Mentalization-Based Therapy (MBT) Explained: Practical Techniques to Improve Clinical Outcomes in Borderline Personality Disorder, OCD & Narcissism

In this episode, Dr. David Puder speaks with Robert Drozek, clinical director of the Mentalization-Based Treatment (MBT) Clinic at McLean Hospital and teaching associate at Harvard Medical School, about practical Mentalization-Based Therapy techniques to improve clinical outcomes in borderline personality disorder (BPD), OCD, and narcissism. Drozek explains the "What, Why, and How" model of mentalizing, how to address psychic equivalence (rigid certainty), pretend mode, and teleological thinking, and offers concrete strategies clinicians can use in session and assign as between-session work to help patients reconnect with difficult emotions, reduce intellectualization, and develop more flexible, reflective ways of understanding themselves and others. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-274-mentalization-based-therapy-mbt-explained-practical-techniques-to-improve-clinical-outcomes-in-borderline-personality-disorder-ocd-amp-narcissism Link to YouTube video https://youtu.be/THFkPjQmSJw

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

• 0:13David Puder?

  Okay, welcome back to the podcast. I am joined by Robert Drozek. He is the Clinical Director of Mentalization-Based Treatment Clinic at McLean Hospital in Massachusetts. He is a teaching associate and the Department of Psychiatry at Harvard Medical School, and specializing in borderline personality disorder, narcissistic personality disorder, and PTSD. He is the author of a new book, Mentalization: Utilizing Reflection to Heal from Borderline Personality Disorder. This is the first book for the general public about mentalization-based treatment. And so where would you like to start out?

• 0:54Speaker 01

  Well, first of all, David, great, really happy to be back. I think you were the first podcast I think I was ever on when we were releasing the narcissism book a few years ago. And I just loved that conversation, and so I'm excited to kind of talk with you again. So really happy to be here. And where to start?

• 1:13David Puder?

  I'm mentalizing the audience, which means I am imagining what they're feeling, thinking, desiring. They want, they want practical knowledge that helps them be better clinicians. And so, yeah, how are you mentalizing the audience? Maybe we can start there.

• 1:31Speaker 01

  Well, it's a good question. I guess my first question is, do you feel, you feel like your audience knows, like, kind of like what mentalizing is even in the first place, you would say?

• 1:42David Puder?

  Yeah, maybe. I think it's a good place to start. And there's actually some kind of like code words that I feel like are used in the sort of subgenre of mentalization-based therapy. So maybe we could start by defining it.

• 1:56Speaker 01

  Oh, cool. Yeah. Well, basically, you know, for those, you know, I think this podcast, I think more than any other, you really, you, you spend a lot of time thinking about mentalizing and reflective function. Really have, in my opinion, like leaders in the field to kind of talk about that. So, but those of you who might be newer or need a refresher, like, mentalizing is the ability to read, access, and reflect on mental states in ourselves and other people. And really, mental states, it's kind of like all the invisible stuff of the mind. So thoughts, emotions, desires, attitudes, values.

• 2:34Speaker 01

  So that is the kind of core aim of MBT, which is to sort of stimulate reflection in the areas where patients tend to really struggle. So for BPD, we would be kind of, or borderline personality disorder, we would be kind of trying to really help folks with their insecure attachment, with their difficulties with self-injury, with maybe their anger issues. If we're kind of helping folks with narcissism, we would want to kind of like aim mentalizing at their conditional sense of self-worth, maybe an elevated sense of self or a dismissiveness of other people's perspectives.

• 3:13Speaker 01

  So depending on what the kind of problem area is, we kind of, the, the shape the mentalizing takes is different. But the, the through line is that it's reflecting on what's going on inside of ourselves and other people.

• 3:29David Puder?

  Okay. Yeah. So it's, it's different than empathy, because how would you define empathy compared to this?

• 3:36Speaker 01

  Well, I would suggest empathy is like a species of mentalizing, because there are different components of it. Actually, one way I like to define it, it's like reflect and connect. You know, we've got to get patients considering their minds and the minds of others, but not just thinking about them. We actually have to help our patients connect with their own emotions and connect with the emotions of others. And so empathy is really not just reading others, but caring about others. And I mean, that is a part of mentalizing, but it's like a kind of sub, you know, a kind of like a sub-part of it, basically.

• 4:18David Puder?

  Okay. So like, let's say you have someone who's newly in a relationship. They're, they're, they're over the moon. They're having a great time. Okay. They're in this kind of like, the honeymoon phase of the relationship. They're just overjoyed, all positive. And then they notice a slight withdrawal of the other person.

• 4:40Speaker 01

  Yeah.

• 4:41David Puder?

  Okay. And this triggers intense abandonment. Now, they feel this. Maybe there's some truth. Maybe there is some withdrawal. But then how can someone, let's say with more of an insecure attachment style, add into that their own fears, their own stuff, right? Because mentalizing would be accurately seeing reality, accurately seeing what's going on in the other person.

• 5:10Speaker 01

  Yeah.

• 5:11David Puder?

  So it's like they're adding in some extra stuff there.

• 5:15Speaker 01

  Yeah, you're, the, the idea that almost their own insecurities are kind of leading to them to interpret the other as potentially like, and maybe as kind of this person's pulling away from me, where really it could be a range of other different things that could be happening. Is that the idea?

• 5:31David Puder?

  Sure. Or maybe they are pulling away a little bit. But, but it feels now like so awful. It feels so horrible. It feels catastrophic to them.

• 5:44Speaker 01

  Yeah. If you're a therapist, how do you show your patients how to mentalize in scenarios like the one you've just described? And essentially, one way to, to kind of spell it out in like a really like clear, like step-by-step fashion is the what, the why, and the how. Okay. So I'll say it again, because it's so important, the what, the why, and the how. So we got it when we're mentalizing. The first step is we've actually got to put words on what's going on for us and what's going on for others. And for this patient, that you're, the hypothetical patient you're describing,

• 6:26Speaker 01

  you know, we would want to be understanding, what is this bringing up from you, for you? What are you feeling, right? And obviously, we'd ask any patient that. And we would want to really be considering the partner's mental states. You know, how do you interpret, like, what's your sense of what could be going on for, for that person? And then also broaden it, because often with these patients, there are what we call biases in mentalizing. They, they, you know, there's been research on this in BPD. It's that neutral facial expressions will be read as negative, right? So in those moments, what we're going to try to do clinically is to try to expand the array of mental states we're considering in the other.

• 7:09Speaker 01

  That's like base level mentalizing. The next level is what we call why mentalizing. What could this be about for, for the partner or the, or the new, the new person? What may, what, you know, could it be about something going on in their life? Could it be something that you actually are doing to potentially push them away? You see, that's like a higher level mentalizing, not just putting words on feelings, but kind of broadening it out a little bit.

• 7:36David Puder?

  Okay.

• 7:37Speaker 01

  And that's sort of the second tier of mentalizing. And then kind of really where the money is, is this, is looking at disruptions in how the person, really the process that they're engaging in to read others' mental states. And I think right now, that's really gets at the heart of what you're saying, which is for a lot of folks with BPD and insecure attachment, there, there are problems with certainty. You know, I know he's pulling away from me, or she's pulling away, or they're pulling away. I know that without this relationship, I'm not going to be okay. You know, I need this relationship in order to be okay, something like that. So then the kind of the, the highest level mentalizing is process mentalizing,

• 8:23Speaker 01

  where really what we're trying to do is, you know, help patients see how they can get a little stuck in their perspectives, and hopefully helping them to be more flexible in their way of seeing or interpreting relationships in themselves.

• 8:39David Puder?

  Okay. Okay. So, so this is good. So we're, so think about like the why, okay? Help me think through the why on this, this specific scenario. Like, why are they pulling away? Is that it?

• 8:52Speaker 01

  Yeah, yeah.

• 8:54David Puder?

  So, so Bob, they're pulling away because they, they don't want to be with me anymore. Okay. They've figured out I'm defective.

• 9:08David Puder?

  Okay, and I'm sure about that.

• 9:10Speaker 01

  Okay, yeah, yeah.

• 9:12David Puder?

  It feels, that feels 100% true.

• 9:16Speaker 01

  Okay, okay, yeah, yeah.

• 9:17David Puder?

  So what I'm doing right now, by the way, it's just kind of pull back from this. I'm not, I'm not thinking, I'm not thinking I'm going to go through a role play with you.

• 9:24Speaker 01

  Okay.

• 9:24David Puder?

  I'm thinking what we're gonna, what we, what we want to really talk about is that. So we've, we're seeing this in the session. We're seeing this air of mentalizing. Okay, for us as the outsider, we're looking at this. And we say to ourselves, well, there's this certainty that this person has. And it's creating this awful, awful feeling inside of them of abandonment. Maybe they're suicidal now. Maybe they're going to act erratic. Maybe they're going to do something in the relationship that is going to create a real conflict.

• 10:00Speaker 01

  Mm hmm, yeah.

• 10:01David Puder?

  Okay. And so the why is certain. The why that they perceive is certain.

• 10:10Speaker 01

  Definitely, yeah. They know the reason, they know what's going on.

• 10:14David Puder?

  Right.

