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Narrative Fallacies in Dynamic Therapy
102 Plays3 months ago
In this episode, Grant and Fara are joined by Dr. Alexey Tolchinsky, a clinical psychologist, adjunct professor at George Washington University, and clinical fellow of the International Neuropsychoanalysis Association. He works with neurodiverse patients and young adults struggling with life transitions. Today, they discuss his peer-reviewed research, namely what he refers to as narrative fallacy in psychotherapy. Dr. Tolchinksky explains what he thinks are the dangers of narrative fallacy in psychotherapy, how it plays out between therapists and patients, and ways that we can consider re-thinking ingrained narratives in the therapeutic encounter.
We hope you enjoy it.
In This Episode
[0:00] Introduction
[1:30] Episode Overview
[04:40] Alexey’s Journey into Clinical Psychology
[6:10] The Concept of Narrative Fallacy
[13:10] Narrative Fallacy in Clinical Setting: ADHD and Anxiety
[21:15] Achieving Patient Wellness
[24:50] Data vs. Theory-Driven Practice
[28:40] Applying Narrative Fallacy in Therapy
[34:30] Static and Dynamic Diagnostic Tools
[44:40] Potential for Dynamic Tools in Therapy
Resources and Links
Doorknob Comments
https://www.doorknobcomments.com/
Dr. Alexey Tolchinksky
https://montgomerycountypsychologist.com/
Dr. Fara White
Dr. Grant Brenner
Recommended
Transcript
Understanding ADHD and Stimulant Use
00:00:00
Speaker
But you know we are taught to think this way this is where the mind goes i can't attend to things there for a dhg there for you know a stimulant and this is sort of connecting the dots very quickly and then my job there's they're already. came to a conclusion, do I have ADHD or not? I can either prove it or disprove it. It sort of limits the field. I cannot go sideways and say, look, attention attention is very complex. Sleep influences attention. Mode influences attention. You could have a neurological issue that is not ADHD that influences attention. And yes, indeed, you can have ADHD. We can do a full neuropsych evaluation to
Introduction to Hosts and Guest
00:00:35
Speaker
rule other things out. but So this is a very short example with sort of ah how referral request is formed.
00:00:42
Speaker
Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob. it's Doorknob comments happen not only during therapy but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves and sometimes we surprise ourselves by what comes out.
00:01:29
Speaker
Greetings. Welcome to the Doorknob Comments podcast. I'm here with my co-host Farah White. Today, our guest is Dr.
Dr. Tolchinski's Background and Expertise
00:01:35
Speaker
Alexei Tolchinski. Dr. Tolchinski is a licensed clinical psychologist and an adjunct professor at the George Washington University. He's a clinical fellow of the Neuropsychoanalysis Association. He runs a private practice in psychotherapy, where he specializes in dysregulated anxiety, panic, and trauma treatment. He works with neurodiverse patients and young adults struggling with life transitions. His peer-reviewed work includes papers on acute trauma, integration of chaos theory into psychotherapy, and what he calls narrative fallacy in psychotherapy. He is currently working on papers on dissociative experiences and dysregulation in the disgust system in OCD. Welcome, Dr. Tolcinski. Thank you. I'm happy to be here. It's a pleasure. Okay, so I guess I'll
00:02:25
Speaker
ah sort of ask how you guys connected. I know that you connected around this topic and both probably know a lot more about it than I do. So tell me a little bit Grant, how you reached out and where your discussions have kind of been. Yeah, so our most recent podcast um is with Dr. Carl Fristen, the world's foremost neuroscientist. And I posted something about Dr. Fristen's model of active inference in the free energy principle, which is a physics-based model of human mind, brain, and behavior.
