communicate quickly,

• 1:05:20David Puder?

  but also like, how do we communicate in a way that's higher reflective function? Cause everyone's unique. So, yeah, these are some things I think about.

• 1:05:29Speaker 02

  So what do you think is, I know there's like another type of therapy. I don't know if it's like part of this other therapy, the transference focused therapy, but mentalization based therapy. Do you have experience like specifically?

• 1:05:41David Puder?

  Yeah, we, we learned about, you know, when I went to the Psychonautic Institute, we had people coming in, we're experts, talk about this. And I've had Fongi, who Bateman, who, who originated, I've, I've done an episode on mentalization based therapy for, for narcissism. Did episode on that as well. Some good books, but I have about six books on my bookshelf. I mean, it's, it's rich, right? And, um, I think it's a, it's a good, it's a good approach. Absolutely.

• 1:06:12Speaker 02

  I have some of the, the key features of that approach if y'all want to hear.

• 1:06:15David Puder?

  Yeah.

• 1:06:15Speaker 02

  Take a summary. So the therapist is asked exclusively to focus on patients' current mental state, their thoughts, feelings, wishes and desire, with the aim of building up representations of internal states. They're asked to avoid situations where patient talks of mental states that they cannot link to subjectively felt reality. Thus there is deviation from traditional psychodynamic technique in that there's a de-emphasis of deep unconscious concerns in favor of conscious or near conscious content, and less focus on past as it is represented in the present. The aim of therapy is not insight, but the recovery of mentalization, achieving representational coherence and integration for intentional states. Therapists avoid describing complex mental states such as conflict, ambivalence,

• 1:06:59Speaker 02

  unconscious, and are asked to make small interpretations referring to ideation that is only slightly beyond the boundaries of the patient's conscious thinking.

• 1:07:08David Puder?

  Right, so it's like, instead of, we're not going to use complex words to describe things that are like archaic, right? Because I think that's, I mean, you go into, I've gone into a dermatology office and they like are talking like, I'm like, I have no clue what this person said, right? Even I'm an MD, I have no idea. It's like, that probably level of interpretation is just not helpful for patients. Actually, it's low reflective function for a patient to spout cliches or like words that they're disconnected from, right? So it's like getting them into the visceral experience of what's going on in the here and now.

• 1:07:45Speaker 02

  Finding the emotions you can play with, in a way, like finding that transitional area of relatedness.

• 1:07:52David Puder?

  Yeah, and I would say it's a lot more complex, and I think that that's a good couple-sentence introduction. But if you're interested in that, please go back and listen to Phone Again, Baiman. And by the way, their connectedness, me capturing that on YouTube, is, it's priceless. Like, you can really feel the love between those two men. Like, they've worked together for years, you know? And they just have this camaraderie, right? Which is kind of what I would hope for, right? And people that, you know, that you don't feel like a competitiveness at all between them. You would hope for that in someone with high mentalizing ability, spouting mentalization-based therapy.

• 1:08:33Speaker 03

  That's reassuring.

• 1:08:34Speaker 02

  There's some genuine mentalization going on.

• 1:08:36David Puder?

  Yeah, because I think about like envy is also a breakdown of that ability to like attune. Because you're like, oh, this person has this thing that I don't have, so I can't be excited for them. Whereas like, the revelry in each other's success and their ideas and stuff, it just, the banter is priceless in and of itself, so check that out.

• 1:08:59David Puder?

  Great. Yeah. Well, shall we put a cap in cabinet for today, guys? And like, this was a great, this was great. I really appreciate all three of you and your contributions and looking at this paper. And we left some of the paper like, undigested for the readers to go back and listen to themselves. Or not listen, but, um, well, I guess you could put it in speechify and listen to it. That's what I do too. But yeah, guys, thank you so much. Appreciate you guys. And if, uh, if you are listening to this in 2025 or later, actually, or maybe years later after, all of this will be also on psychiatrypodcast.com. That's where we'll have links to the articles.

• 1:09:43David Puder?

  We will have our own article, kind of summarizing this and everything you might be curious to learn. Okay.

• 1:09:50Speaker 01

  Yeah. Thank you for having us.

• 1:09:52David Puder?

  Thank you for coming.

• 1:09:53Speaker 02

  It was a pleasure.

• 1:09:54David Puder?

  Yeah.

• 1:09:54Speaker 03

  It was amazing. Thank you so much.

• 1:09:56David Puder?

  Let's, let's do it again. All right. We'll leave it there for today.