• 10:15Speaker 01

  Yeah. Well, so this is, essentially, the clinical question here, which is worth thinking about for your listeners is, one is, in the moment that we're encountering that certainty in the mind of the patient, what can we do about it? That's kind of one question. What sort of the, what I'm trying to do, sort of in this kind of new model of mentalizing is, let's say, outside the heat of the moment, how would we teach patients to target and address their own certainty? So they're kind of different questions clinically. And a lot of our work in M B T thus far has been teaching clinicians how to address it when it arises in the session. And essentially, there's this other technical option, right?

• 10:59Speaker 01

  Which is that, how, for our patients who struggle with that certainty, outside the heat of the moment, how do we actually teach them to look at their certainty? So it's kind of a choice point, if that makes sense.

• 11:12David Puder?

  Right, right. It's like, in, in the moment, it's hot.

• 11:16Speaker 01

  Yeah.

• 11:18David Puder?

  So you don't always strike the iron when it's hot.

• 11:21Speaker 01

  Totally, yeah, yeah, yeah. Strike, M B T's line is, strike when the iron is cold.

• 11:27David Puder?

  Okay, so in, in the moment of hotness, for, for a patient, they may have a different set of things that may help them cool down a little bit.

• 11:37Speaker 01

  Yeah.

• 11:37David Puder?

  And to create some ability to then reflect. So in, in that moment, they've lost their ability to mentalize.

• 11:47Speaker 01

  Yeah.

• 11:47David Puder?

  Is, is, and their reflective function be, would be low. It would, there would be assumptions, there would be this kind of like, they're mind reading, they're in like a more C B T model, right? They're mind reading, they're, they're all or nothing thinking. Okay, so then what do, what do you do in the moment? What's the tendency of, of an M B T clinician?

• 12:11Speaker 01

  Okay.

• 12:11David Puder?

  To do in the moment?

• 12:12Speaker 01

  Well, so, yeah, so the, the first step is to invite the patient to reflect on how they get there.

• 12:21Speaker 01

  So we don't challenge it in the moment. That's always the first step. Okay, so you, it's really clear to you that your partner's pulling away from you. Kind of what clues you into that? Don't challenge it, ask them to start making their case.

• 12:37David Puder?

  Okay.

• 12:38Speaker 01

  And when the patient may say, well, he hasn't responded to my text in, in three hours. Okay, or, you know, or, you know, we haven't been having sex as frequently as we had when the relationship started, or something like that, right? And then you're just, as a therapist, you're just kind of like trying to kind of gather. I see, so for you, and then you empathically summarize all the case, right? He hasn't responded to your texts, you're not having sex as frequently. He kind of like hasn't yet invited you to kind of, you know, visit his parents or get to meet his parents. So that feels, for you, that really shows that he is pulling away from you. Yeah. And so that's the first step.

• 13:22Speaker 01

  Second step is, according to M B T, is examine or explore the impact of the certainty.

• 13:31Speaker 01

  So then you ask the patient, so wow, so for you to have this sense that he is pulling away from you, what does that do to you? And then the patient will share about their feelings and sort of like, you know, basically like, all the kind of emotional consequences of feeling quite certain of this thing.

• 13:52Speaker 01

  Yeah.

• 13:52David Puder?

  Okay.

• 13:52Speaker 01

  And, and then, once we get there, that's all within the patient's viewpoint. Now we've got to start working towards seeing things more broadly, more, from a broader perspective. And the best, this is what Anthony Bateman, who I know has been on the, um, this podcast before, will say, you got to find a chink in the armor. You got to find some area of kind of flexibility or nuance within the patient's perspective.

• 14:21Speaker 01

  You know? And it may be something, because actually, when, I think when you were like laying this out, I just say, I just want to check in. You said earlier that it quote, seems like he's pulling away from you.

• 14:34Speaker 01

  What were you getting at there?

• 14:36David Puder?

  Okay, interesting. You caught that, right? It's the, it's, it's maybe not how it was felt by the patient. But I added that as someone who's mentalizing the, the patient's experience. But for the patient himself, he is pulling away.

• 14:55Speaker 01

  It's true, but, but when patients talk about it, and as you ask, ask them these questions, what's the case? What clues you in? How does this impact you? You will hear, and often, if you're listening, you will hear some things that will just be slightly more multifaceted or nuanced, slightly more flexible.

• 15:14David Puder?

  Okay, you're, you're noticing a higher, the, the, the moment of higher reflectiveness. Yeah.

• 15:20Speaker 01

  Exactly.

• 15:21David Puder?

  You're noticing this chink in the armor, okay, so to speak.

• 15:26Speaker 01

  Yeah.

• 15:27David Puder?

  Okay, go ahead.

• 15:27Speaker 01

  But then when you do that, when you find it, the, the job there is open it up. Don't make your case still, like I'll say, yeah, you said seems. Can you say more about what led you to say seems? And then just have them open it up. So it's a kind of a cool technique. It's not C B T. It's not like, try to kind of argue against your own perspective or try to revise it. It's that we've got this pathway of certainty. Now let's open up this other pathway right alongside it. So that's sort of, that's step three. So we have, examine the case, examine the impact, explore nuance from within the patient's viewpoint.

• 16:09Speaker 01

  And then the final step of how we treat, and we're calling this certainty, as you know, in M B T, the, the technical language is quote psychic equivalence mode. Like, basically like, I, because I think it, it makes it true. So the final step in treating psychic equivalence or certainty in M B T is to share our own perspective. And this is something that I think is really important because for, especially for therapists who are a little more exploratory in nature, or they are kind of taught to kind of be very client centered and kind of just kind of like, be a little more kind of validating of what patients are bringing. A lot of times therapists will not actually share their view.

• 16:55Speaker 01

  And in M B T, because it's about two minds in the room, we have to share our view at the end of the sequence. So in this case, for me, it could be me saying something like, my, my different view might be, um, you know, it's not, um, as you share about this, I hear all your points. And it's not quite clear to me yet how much of this is that he's pulling away versus, could this be somewhat of how the relationship is just unfolding? Because in my experience with relationships, they don't tend to be at the same level of intensity, like all throughout.

• 17:38Speaker 01

  What do you think about that? You share your mind and ask the patient to kind of consider your mind.

• 17:45Speaker 01

  You know, there, there might even be a side move you do though, too. You may end up saying something like, um,

• 17:52Speaker 01

  you know, this makes me think a little bit about the last relationship and you had a similar concern.

• 18:00Speaker 01

  Right? That may be the move. We don't actually take issue with it, or we just kind of broaden it a little bit. And then have the patients consider our mind. So those kind of four steps are the, the steps that clinicians can engage in or use in the moment to try to kind of like, address patients, maybe like rigid thinking.

• 18:20David Puder?

  Okay. Yeah. So it's like you're, you are taking your, your own reflective stance. And then asking them to reflect on your reflective stance.

• 18:32Speaker 01

  Exactly. Yeah, definitely. But do it at the end, not the beginning. Cause if you do it too early, patients will feel like we're, we're invalidating them.

• 18:42David Puder?

  Okay.

• 18:43Speaker 01

  So it's always start within the patient's viewpoint. They need to feel seen by us. They need to feel like we're really getting what it's like to be them. And at the end, they've got to actually get a sense of what it's like to be us. You know, we're kind of, but we, we kind of include that at the end of the sequence, but we, you gotta have both for it to be M B T.

• 19:03David Puder?

  Mm hmm. So, okay. We've talked a little bit about psychic equivalence. Tell me about how pretend mode might apply in this scenario.

• 19:13Speaker 01

  Yeah, definitely. Or, well, in this scenario, this does feel like more like psychic equivalence. But, um, but yeah, we could talk if you want.

• 19:21David Puder?

  Okay. So it's, it's kind of like, um,

• 19:26David Puder?

  the person is talking about something detached, not really emotionally congruent. They're emotionally decoupled from the real experience. So it's like, oh, what's happening? Is my insecure attachment and my, um, and they're using these big words to describe, you know, maybe that they don't really feel resonating. They're not resonating with these big words. Is that?

• 19:52Speaker 01

  Yeah, definitely.

• 19:54David Puder?

  It's like, or how would you just define how this could be taking place as like?

• 19:59Speaker 01

  Definitely. Well, so pretend mode is essentially disconnection from authentic mental states in self and other. And there's really like, I would say like three types of pretend mode. There's disconnection from self, disconnection from others. In other words, like problems and empathy. Or disconnection from reality, which is something that we see a lot in narcissism. So, um, so there are these three kind of forms of pretend mode. So, um, this is one of the hardest things in my opinion to treat in therapy. So that was one of the things I was most excited about with in terms of actually kind of like,

• 20:40Speaker 01

  cause essentially the, the broad technique we use in, in M B T for, for pretend mode is, is challenge. It's getting more in reality, asking factual clarifying questions and ultimately bringing in our mind in a way that disrupts the patients. But how do we help patients do this themselves? A little challenging, right? Or maybe because like there, there's no therapist. Well, if you don't have a therapist to challenge you, how do you then get more connected? So basically, um, one sort of, I think this is sort of what, how do we teach patients to get connected to themselves is essentially the question.

• 21:20Speaker 01

  And the first step is helping them identify essentially what is the emotion they need to connect to?

• 21:29Speaker 01

  Like you can't access it if you don't know what, what might be there.

• 21:33David Puder?

  Well, it's definitely, it's definitely not anger because I would never feel anger.