00:03:00
Speaker
and Alex and I are connected on social media. And he reached out and he was like, are you joking? Is this a joke of some sort? And I was like, sadly, no. This is my kind of serious, half-baked attempt to integrate some of these thoughts into a model of psychotherapy. And we ended up having a really good conversation on chat. And then via video last week, where I explain that I'm not always sort of fastidious about things like this, but one of my strengths is being able to chunk ideas together, sometimes inaccurately, and bring them out into a sort of a preliminary form. And for me, that's that's kind of a trial and error process, like I'd rather put it out
00:03:46
Speaker
And then get feedback and then actually that we ended up actually getting really great feedback and we had a conversation where we went through some of those things and help to kind of refine it which. I think segues right into our topic but do you have a different take there may be some fallacious aspects to how i portrayed that. no fallacious aspects of any kind. Yeah, I was on the social media and we have, we share interests. I mean, in active inference, in addition to clinical work and also your photographer, which, you know, I used to shoot ah professionally. And so you're very diverse and certainly you spike my interest. And I, um I, I, I followed some of your work and, uh, listen to several
Career Journey: Moscow to George Washington University
00:04:25
Speaker
podcasts. I really enjoyed your podcast together.
00:04:28
Speaker
on guest lighting. And I just finished yesterday, Carl Fristen's episode. So thank you for doing it. Yeah. Can you tell us a little bit about your story, how you grew up, how you became a therapist, how you got into this sort of Matthew stuff? Sure. It's a story with many pivots or twists, if you wish. I was born in Moscow, Russia. My first university of was Moscow Institute of Physics and Technology, where I've spent six years. And then I studied IT. I was an IT engineer for a long time, 18 years. Part time while I was doing IT, I developed strong interest in photojournalism and
00:05:07
Speaker
gradually build up to doing freelance work for the Washington Post. And eventually I realized through my personal therapy and just reflecting that it wasn't the light and composition I was interested in, but more people and their intentions and motivations. So I applied to a graduate program in clinical psych in DC at GW. And the rest is history. And since then I've been doing clinical psychology and ah I think very recently developed interest in writing peer-reviewed papers. And that's that's a lot of fun, but that's not the day job. The day job is seeing patients full-time.
00:05:46
Speaker
You're a serious man though. Thank you. Was the Moscow Institute of Math and Physics? MIPT, mostly a physics school, ah but I realized also that I wasn't a physicist, but you know it was was sort of prestigious and you know was a good education. and And if somebody were to prepare for a career in engineering or something of that sort, then this was a solid base to do that. You know, our listeners are
Exploring Narrative Fallacy
00:06:13
Speaker
mostly people outside of the field. So I think they're wondering, Grant, you've talked a lot about um sort of different models of psychotherapy and how we can integrate some of these ideas. And I think because Alexei is here as our guest, I would like to hear about how your study of this informs your day-to-day practice, ah seeing patients.
00:06:37
Speaker
And could you define for us what narrative fallacy is and how that relates to the process of growth and therapy, say? Sure. um So this term, I just want to say that people sometimes make assumptions based on the word narrative, which is widely used. There's a lot of work in anthropology, linguistics about narratives, well developed everywhere. And ah also the question of fallacy versus truth is well written in philosophy and elsewhere. But the two words together have emergent properties. It's a technical term narrative fallacy coined by Nassim Taleb. And it simply means ah when there's A and a B and we connect them without having enough data that A and B are connected or related. That's all. So that I can provide some illustrations of that if you'd like.
00:07:24
Speaker
Yeah, I think some examples would be helpful because i I can think of some benign examples and some probably more pathological ones. So maybe we can kind of put that. So maybe we'll do something together very low level, very far away from complexities of psychoanalysis. um So let me read you some words. Red, square, yellow, triangle, blue, circle. What I think most people do without realizing it unconsciously is red square becomes a red square. So they bind a color and a shape. And the same happens to a yellow triangle. And why is that?
00:08:05
Speaker
There's no reason to bind them, but we do that anyway. One of the sort of hypotheses that I have in the paper, I don't have proof, but my thought is we do that because our minds are constructed in a limited way evolutionarily. I think you know they were developing for thousands of years to climb trees and solve local tasks. They were not designed for being bombarded with data from all over. And so our part of the mind that we think with actively, the work in memory, is much smaller than the similar units in a computer. Ours is about seven chunks of information plus minus two, which is why phone numbers are seven digits long. Computers have 16 million bytes of ah random access memory. And so we think through that. So if, for example, I'm doing 17 times 69 in my head without pen or paper or computer,
00:08:54
Speaker
If you you will see my pupils dilate, it's effortful. This is Kahneman's example. So I better not make a left turn into traffic while doing that in my head, because my my mind is full. they're Just for listeners, did you you referenced Daniel Kahneman, who was famous publicly for his book, Thinking Fast and Slow. So you have to think slow to do calculations. Yeah. And so I think this is one of the reasons why we have certain shortcuts, certain crutches, certain heuristics, where we chunk things together. We associate them. And the two most common things is indeed chunking, where phone number 301 becomes one unit of information and not three different ones. And another one is using what we know to process what is common at us.