• 21:37Speaker 01

  Okay. Well, this is the thing I would propose, David, you're playing the patient there. That's certainty. Right? So I wouldn't be treating.

• 21:45David Puder?

  Okay, okay.

• 21:45Speaker 01

  Yeah. You know what I mean? Like, but if it's, um, yeah.

• 21:49David Puder?

  But I, I think what, I think what I'm kind of hinting at is, um, they're for, for good reason. People may not want to say that they would feel, uh, various emotions.

• 22:01Speaker 01

  Definitely, definitely. And if that's the case, then it's a problem of certainty. You gotta treat the certainty first.

• 22:09David Puder?

  Okay.

• 22:10Speaker 01

  Because there's often self judgments around what emotions they're feeling and they can't find them because it make them feel bad about themselves.

• 22:18David Puder?

  Yeah. Self judgment. Okay. So the self judgment keeps people from being congruent or seeing what they feel.

• 22:26Speaker 01

  Yeah.

• 22:27David Puder?

  Okay. So then getting back into pretend mode, so they might pretend in a way to be disconnected from what they're really feeling.

• 22:39Speaker 01

  Yeah, it's a good, it's a good point. Um, that's how that, that's one of the challenges of the term pretend mode. Is that literally the word pretend is in it, but in general, the way that it's used is it's more just that often people, when they're in pretend mode, they don't know what they're feeling. They really are just, they're really just disconnected or they kind of know, but they're just not feeling it. So, so an example, like basically what the proposal is this, we can treat it in session. But what I'm proposing now is that in addition to that, we've actually got to help patients access emotions outside of sessions as well and teach them how to do that.

• 23:22Speaker 01

  So for example, if you think of a patient who really struggles to feel a certain feeling, can you, can you either hypothetically or a real patient you have, what's a, what's a, a specific emotion that you think, that you can, that you think one of your patients struggles with?

• 23:39David Puder?

  Um.

• 23:41Speaker 01

  To find.

• 23:43David Puder?

  Let's, yeah, let's go with the, uh, let's go with the anger.

• 23:47Speaker 01

  Perfect.

• 23:48David Puder?

  So, so, but let's, um, let's put it to a clinician. So let's imagine a clinician coming to you that struggles with the thought that they could ever be angry.

• 24:03Speaker 01

  Yes. Love it.

• 24:05David Puder?

  Okay.

• 24:05Speaker 01

  That's very common, very, very common. You know, anger can feel very dangerous to people. And they can struggle to find it. So there's the one pathway to treat it is, is the certainty stuff. The other pathway is to just really try to help them connect more with the anger. So, um, so basically, um, just to kind of go through, if you wanted to kind of work with, and if you're going to help a patient with that, it can't just be in the moment. Like you're going to need to kind of, I would propose like, there's going to need to be work done outside of session. Like you need to kind of give some mentalizing assignments, so to speak. Where the, the person starts by putting the anger they're trying to, they're putting the emotion they're trying to find and access.

• 24:47Speaker 01

  So they would write down anger. The first step is to actually like try to essentially imagine what it would look like, what would it look like for me to access this anger? Try to really envision the accessing of it. You know, have them kind of like imagine I could see myself doing this. I could see, so actually kind of like spelling it out.

• 25:15Speaker 01

  The other is actually what we call invoking an emotional memory. And they've got to kind of do this on their own. You can help them with, with this, but say, I'm just curious. Is there a time in your life where you can remember actually feeling angry?

• 25:34Speaker 01

  Tell me about it.

• 25:37Speaker 01

  And then you kind of invite them into that. The other is, and this is something that ACT does a little bit too. Um, acceptance and commitment therapy, but you sort of imagine somebody being with you. Where if they were kind of relating to you in a certain way, it would be easier to find the emotion.

• 25:58Speaker 01

  So is there anybody in your life that you find it easier to access that anger with?

• 26:05David Puder?

  Okay.

• 26:06Speaker 01

  And so you're, and then you kind of instruct patients, I want you to write about that. Write about what it would look like for you to be with that person and to feel or access like that feeling. Additional steps, uh, self-validation. A lot of times to your, to your point that you were making, like patients who struggle to feel a certain thing. Will, they have judgments of themselves for feeling it. So they write out, it's reasonable that I would feel this way because.

• 26:40Speaker 01

  And then finally, the last step is just having them close their eyes into really try to inhabit the emotion in question. So this is an example of what it looks like to kind of teach the skill of treating pretend mode. And my experience, sort of like as patients are kind of practicing this more and more, is over time, they get better at feeling the feeling.

• 27:05David Puder?

  Yeah. So, you know, it seems like this is kind of like intellectualization, isolation of affect, rationalization, denying the emotional reality. Sometimes there's some somatization that takes place with this kind of like distancing from the actual emotion. I like how you're pulling together these different types of lines of reflection, reflecting upon, right? So these are reflecting upon, writing upon both a time where you were angry, a time where you were able, or a person you're better able to connect with in the midst of anger,

• 27:48David Puder?

  or the person you feel the safest with, right?

• 27:51Speaker 01

  Exactly, yeah.

• 27:52David Puder?

  I was thinking about how, so I've been teaching cohorts and we'll do writing assignments, and some people will heavily intellectualize early on.

• 28:03Speaker 01

  Oh, yeah.

• 28:05David Puder?

  They have maybe the language of a psychotherapist, right? They have big words that they can pull upon, and they'll throw in all those big words together. And it kind of distances themself from

• 28:20Speaker 01

  Definitely.

• 28:21David Puder?

  the, what they're actually feeling. And in the process of leading these groups, one thing I've realized is that it's almost like you have to start with trying to get to a lower reflective function, writing?

• 28:36Speaker 01

  Nice. Oh, same, Mark. I love that. Yeah, yeah.

• 28:40David Puder?

  So the lower, so because people think that they have to articulate in a certain way to be accepted, right? They're imagining me wanting a certain, you know, these more psychodynamic language, or more, you know,

• 28:58Speaker 01

  Hmm.

• 28:59David Puder?

  They, they're, they want to be appearing articulate, or all put together, and so they write in a certain way that's distancing themself from their own internal experience. Okay.

• 29:12Speaker 01

  Definitely, yeah. No, it's a huge thing, and to be honest, what I start by saying is that we need to actually, I call this like, stop dissociative behaviors. For, like, literally, stop doing actions that disconnect you from yourself. Because you can't, then you're working across purposes, right? For a lot of people, especially smart people, one of the biggest behaviors you can engage in to disconnect yourself from your emotions is talking. Like, talking, people, I see this in groups, when somebody starts to feel something, and then they start talking, and they kind of, they choke up, and then they start talking, and they leave the emotion.

• 29:54Speaker 01

  So there, from an MDT perspective, we'd want to say, I just want you to pause, don't say anything.

• 30:00David Puder?

  Yeah.

• 30:02Speaker 01

  What were you just feeling? And you're right, the more words, the less feeling, and you've got to kind of start it more basic, or else the person's going to lose the emotion.

• 30:13David Puder?

  Right, more words, especially, you know, like, the doctors, and the higher professors, it's like, words are a way of obfuscating away from, right? So it's like, just, just because the words articulate word doesn't mean that there isn't a heavy degree of intellectualization.

• 30:34Speaker 01

  Definitely.

• 30:36David Puder?

  And the more primitive stuff can, can seem like a lower reflective function starting point, you know?

• 30:44Speaker 01

  Yeah, it's a good point. Yeah, that's why I like to say, like to define mentalizing as reflect and connect. Sometimes we need more reflection, other times we need more connection. And so, you're right, you're going to turn down the reflection a little bit, and kind of like beef up the inhabiting.

• 31:03David Puder?

  The inhabiting, right, yeah, the inhabiting, yeah. So, so I like how you are kind of like assigning people, or sort of getting people to think about like, okay, what is a time that you did feel angry? Talk about that, right? And you, you could get someone to do that, and then they could almost like distance themself in the talking about it. So that's, as a clinician, we're looking at that.

• 31:27Speaker 01

  Right.

• 31:28David Puder?

  And we're being curious about, like, are they, the more they talk, are they distancing themself from it?

• 31:33Speaker 01

  Definitely.

• 31:34David Puder?

  Right? And, and then in the midst of, you know, finding that person that they're most able to share that emotion with, you know, which, it could be you, it could be the therapist, right? Like, potentially, long-term.

• 31:50Speaker 01

  Well, that's true, yeah, yeah.

• 31:51David Puder?

  You know, like, oh, this, you know, how many times have you heard from a patient, like, I feel safe being angry, or feeling something that I don't feel safe with other people?

• 32:01Speaker 01

  So true, definitely, yeah.

• 32:03David Puder?

  So we're talking about, how do we, how do we kind of overcome the intellectualization, the isolation of affect? How do we get back to the real emotion without hypermentalizing? Which is another thing you guys talk about.

• 32:17Speaker 01

  Yeah.

• 32:18David Puder?

  This kind of like distancing yourself with a lot of words, over analytical, hyperreactive, RF.

• 32:26Speaker 01

  Definitely.

• 32:27David Puder?

  And I think that's where it's tricky. So where, so when I talk about like, writing a lower reflective function, it's like getting more in touch with the raw feeling, I think? And then from there, it's like, okay, why am I feeling this raw, this, the rawness of this?