00:09:38
Speaker
Maybe there's an example that is also very recent and experienced near when I was listening to your episode with Carl Friston. And he says that, you know, evidence is, you know, ah accuracy minus complexity and precision weighted prediction errors and, you know, ah marginal likelihood and, you know, all of that epistemic foraging. And when I heard you process the data, clearly you understood what he was talking about. But your mind went to Freud's repetition compulsion and psychological defenses, right? Well, I had that example queued up. yeah I think, yeah, like what is epistemic foraging? Like, you know, I kind of know what that means. It it means searching for knowledge in a kind of trial and error way. yeah And I think what you're saying is kind of like we talk about the lazy brain. Evolution has made our brain need to take shortcuts.
00:10:25
Speaker
You don't need to know every detail of the composition of the bark and the friction between your hand and your shoes and the bark to climb a tree. You need to chunk it together. You need to make the world simple for survival. And I think that may not be true as much as it used to be. And in therapy, the task that we face in therapy isn't always served by taking those kinds of shortcuts. In fact, if we do the same type of thinking in therapy, maybe it is not useful. And it may also be an example of why things in our lives weren't working well. So, for example, if you see someone who looks upset and you assume it's because you did something wrong, that's like putting square and red together. But there may be no red square. There may be no there, there, as analysts like to say. Before you proceed, Alexei Farah, I want to hear what your take is.
00:11:17
Speaker
Well, I think that that's part of our job as therapists is to try to understand why and how people are making these connections, to be curious about, you know, and we never know whether we're right or wrong or the patient is right or wrong. and I don't think it's about that, but I think it's about the many different possibilities and the ways that things can be connected. So a big thing that we'll say when there's a mysterious feeling that seems to come out of nowhere, is, well, when was the first time you had that feeling? And when was the last time you had that feeling? Because we're looking to place it. So I am sort of curious about these theories, but only you know insofar as how they can help people move through therapy and make progress.
00:12:08
Speaker
Yeah, absolutely. I'll bring it home to therapy in just a moment, but I wanted to say that I'm not sitting on a high horse by any measure. One of the main messages in this work is narrative fallacy is ubiquitous. You know, when I presented to analysts, they some of them got a little defensive, but it applies to economists and journalists and certainly me. It's it probably happened in this conversation will happen again. And what I mentioned about your podcast is completely normal. It happens the same thing in our peer group in Washington when we use active inference to try to understand clinical issues. People immediately bring up OCD or something like that and trying to apply it. But I'm saying it's it's you can see it in kids who learn to read when they know the word. They use the semantic knowledge to read more fluently.
00:12:49
Speaker
The basic idea is that we use long-term memory banks to process data common at us. This is pretty probably a neuropsychological idea more so than, and I certainly didn't mean any criticism. But let's take a story that is a little more- I'll let you know when I feel criticized. um Yeah. ah So before we go there, one other thing that Kahneman said in processing Taleb's ideas is that we are not ah statisticians in our head. We're storytellers. Yeah. So if we hear where the forecast and people say the rain is going to be today, this afternoon, with 65% probability, who remembers 65
Over-Diagnosis of ADHD and Evaluation Importance
00:13:25
Speaker
% probability? People grab an umbrella. This is how we make sense of stuff. What does it mean for me in practical terms? What do I do with this? right And that's sort of substituting probabilistic assessment with data, with with with a story. right So when I was doing psychological testing, the most frequent phone call I would get was, do I have it each?