• 32:45Speaker 01

  Well, this is a good question. So basically, why questions, in general in MDT, we don't kind of ask explicit why questions for a couple of reasons. One, this is exactly what you're saying, when we ask why, that pulls more cognitive, right? So, in general, we're not going to ask why, we are going to probably, you know, we're going to be curious about where it comes from, but if the person is more disconnected, we would not want to be like, where is this coming from? We just want to say, I just want you to pause. Try to, tell me, what are you feeling right now? We want what questions when the person is more disconnected.

• 33:29Speaker 01

  And then, if they start talking, well, I think what's going on for me is I'm, no, no, no. What is the emotion you're feeling? Like, you almost got to get them to stop talking and just focus on what they're, what's happening for them in the moment? Or, can you just put words on what you're wanting right now? And then, well, I think what's important to me is that I really get better, no, no, no, I'm saying right now, in your interaction with me, what's the wish? So you almost have to kind of stop the intellectualization in its tracks, and reorient to present affect. If you're working on it in the session, that's like, we would have to be very active in

• 34:13Speaker 01

  MDT, that's what we'd be proposing.

• 34:15David Puder?

  Okay, so, so this is the interesting conundrum, because the why questions are the demand reflective questions in the adult attachment interview.

• 34:28Speaker 01

  Okay.

• 34:29David Puder?

  And so, and so this is, this is always, this has been a puzzle, but I think we can kind of like make sense of what's going on here.

• 34:38Speaker 01

  Hmm, right, right.

• 34:41David Puder?

  So, in the adult attachment interview, when you're, when you're trying to gauge a reflectiveness, you're, you're asking a why question. Well, why do you think your parents behaved the way they did? Why do you think you felt that way, right? Which, and interestingly, when they looked at transference focus therapy, which is the therapy where they've looked at reflectiveness before and after, which is, it's kind of, it's kind of a funny research competition between you guys and transference focus therapists. Because they used your own early research to show that their research was superior

• 35:23David Puder?

  to, not to your research, but to the, the other, you know, like, things like dialectal behavioral therapy and such.

• 35:29Speaker 01

  Right, right, yeah, yeah.

• 35:31David Puder?

  So, they were, they were looking, and there's more why questions in their therapy profile.

• 35:38Speaker 01

  Oh, in TFP.

• 35:39David Puder?

  There's more, yeah, there's more demand questions. And, something like twice as much in this one study they did, where they were looking at transcripts. So, so, but I kind of remember the words of my mentor, Dr. Tarr, and he was like, be careful with why questions, because it can induce shame. Because a lot of times, people don't know why.

• 36:01Speaker 01

  Exactly.

• 36:02David Puder?

  And what I found with clinicians, in kind of like asking the why questions, is sometimes it can induce shame, because they may not know why, right?

• 36:15Speaker 01

  Exactly, yeah, definitely. And also, I would propose that sort of one of the challenges here is that, often when we're asking why questions, that presumes that the why matters.

• 36:26David Puder?

  Okay, okay, but going back to this initial example of this, this, this person that felt abandoned by their partner.

• 36:36David Puder?

  Okay, if you were to ask them in early, well, why did this happen? Right? They would give a low reflective answer. Well, obviously, with 100% certainty, they're rejecting me, they're tired of me, they've lost interest in me, right? Whereas where if you did all these steps that you gave me and you asked that why question again.

• 36:59Speaker 01

  Yeah.

• 37:00David Puder?

  Then they would say, well, at first, I felt like I was 100% sure that they had abandoned me.

• 37:08Speaker 01

  Yes.

• 37:08David Puder?

  But now, after talking with you, I'm realizing that this is kind of this pattern that I've been having throughout my life, where I will jump to certainty that this person has rejected me, maybe before they fully have, right? And with that certainty, I'll act in a way that maybe pushes them away.

• 37:28Speaker 01

  Love it.

• 37:28David Puder?

  But what I'm, but what I'm realizing is that it's because I've had this deeper longing for this type of love, and I'm just so hungry for it.

• 37:39Speaker 01

  Hmm.

• 37:39David Puder?

  Because I didn't get this maybe in a stable way.

• 37:43Speaker 01

  Yeah.

• 37:44David Puder?

  Okay, so me, I don't like, do you see what I'm talking about?

• 37:47Speaker 01

  You're making the point, you're making the point that if we target the certainty in essentially what we call process mentalizing, that patients will then be able to kind of reflect on where this is coming from in a more flexible nuanced way, which that is definitely M B T's argument, like essentially stimulate a process of reflection, and then patients are going to be in a spot where they can see things from a variety of perspectives. I would still propose, though, we need to give patients more resources to kind of understand where all these things are coming from. And so part of it is that essentially, if, if people are trying to, oh, let's say they

• 38:26Speaker 01

  know, okay, so in this case, they feel clear that what's a mental state that they think is going on in their partner, it's like the, the partner's pulling away from me, I guess. So the question would be, all right, so let's, let's presume that there's some way in which your partner is not wanting to engage with you as much. Bracket, that's a mental state, right? That's a mental state in the other. Then there are basically arguably three things that could be causing that.

• 39:03Speaker 01

  Something in the partner's life, some other emotions the partner might be feeling, or behaviors that the partner or the patient is, are engaging in. So essentially, situations, emotions, behaviors. So that is very, very common for people with B P D to not know why they're feeling what they're feeling, or why others are kind of feeling what they're feeling. So, all right, think about it, what other situations are going on in your, in your partner's life that could be affecting, you know, their wish to engage with you? Okay, consider that.

• 39:46Speaker 01

  What other emotions could your, could be actually happening in the partner that could be impacting this wish?

• 39:54David Puder?

  Hmm.

• 39:55Speaker 01

  And then finally, I'm just curious, is there anything you've been doing that has been impacting your partner's level of potentially like interest in connecting with you? Well, I was critical of him last week. Okay, tell me more. So the idea is if we can sort of, there's a whole structure to do this, that patients can do on their own, where they can basically try to see things more broadly, and that would be the hope, is that if they are able to consider situations, emotions, and behaviors, that, that actually that can broaden out the reflection. But we got to kind of give them some education about the ways to do it, because a lot of

• 40:40Speaker 01

  times in therapy, to your point, patients don't know how to do it yet.

• 40:45David Puder?

  Hmm. I, I think, and we're sort of watching as well for the second portion, right? Are they starting to over-intellectualize? Are they isolating away from their affect? But I, I love those steps. I think that is great. I think that maybe the pet peeve of modern therapy is that instead, the therapist goes bad on the partner.

• 41:15Speaker 01

  Okay, wait, sorry, what do you mean, how?

• 41:18David Puder?

  Yeah, I mean, this, this guy is, you know, pulling, it's, he is gaslighting you, he is, he's, he's stonewalling you is what's really going on. He is, he's, he's love bombed you, and now he's withdrawn, right? And that withdrawal is part of the game that he's playing.

• 41:37Speaker 01

  Oh, man, yeah.

• 41:39David Puder?

  Go ahead.

• 41:39Speaker 01

  No, I just totally, I totally hear that point, like, you're right, like therapists can almost align with the patient's certainty, and then get what we in M B T we call teleological, that we're like, the solution is leaving these losers. And sometimes that's absolutely right, like, obviously, in situations of abuse or really maltreatment, we do need to kind of not be in relationships with those people. And, you know, a more reflective or kind of like mentalizing therapy would want to be kind of trying to see it from broader, a broader perspective, what more is going on in you, what more is going on in the other, and hopefully not just kind of arrive at a concrete behavioral solution.

• 42:24Speaker 01

  But I totally agree with you, this is a, this is a thing in, in, in the therapy world.

• 42:30David Puder?

  Well, it could be, it could be like a lens, right? A lens of, of a pop culture lens that could be overly placed on the situation, right?

• 42:42Speaker 01

  Yeah.

• 42:42David Puder?

  And then, once you have, yeah, it does increase certainty in a way, right?

• 42:47Speaker 01

  Oh, yeah.

• 42:48David Puder?

  And I think this is what sometimes friends will do it for other friends, right? They'll, they'll go bad on the partner to allow some sort of psychological escape, right? So it can be helpful in the moment to psychologically stabilize someone by making the other person all bad, right? But it, it can be harder, the harder work is to increase the uncertainty to allow for accurate understanding of the self and the other.

• 43:19Speaker 01

  Definitely, no, absolutely. And that's, that's kind of the good news, in my opinion, is a lot of patients, when, well, a lot of times when patients are caught in certainty, they're, what they go back to is like, well, sure, I'm certain, but I'm right. And that's kind of the case, like, but I'm right, I'm right to be certain. And then we also kind of have to dodge that a little, it's like, I, I'm not denying that you, you do have a point, and I see the point, but I'm wondering, could we also look at what's leading you to feel so certain, as well as other ways to see it too? Like, would you be up for that? And my experience is, if we do that, like, things tend to go in the right direction,

• 44:04Speaker 01

  like, problems happen in treatment when we just kind of either ignore or align with patient certainty. But if they're up for kind of trying on multiple perspectives, and that's what I'm trying to do as a clinician, things tend to move the way that they're supposed to move.

• 44:23David Puder?

  Hmm. What do you think about, you know, OCD is a big disease of uncertainty?

• 44:31Speaker 01

  Oh, yeah.

• 44:32David Puder?

  You know, so it's a quest for certainty.

• 44:34Speaker 01

  Yeah.

• 44:35David Puder?

  So OCD is like the doubting disease. So I doubt, you know, so the most simplest is like, you know, I think my hands are dirty, I think they're contaminated, and then to create certainty, I'm going to go wash my hands.

• 44:52Speaker 01

  Right.

• 44:52David Puder?

  That they're clean, okay? And then 10 minutes later, I think my hands are dirty, and so they do it again, right? So then they're doing this quest for certainty over and over again.

• 45:03Speaker 01

  Definitely.

• 45:04David Puder?

  So, you know, is that also the case in some of these more anxious attached folk, where it's like, I'm feeling anxious about the relationship, I need a quest for certainty, I need reassurance, so the compulsion is to then seek it through a different, you know, maybe reassurance, right? Reassurance is, is a form of compulsion.

• 45:28Speaker 01

  Well, I like what you're doing, because in some ways, just by the nature of your questions, you kind of begun to cover all of our non-mentalizing modes. So in M B T, we, you know, we essentially say there are three non-mentalizing modes, certainty, or psych equivalence, disconnection, or pretend, and then the last one, which I think is implicit in your question, is what's called teleological mode, or an excessive focus on what's visible, you know? And behaviors are visible, right? So this idea that if I experience uncertainty, I need to take this action, that's the heart

• 46:12Speaker 01

  of OCD, or any other sort of kind of like compulsive checking interpersonal kind of process as well. So in M B T, I mean, I do tons of that work with patients, like, I do exposure-based work, using, you know, exposure and response prevention for OCD, but if we want to see it through a mentalizing lens, it's certainty that in, in order to avoid this feeling, I need to take this action. And Peter Fonagy, I don't think he's written this, but it's sort of, it's a very simple line, but Peter Fonagy, when I was like first learning M B T, he just said something

• 46:52Speaker 01

  very simple that I'll never forget, he says, "When somebody is not mentalizing, you need to stop it." Which is so obvious, but checking, asking those questions, like, that's got to stop. And so a lot of times in the treatment of B P D, all those behaviors that patients engage in, that kind of kick up more dust, or kind of cause more trouble in their lives, any effective treatment needs to organize itself around that, I would propose. So if it's asking constantly how you feel about me, if I'm in a relationship with you, that's going to have to be a treatment target.

• 47:34Speaker 01

  And, and we would work on helping patients not do that by mentalizing rather than acting. So I would say any treatment is going to have a version of what you're describing, and, and we, we need to kind of help patients kind of not engage in those behaviors.

• 47:51David Puder?

  So teleological mode, okay, we gotta like, we gotta make this more concretely understood.

• 47:58Speaker 01

  Yeah.

• 47:59David Puder?

  We need, we need to make this like completely observable, right? So that the, only the action counts. No, that's, that's a joke. Okay. So the teleological mode, it's like if the, if this patient that I had brought up before said, you know, I want you to cancel, if you really cared about me, you would cancel your fun adventure with your guy friends and stay with me tonight.

• 48:25Speaker 01

  Wait, wait, stay with you tonight? How? Wait, what do you mean? Like, maybe not leave town is the point?

• 48:30David Puder?

  Not, not leave town with your guy friends.

• 48:32Speaker 01

  Okay, good. All right. Cause that's, yeah, all right, good. All right. So the basically you caring equals you staying. And then if you, if you go, then that means you don't care.

• 48:45David Puder?

  Yeah.

• 48:46Speaker 01

  Okay, perfect.

• 48:47David Puder?

  Is that teleological mode?

• 48:49Speaker 01

  That's a beautiful description. Yes. And that's another thing is that when patients are in teleological mode, how do we teach them to treat those tendencies in themselves? And essentially, the first step is whenever somebody is in a teleological state, there's an equation. They're linking some outside thing to some inside thing.

• 49:15Speaker 01

  Okay. So in your case, the teleological equation is either, there are two options. One, you care equals you don't go on the trip with your friends.

• 49:25David Puder?

  Mm hmm.

• 49:26Speaker 01

  The other equation is if you go, that means you don't care.

• 49:32Speaker 01

  Right? So basically, like what, you know, sort of I'm doing with patients now is what are your teleological equations? And then work, what would it look like to work on that? And it's the, the, the early part of it follows the similar steps that I mentioned earlier, which is what's your case for that connection that you going, that, that therapist David going means he doesn't care? Um, how does it impact, you know, you to see it that way? Right? Those are the early two steps. The next step is trying to envision things more broadly. So let me like, just make it very concrete for your listeners.

• 50:12Speaker 01

  The first step is, can you imagine, just take a minute and consider this possibility that essentially David cares about you,

• 50:26Speaker 01

  but still goes on the trip? Can you just picture that possible world?

• 50:32Speaker 01

  Well, I know that. No, no, no, I don't want you to, I don't want you to just say you know it. Take a minute and just picture him caring about you while he's on the trip.

• 50:42Speaker 01

  People will write this out, actually. They'll actually write it out. Okay, I can see David on this trip and I can imagine that even though I'm not the most important thing to him, that he still does value me as a person.

• 50:56David Puder?

  Mm hmm.

• 50:57Speaker 01

  Okay. That's one way to treat it. And it's really pretty cool. As patients start to do that on their own, things start to get a little more flexible, but we're not done yet. What about now, I'd like you to imagine, this is gonna sound really aggressive, what I'm about to say, but try it on for size. I also like you to envision me staying here,

• 51:21Speaker 01

  not going on the trip with my friends, but not caring about you.

• 51:26David Puder?

  Okay.

• 51:27Speaker 01

  And then I can imagine that, okay, I'm gonna picture it like you stay, but you really don't care about me. It's just about the paycheck. It's just that you, you know, whatever, don't want to get into a fight with me. Okay.

• 51:42David Puder?

  Right. Okay.

• 51:45Speaker 01

  Then you're basically, what you're doing is you're taking issue with both sides of that equation, David, and patients themselves. And then I, then you kind of envision it. Okay. Well, so imagine all the feelings David could have on that trip with his friends. You know, just broaden it out. He could care. He could not care. He could want to spend time with his friends. He could want to maintain professional boundaries. So there are literally these bubbles, like thought bubbles, that you can kind of broaden the range of mental states you envision in the other. So that's something that I'm excited about is that it actually is letting patients, not just therapists doing this for patients, but patients starting to do that for themselves and to start to challenge their own teleology, if that makes sense.

• 52:31David Puder?

  Okay. So you're, it's like you're having them challenge both sides.

• 52:34Speaker 01

  Exactly.

• 52:35David Puder?

  Of this thing. Okay.

• 52:36Speaker 01

  Try it out. It actually is really, this is, again, this is Anthony's genius. It really works in a, in a cool way.

• 52:43David Puder?

  I, okay. So it's, cause, cause in the, in the certainty,

• 52:50David Puder?

  you're challenging both sides of the certainty.

• 52:54David Puder?

  Well, yeah, I do, I do think if I imagined him home, not caring about me because he's upset at me. Cause like secretly he knew, maybe now he's really upset at me. Now he's really pulling away because he, he gave up his, his time with his guy friends. So he's upset.

• 53:12Speaker 01

  Oh, I see. I see. Okay. Okay. Yeah. So that he's resentful, your point is that he could be like resentful of you.

• 53:20David Puder?

  Yeah.

• 53:20Speaker 01

  Because he didn't go on this trip.

• 53:22David Puder?

  Yeah.

• 53:23Speaker 01

  Okay. But I want to propose another possibility. Just imagine him not going with these friends. Okay. Can you picture him caring about you? Just take a minute and really see that.

• 53:40David Puder?

  Yeah.

• 53:41Speaker 01

  Okay, okay.

• 53:42David Puder?

  No, I, I, I, um.

• 53:44Speaker 01

  You see?

• 53:45David Puder?

  I'm thinking like, okay, so you're trying to get them to imagine that he could, he could go with his friends and also care about, about me.

• 53:53Speaker 01

  Exactly. Yeah.

• 53:54David Puder?

  Okay.

• 53:55Speaker 01

  And he could stay home and not care about you. And we do the same with this, this version. It's a, it's such an elegant inter, set of interventions, but it also works with ourselves. So for example, let's say you have a patient who is, um, feeling like all of their worth derives from having a specific type, type of job. Right? And that if they don't have that job that's successful enough, then they're bad.

• 54:22David Puder?

  Mm hmm.

• 54:23Speaker 01

  Okay. You do the same thing. Okay. Sorry. Well, I want you to kind of do the, the teleological equation toolkit and like actually like, what's the equation here? And they'll say, okay, it's that my worth depends on me having this job. My worth equals having a job. Okay, great. So what's the case for that? How does that impact you? But then getting to the intervention point we're discussing, I want you to imagine, can you imagine having this job and still feeling bad about yourself?

• 54:59Speaker 01

  Of course. I always feel bad about myself.

• 55:03Speaker 01

  Interesting.

• 55:04David Puder?

  Okay.

• 55:05Speaker 01

  Can you also imagine not getting the job in a world in which you could still feel like you had value? Can you just even picture it if it's highly unrealistic?

• 55:18David Puder?

  Okay. I'm seeing something else that you're doing here. It's like you have this, in teleological mode, you have this concrete, you know, like this concreteness. And you're asking them to go into kind of a pretend or playful place.

• 55:32Speaker 01

  I guess you're right.

• 55:33David Puder?

  Can you imagine, right? Can you picture something the opposite? Can you picture opposite?

• 55:40Speaker 01

  Exactly.

• 55:41David Puder?

  The opposite thing.

• 55:42Speaker 01

  Yeah. I like your point. That's a good point. It is kind of like inviting imagination of these possibilities that may not be true, but mentalizing is itself imagination, right? Cause we don't see mental states.

• 55:55David Puder?

  Yeah. So you're imagining, you're imagining the opposite in both situations.

• 56:01Speaker 01

  Yeah.

• 56:01David Puder?

  As a way to kind of like bring some looseness or flexibility.

• 56:09Speaker 01

  Exactly. You're, you're kind of disrupting the equation. That's what we gotta do. We gotta help patients disrupt their own equations. And the cool thing is, is when they do, everything feels less pressured. So with that patient who feels like you don't care about them when you, when you leave and they consider it more broadly, most likely they're gonna put a little less pressure on you if they really do the exercise. Similarly, the person, this is a little harder, but the person who believes that all their self worth resides in this job, then if they have moments of really imagining, you know what? It's true. If I got the job, I would still hate myself because I have hated myself since I was

• 56:50Speaker 01

  like 16 years old. It puts a little less pressure on getting that job. And so, once we loosen the equation, everything that stems from the equation gets more flexible and kind of open in a way.

• 57:06David Puder?

  Okay. You said earlier, you want people to stop doing the things that dissociate them.

• 57:12Speaker 01

  Definitely.

• 57:14David Puder?

  One thing that jumped into my mind was like short form video. You know how prevalent that's becoming, how many hours we'll watch, we can watch that.

• 57:23Speaker 01

  Oh, my gosh.

• 57:24David Puder?

  Binging on Netflix or video games, you know, there's all these like modern ways that we dissociate into other worlds. Right into, you know, are they all bad? Are you saying we need to stop all of those things? Or like, what, what are we actually talking about?

• 57:40Speaker 01

  Thank you. Yeah, it's a really, really thoughtful question. So it's not categorical. So there's no like list of these dissociative behaviors in MBT. It's got to be tailored. How does the person use them and what is their impact? So that's ultimately, um, when you're working with a patient in MBT and sort of building the formulation, patients will list all the behaviors that they feel compelled to engage in. Or they're going to list the behaviors that they feel like separate themselves from their emotion. And they're like, literally, there's like lists that people can choose from to kind of arrive at that. So it's tailored to the individual.

• 58:22Speaker 01

  And then the question is, if you, if you with your own patient really get it, wow, it seems like you're like using, you're using these things to get away from yourself. Would you be up for working on that? So I will tell, I'll tell a, a story about a patient that I published about in a psychoanalytic journal. So it's, I'll go the, the de-identified root of this, but I have a patient that I started seeing when he was in his, um, early, early twenties, who was, had never been in a relationship, um, had tried dating women, but you know, struggled with ED. Whenever they're sort of come close to kind of like, you know, fooling around and he would feel humiliated by that.

• 59:05Speaker 01

  And so he was very isolated, didn't, didn't date, um, just focused on work all the time. But he spent all of his time with technological devices. You know, he was basically playing video games all the time, watching YouTube all the time. It was all just porn. It was just all screens all the time. And I don't know how this happens, but I started to become concerned like, it's like you're, and he was so disconnected. Such like, so like wooden in his presentation.

• 59:40David Puder?

  Wooden.

• 59:41Speaker 01

  Yeah, like it just, you could tell it's like he would talk in a monotone. So I basically started like, it really seems to me like you're using these things to not feel your feelings like, oh yeah, definitely. Well, would you be interested in not doing that? And so he says, okay, so he starts gradually shedding these things. And he basically, we ended up, it was really hard, David. It was like, he, we had to do like, he had those, I don't know what they're called, but parental locks on some of these things. So he couldn't visit certain websites and all this stuff. But what was amazing about it is this man would just start to show affect spontaneously. He just would start to kind of feel his feelings.

• 1:00:26Speaker 01

  And he ended up, basically it turns out, this is going to sound like totally out there, but this is a true story. Turns out he's gay.

• 1:00:36David Puder?

  Okay.

• 1:00:36Speaker 01

  And he had no idea he was gay.

• 1:00:40Speaker 01

  And he had no idea he was attracted to men. And through this work, he started realizing like, oh man, I'm not attracted to women at all. And, you know, he ended up like, basically like, you know, starting to date, you know, he had, you know, never, had never worked out with women for reasons he could never quite explain. So you wouldn't ask him the why question about that because he has no idea why, right? And then now he's in a like long-term committed relationship with somebody that he's been with for, you know, five, six years. And, um, I would propose, and he actually, he says, not I would propose, he says, if I had not stopped using those screens, I never would have realized this about myself. So this is not me making an argument against screens.

• 1:01:24Speaker 01

  This is me making an argument against dissociative behaviors. If our patients are engaging in these behaviors.

• 1:01:32David Puder?

  Yep.

• 1:01:32Speaker 01

  That are separating themselves from themselves, that should be a treatment target.

• 1:01:38David Puder?

  You know, it's interesting. I was reading some of the research on like short form video.

• 1:01:45Speaker 01

  Oh, cool. Okay. Yeah.

• 1:01:47David Puder?

  Like how, how it's, how toxic it is to the brain and when it's toxic to the brain. And the, the piece of the literature that I think directly connects with what you just shared is that it was the worst when people were going to it for anxiety or going to it to cope.

• 1:02:07Speaker 01

  Yeah.

• 1:02:08David Puder?

  So if they were turning to this thing to help them dissociate in the midst of distress, that's when actually there was negative, the most negative impacts of it, right?

• 1:02:19Speaker 01

  There we go. Yeah, you're right. Yeah.

• 1:02:21David Puder?

  And so this guy, you know, and people hide all sorts of things from themselves, right? And for good reason.

• 1:02:29Speaker 01

  Yeah.

• 1:02:29David Puder?

  Right? Maybe there were good reasons why he hid that piece of himself from himself, right? And, you know, for him, it was so horrific that, that he had to continually find ways to dissociate. And so that I think is the, the beauty of, of psychotherapy. It's like, what is this thing that you find so reprehensible that you're, you're dissociating from yourself all the time?

• 1:02:58Speaker 01

  Definitely.

• 1:02:59David Puder?

  And is it really as bad as you imagine? Like, is it, like, is it as awful as you think it is?

• 1:03:06Speaker 01

  Well, you're really underscoring there, um, the sort of conjoining of a pretend mode with teleological mode. So let me explain. It's that if I think this quality or characteristic, like say, you know, the one sexual orientation or something makes me bad,

• 1:03:26Speaker 01

  then I'm going to be disconnected from those desires. Right? So the certainty is linked with what we're dissociating. So we got to hit it on both fronts. We got to treat the certainty, the self judgment, the shame, all the opinions or convictions the patient has about what makes them bad. But then we got to help them access those parts of themselves. And we gotta, I would say we gotta hit it on both fronts.

• 1:03:55David Puder?

  Have you ever, um, read Tolstoy? Any Tolstoy?

• 1:03:58Speaker 01

  No, I haven't. No. I, Dostoevsky, I would mix them all up, but no, I've never read Tolstoy.

• 1:04:02David Puder?

  Tolstoy, uh, the biggest books were, uh, Anachronia and War and Peace.

• 1:04:07Speaker 01

  Okay. No, I never read them. Yeah.

• 1:04:09David Puder?

  Later in life, he wrote this book called, called the, the Kreutzer Sonata.

• 1:04:14Speaker 01

  Okay.

• 1:04:15David Puder?

  And, um, it was fairly autobiographical in a lot of ways. And so it's, it's a short story in which a man murders his, his wife, who he imagines his wife is starting to have this like affair. And, um, he comes to this point in this, this argument in this book that if, if you're really a Christian, you should, you should be completely abstinent from sex completely.

• 1:04:43Speaker 01

  Okay.

• 1:04:44David Puder?

  And then he wrote a follow-up saying that he actually believed this to be the truth.

• 1:04:48Speaker 01

  Tolstoy believed that?

• 1:04:49David Puder?

  Tolstoy, yeah. And then his later, in his later life. And, um, his wife was very upset that he wrote this story because she, so that the, the Kreutzer Sonata is this musical piece that his wife is playing a duet with this man. And it, this is what angers him to this point of killing his wife. Right?

• 1:05:09Speaker 01

  Okay.

• 1:05:09David Puder?

  In the, in the short story, he didn't actually kill his wife. But he had that degree of, he understood envy to the degree, right? And he understood this murderous rage.

• 1:05:20Speaker 01

  Yeah.

• 1:05:21David Puder?

  And through his writing and through his belief structure, he, he felt like the, the real problem was sex and sexuality. So we should completely be abstinent.

• 1:05:33Speaker 01

  Wow.

• 1:05:34David Puder?

  Okay.

• 1:05:34Speaker 01

  I didn't know that about Tolstoy. This doesn't seem healthy.

• 1:05:38David Puder?

  And, um, and so it's interesting because I like, um, in his journals, he was very obsessive. He was very self punitive.

• 1:05:47Speaker 01

  Oh, yeah.

• 1:05:49David Puder?

  He, his wife wrote about his marriage and stuff. And she wrote about, she wrote, she paints a more narcissistic picture of him. His kids writes long things about him as well. He had 12 kids, I think 12 or 13. And a couple of them wrote somewhere more idealizing of him. But, um, he was a little bit more distant than I think he likes to portray. And so he had, he's a complicated person. But what made me think about it was here's a guy before psychotherapy existed, who was incredibly insightful about the human, about human nature,

• 1:06:30David Puder?

  about internal, internal emotions. But he was never able to come out the other side into a connectedness. It always stayed in a very obsessive narcissistic or like, um, masochistic, depressive, like very punitive towards himself, very like, very regimented.

• 1:06:53Speaker 01

  Yeah. Sounds like a little OCPD too, maybe.

• 1:06:56David Puder?

  OCPD, yeah, a little bit. Yeah. Some people have thought that. And, you know, at one point he tries to give away his estate. He was very, he was born wealthy. He tries to give it away and his, his, um, wife and his kids like, you know, try to stop him. And so he gives away most of his wealth.

• 1:07:15Speaker 01

  Wow.

• 1:07:15David Puder?

  And to, to them, he gives, he, you know, he's left with very little. But anyways, the, the thing that made me think about this was one, because I've been reading it recently and just it's, I've been trying to kind of think about, okay, what were, what were his gaps in mentalizing, right? Where were, where was he? Because he, he saw it, I think, in this character. He saw this murderous rage and he wasn't like, and, and he saw it from the perspective of this person and this envy. But, but he never had a second person in the room.

• 1:07:52Speaker 01

  Meaning what?

• 1:07:53David Puder?

  He never had a person to bounce off the other. So he had characters in his stories that would bounce off the things, but not in a way that would actually change him.

• 1:08:04Speaker 01

  I love it.

• 1:08:05David Puder?

  Because to be changed, you kind of have to have another mind.

• 1:08:09Speaker 01

  Yeah.

• 1:08:10David Puder?

  And so.

• 1:08:12Speaker 01

  I love that. I love that point. Yeah. It's sort of consistent with what you were saying about the kind of therapist who kind of colludes with a patient's devaluation of their partner. Like that's, I would say that's partly the problem in that setup is it's only one mind. You know, it's the therapist is aligning with the patient's mind. And you're really making the point that psychotherapy, you know, MDT really believes this, that like psychotherapy by definition is about the kind of, I don't know, collision or engagement of two minds.

• 1:08:50David Puder?

  Of two minds, yeah.

• 1:08:51Speaker 01

  Yeah. And just to your, I hadn't known about all that about Tolstoy. And so I really think it's highlighted a couple of things clinically that are really important that I would want to underscore from a mentalizing problem. When you talk about what are his gaps in mentalizing? One, it definitely seems like there's a ton of self judgment around desire. And really like self punishment around desire. Like I kind of like, not just the certainty that I'm bad, but a kind of like an almost effortfulness to kind of extinguish desire. And, and then certainty that these desires are bad.

• 1:09:33Speaker 01

  And then the idea is that certainty ultimately perpetuates dissociation. Like my guess is despite the fact that he had 10 kids.

• 1:09:42David Puder?

  Yeah, right.

• 1:09:44Speaker 01

  That there's a way in which he wasn't able to comfortably inhabit his, his own sexual wishes. And, and really like to that point, and I see this with patients all the time, where oftentimes the patients who are like really struggle to comfortably inhabit their wishes. They can speak very, very cruelly to themselves. They can be mean to themselves. They can kind of talk to themselves in a really, really aggressive manner. And I would say there, David, that's the dissociative behavior.

• 1:10:19Speaker 01

  Self criticism is also a dissociative behavior. So then I have to, you know, with patients, I'm going to say, listen, I know you believe all these negative things about yourself and I don't know what we're going to be able to do to kind of fully address that. We can work on it, but I'm interested in this question. What I'm also concerned about is the language you use, the way you speak to yourself.

• 1:10:42Speaker 01

  Would you be up for actually trying to kind of work on this in this treatment and do it less? And, and a lot of times I think that when patients, just like the patient stops using the screens, because that's his dissociative behavior, when other patients stop being as cruel to themselves, then they experience different emotions and desires. But often I think about self criticism as like an effort to cauterize desire and wish. You know, and once we can, if we can disrupt that, then you'll start to see patients start to have a more, a broader array of their own experiences.

• 1:11:22David Puder?

  Okay. Yeah. Interesting. So it's the self criticism as a, as a form of dissociating. What are they dissociating from then?

• 1:11:30Speaker 01

  Oh, I mean, I see this vulnerable narcissism all the time. It's often the desire for care.

• 1:11:37David Puder?

  So the desire for care is more scary than the desire to be punitive towards themselves?

• 1:11:43Speaker 01

  Oh, definitely. Because self punishment is, it's like, I'm in charge. I'm relying on me. I'm bad. It's about me and my standards. And so oftentimes they'll just be really mean to themselves and try to push down those wishes for connectedness because it's easier to be mean to themselves than it is to face like rejection or abandonment, actually.

• 1:12:08David Puder?

  Okay. Yeah, I see that.

• 1:12:10Speaker 01

  So, so yeah, I think those are really important processes and that that's like the progress in treatment. Like a lot of people with narcissism, when you're working with them in treatment, think I need to, I need to kind of like make it less about my desires. And I'm like, well, yeah, maybe. And maybe we should actually help you experience some of those desires without being mean to yourself for having them.

• 1:12:34Speaker 01

  And that's, you know, that can be a part of, of these treatments, actually.

• 1:12:40David Puder?

  Yeah, I was thinking about that, like if I had Tolstoy in my, in my office, like maybe the envy is an awakening of his care and love, because at times he feels very loveless towards this other person, you know? But then what if we were to put the, these, these things to words? You know, the protectiveness of how do we protect the, the connectedness rather than murderous wife, for example, you know, like it's like, it's like the, it's the furthest extreme, but this like the murderous rage is to protect the family, right? To connect, to protect.

• 1:13:20David Puder?

  And is there, is there a positive sort of understanding of the emotion in a, in an adaptive sense, right? The envy is there as an adaptive way of protecting something that's very important to you. And yeah, if, if, if this were to be lost, if the connectedness to this person would, were to be lost, which he devalues simultaneously, right? So he's devaluing of her all the time. And then he's also like this extreme envy. I actually think it'd be a lot of fun for you to read this and for us to have a longer discussion on this.

• 1:13:53Speaker 01

  Yeah, that'd be very fun. I read, I, one of my favorite books was like Crime and Punishment by Zsiewski. Love Crime and Punishment. It's, it's actually similar themes. Maybe because they're both, they're both Russian, I guess, right?

• 1:14:07David Puder?

  You know, I, I find Tolstoy is harder for me to connect with. Like I can, I feel like it's, Dostoevsky, I feel like arrives at this, there's beauty, there's an existential beauty. And there's this kind of like, like it's like, I feel like he arrives at a place that I feel more resonant with the Tolstoy.

• 1:14:31Speaker 01

  Well, I mean, I'm not saying by comparison, but I really resonate with, with Zsiewski. Yeah, it's quite beautiful.

• 1:14:38David Puder?

  Tolstoy, I'm left with this feeling of like, okay, I feel like, I feel like this was, um, this was, this was a really difficult read. Like I'm, I'm thinking about having the cohort read it and discuss it on the podcast.

• 1:14:51Speaker 01

  Oh, really? That's so cool.

• 1:14:52David Puder?

  But then I'm simultaneously hesitant to, because it's, it's such a, it's, it's like a painful read.

• 1:15:00Speaker 01

  This makes me think, I mean, granted, I'm learning this all from you and you know, we never are supposed to diagnose somebody through another person's reports. However, this is the experience that, you know, you can have with people with sort of like really notable obsessive compulsive personality disorder. Cause there's a way in which in OCPD, it's such a world of shoulds. That like breath and life gets strangled.

• 1:15:28David Puder?

  Yeah.

• 1:15:29Speaker 01

  And there can be this experience, I do a lot of treatment of folks with, with OCPD and some folks, there are just so many shoulds. It almost feels like you're just, it almost feels there's a sense of dread or deadness or something like that. And so it's an interesting thought of like, to what extent can that be communicated through art, actually? You know, and that if, if, you know, I'm, there's a way in which our character structure has to like be communicated through what we create. And I'm, I wonder if what you're describing is almost like, it reminds me a little bit of how I can feel with some patients who are very, very strict with themselves and, and very masochistic, actually.

• 1:16:11David Puder?

  Masochistic, yes. Definitely. Masochistic is like, how do I get love? Love, I, I have to suffer to get love.

• 1:16:19Speaker 01

  Right. Yeah.

• 1:16:23David Puder?

  Like, what is the, what is the meaning? What is meaningful? I have to suffer for something to be meaningful.

• 1:16:30Speaker 01

  Hmm, right, definitely. Yeah, it's got to be earned in a way.

• 1:16:35David Puder?

  It's got to be earned, yeah.

• 1:16:37Speaker 01

  Yeah.

• 1:16:38David Puder?

  So whereas obsessive, it's like, I have, I have to create order to feel okay. Like, and the orderliness and the obsessions, obsessions through, through just the thoughts, right? You could be, someone could be just very much caught in their thoughts and they could do very little action, or they could be very compulsive and do not have a lot of thoughts, but just do compulsive, compulsive, compulsive, compulsive behavior. It's a little bit different than the OCD in my mind, because with OCD, they're, it's more of that doubting and it's more the doubt leads to the compulsion and they're doing it like four to six hours a day.

• 1:17:22David Puder?

  Whereas like OCPD, it's more of the personality organization.

• 1:17:27Speaker 01

  Yeah, and the other part, you know, I think that, and this is where some of these constructs can converge is with OCPD, there's obviously the scrupulosity, this excessive focus on ethics, this need to always perfect oneself ethically, you know, which can be absolutely exhausting. And it sounds like, you know, to some degree, that was present with, you know, just, yeah, no, Tolstoy. But also makes me think, because a lot of the work that I did prior to coming to, to, you know, mental health was I was in grad school for philosophy. And my favorite philosopher was, was Kant.

• 1:18:07Speaker 01

  I don't know how much you know about Immanuel Kant, but he has a very, is a beautiful model of ethics. Like, you know, organized around the kind of the inherent worth of the person, which I bring into mentalizing and think about a lot still. And he was so self-negating and feeling like the only ethically good act that we, that, well, the only thing that had ethical value is essentially if it kind of could often work against our wishes and desires.

• 1:18:37David Puder?

  Hmm.

• 1:18:38Speaker 01

  You know, so there is this sort of moral perfectionism that you can see, which, again.

• 1:18:45David Puder?

  There's a little bit of masochism in that, right?

• 1:18:47Speaker 01

  In that, exactly. Yeah, yeah, yeah. It's interesting to think about masochism as part of like the moral perfectionism of OCPD, yeah.

• 1:18:55David Puder?

  Hmm. Well, yeah, it could be this kind of like persona where in order to do something truly good, I have to suffer, or I have to basically take away my own desire. Whereas I'm more in the, in the lens that, you know, it's good to operate where there's a multiplicity of wins.

• 1:19:18Speaker 01

  Yes, yes.

• 1:19:19David Puder?

  You know, like, we enjoy our patients, our patients get better, our patients get helped. You know, it's okay to enjoy this job, right? And to enjoy the connection that we feel with people, feeling, you know, we're, it's such an, such an honoring place to actually enjoy the work too. I can't imagine my own therapist that I see secretly not, not enjoying it, you know?

• 1:19:50Speaker 01

  Yeah, yeah. No, it's, yeah, I like what you're saying. And I mean, this sort of just like, I'm thinking about, there's this, I don't know how much you talked about this in this podcast, but essentially, MBT has been, and this is actually the last chapter of the, of the book, is sort of about this construct that's been probably like the newest theoretical innovation in MBT that Anthony has really developed with Peter's help, is called the vantage points for mentalizing. Actually, I call them that, you know, but also Anthony will refer to it as, quote, social mentalizing. But it relates to what you're talking about, which is that there's, it's basically what's the position

• 1:20:32Speaker 01

  that we're standing in to try to understand self and other? And so essentially, there's I mode, you mode, and we mode. So I mode is where it's really all about like our perspective, right? And like what we want, what we, how we're experiencing things and a lot of our patients.

• 1:20:55David Puder?

  Wait, wait, you just went, you said I, but then we, you said we, what we want.

• 1:21:01Speaker 01

  Oh, I'm sorry, I shouldn't have. Okay, good point, good point.

• 1:21:03David Puder?

  Isn't that interesting though? Because it's so hard for you, in your experience, to ever think, to ever think purely about yourself.

• 1:21:12Speaker 01

  That's funny, okay, good catch, I love that. So I mode is like my perspective, what I want, how I see it, right? Some patients, we all know those patients, right? Where there's more kind of in my, an I mode, we all can fall into that ourselves as well. Then there's you mode, where it's more of where we get caught up in the other person's perspective and we're prioritizing what they're going through. And a lot of patients can just flip flop between those two modes. And, and really what I think you're talking about, when you're talking about the kind of just joy of connectedness, is really what MBT says we're going for now, which is we mode.

• 1:21:55Speaker 01

  Which is, that's where I'm in my own experience, I'm simultaneously considering yours, and together we are working to do something and to collaborate and be connected to each other from a shared position. And so that's really the idea MBT is proposing now, that is, that's the point of psychotherapy. You know, that is the point, is we are trying, that's why we need two minds in the room, because if not, patients will just easily fall back into I mode. And so it's this idea that if we can consider each other and work towards something beyond like each of us,

• 1:22:38Speaker 01

  that we're going to actually have a greater sense of meaning, purpose and connectedness. So that's kind of MBT, MBT's newest theoretical innovation, which also has, as you can imagine, like really important implications for like clinical practice as well.

• 1:22:51David Puder?

  Hmm, really good, yeah. I, wonderful place to stop.

• 1:22:56Speaker 01

  Yeah.

• 1:22:57David Puder?

  I think that's a good place to stop. I think the, the we-ness, you know, like, makes me think of Dr. Tarr always talked about like, you know, the importance of the we, right? In the, in the room, what are we thinking about? And, and I also think about like this kind of like, you know, pop culture, codependency is a word that's often used, and I dislike that word. Because I think we're all interdependent. And, and I think if, if, or like enmeshment, you know? It's like another, another buzzword, right? Whereas like, we all are like, like very much connected in a way, right?

• 1:23:39David Puder?

  That's like, that's, it's like, it's torture to not be connected. It's torture, isolation in a prison is, is torture for the worst psychopath. Even for the worst psychopath, it damages their brain permanently to be in isolation for years.

• 1:23:56Speaker 01

  Yeah, definitely.

• 1:23:57David Puder?

  And so, yeah, there is, there is a strong importance of connectedness and, yeah.

• 1:24:07Speaker 01

  No, I, I love the point and there's a way in which like, I think with those ideas about enmeshment or codependency, there can be like a pathologization of kind of the need for connectedness. And that's not good for any of us, you know? And oftentimes when we're too enmeshed, it's, that's not real connectedness. That's more like you mode really, where it's just sort of like, it's all about you, there's no, there's none of me, right? And so we need to then kind of like, what's the, how do we kind of treat that? How do we help patients increase their connectedness themselves while also considering others more? And that will lead to actual we-ness, you know?

• 1:24:51Speaker 01

  And so we don't want to pathologize the need for connectedness, because that, that's what we're working for.

• 1:24:56David Puder?

  Right, I think, I think that what you're saying is that we could over-pathologize good things in, in pop, in pop culture vernacular, which is something I've been thinking a lot about. It's like, maybe the pathilization, pathilization.

• 1:25:14Speaker 01

  Pathologization, right. I know, it's too many syllables, yeah, yeah.

• 1:25:19David Puder?

  But enmeshment, and it's like, where, where is it toxic, right? Because there is, there is a place of true toxicity when someone enters into a cult, right?

• 1:25:30Speaker 01

  Oh, totally, yeah.

• 1:25:32David Puder?

  A cult being like, you know, a singular leader is now, his needs are the only needs that matter, right? And everyone is there to serve this person's needs. Like, those, those environments do exist, to say that they don't exist is silly. You know, there, there are some people who create cults and operate cults for their own, for their own pleasure and for the, the lack of pleasure of anyone else in the cult, right?

• 1:26:01Speaker 01

  Yeah.

• 1:26:01David Puder?

  But I think, I think a lot of enmeshment or codependency is really inter, interdependency. Like, we're, we're synergistically connected in a positive way with people. And, and sometimes we're, it's, it's more intense than others and sometimes less intense. And so there's probably good reasons for it to be intense at times. And good reasons for it to be less intense at other times.

• 1:26:31Speaker 01

  Totally, and I think the, the best case scenario is if we can be connected as long as there's enough us and enough other, that would be the idea. So I do think that's been a bit of a theme of the discussion today, is the two-mindedness of psychotherapy, but in this model, kind of like the two-mindedness of relationships that kind of like make sure we're in the room and then there's another person in the room. And that is going to be, I think from an MBT perspective, that's going to be their best recipe for feeling connected to others, but also for helping patients change through psychotherapy.

• 1:27:06David Puder?

  Okay, so in summary, like, mentalization, the approaches to mentalize their own internal experience, to not dissociate from their own internal experience, to, to mentalize the experience of others, including you, the therapist. And then the, the togetherness is its own mentalizing process. There's a, there's a we-ness in the room and you, and we're looking at that as well.

• 1:27:30Speaker 01

  Exactly, so perfectly said, yeah.

• 1:27:33David Puder?

  Okay, all right, we'll leave it there for today. Thank you so much for coming on.

• 1:27:37Speaker 01

  Yeah.

• 1:27:38David Puder?

  And, you know, there, I think that this book that you have written, we'll put links in the show notes and on the website. And if people want to check it out and give you feedback, if they want to send me a message or send it directly to you, I will forward it to you if it's been helpful. And, you know, I think it'll be a good addition to the, the importance of psychotherapy and the importance of the, the two-person connectedness, so.

• 1:28:07Speaker 01

  Awesome, well, David, I always love talking with you. I just really just enjoy you as a person and just love the conversation, so thank you for having me.

• 1:28:14David Puder?

  All right, good to talk with you. Okay, we'll leave it there for today.