00:13:45
Speaker
And I start talking to to them, and I would find out a bit more details. And it seems like there's a prominent dysregulation of anxiety. you know between you know Just my observations, I could be very wrong, but I see sometimes ADHD, I think, misdiagnosed or over-diagnosed when people have inattention due to dysregulated anxiety. But you know we are taught to think this way. This is where the mind goes. I can't attend to things, therefore ADHD, therefore you know a stimulant. And this is sort of connecting the dots very quickly. And then my job, there's they're already
00:14:21
Speaker
came to a conclusion, do I have ADHD or not? I can either prove it or disprove it. It sort of limits the field. I cannot go sideways and say, look, attention attention is very complex. Sleep influences attention. Mode influences attention. You could have a neurological issue that is not ADHD that influences attention. And yes, indeed, you can have ADHD. We can do a full neuropsych evaluation to rule other things out. but So this is a very short example with sort of how referral request is formed. It's a great example because it happens all the time and plus like you saw some TikTok videos and so you have an insufficient narrative you know versus a good enough narrative like from a pragmatic point of view you might ask okay we're storytellers we can't all conduct the experiments that would be ideal
00:15:08
Speaker
But we can ask whether our stories are good enough or not, which is a little, like you said, Farrah, like it it's not so much is it right or wrong, though I think that can be important, but is this a functional narrative? And having that narrative of do I have ADHD or not is overly restrictive. And unless you're a good tester, like as I'm sure you are, you can kind of fall into that trap. But again, so people are not at fault for posing the question like that. I mean, this is the consequence of ah the the data that that they were exposed to and the prevalence of the story. But let's take a therapy example. Let's say it's the first meeting and the patient walks in the door and they talk about their distress. And one thing I learned is they they have a hard time falling asleep and staying asleep.
00:15:55
Speaker
And later in an interview, I learned ah that ah it does seem like they worry a lot and about a variety of things, and it has been happening a while. In fact, when they're in bed, they have what-if thoughts, right? So it is not unusual, and I think it's human and normal you know in a clinician to have a fleeting thought that anxiety could be one of the possible reasons for a sleep problem. There's nothing wrong with it. It's an inference, and this is fine. It's a differential diagnosis, we would say, in medicine. Right. like Let's make a list of possibilities and go through them methodically.
Forming and Testing Hypotheses in Therapy
00:16:28
Speaker
Right. Right. So it's OK. But I want to point out that among it being normal and and healthy, it's also a beginning of a narrative fallacy. We start connecting one to another. We start saying anxiety is indeed causing, let's say, sleep onset insomnia. While we start learning more and you realize that this person is overweight, they probably have pre-diabetes. Because they don't sleep well, they do four expresses in the morning. Then they have afternoon fatigue, which they also combat with coffee. And coffee is irritating their bladder and they urinate four times during the night. and They also have sedentary lifestyle and they sit at home. There's a vitamin D deficiency. All of that at the same time.
00:17:07
Speaker
So if I talk to, you know, one of the leading sleep specialists in DC, Helen and Salem, she says, look, sleep is a nonspecific body response. I could possibly not be able to tell you why you can't sleep. That's the science. This is the truth, uncertainty. But what we do instead of that is we pick a hypothesis. The problem then is once I pick it and I say anxiety induced insomnia in the circumstances that I described, it is nearly impossible to test it formally. apnea we can rule out by sleep study and say apnea present, apnea absent, but but this this idea is, but what we do when we're content with just talking to the patient is exactly that. We'll listen to them, we think about what they said, we form hypotheses, and then we think we're testing these hypotheses.
00:17:53
Speaker
But also in the paper, I've showed that this is a very difficult process to truly test a hypothesis. This is not a scientific experiment and we may not succeed at testing it, but when we hold on to the hypothesis and then it becomes narrative. People connect the dots and then, you know, I'm absolutely sure that when the gods died, they went into the heavens and made the constellations. And that may not be the case. I'm curious Farah how you're thinking of this in terms of the the process of, say, psychodynamic therapy, I think, because I think we're all familiar with psychodynamic therapy, which is quite open-ended. And I think at particular risk of maladaptive or unuseful narrative fallacy, where people may connect dots. Let's say you have a theory, a good example might be Freud's Edible Complex, like there are certain types of tensions that
Comprehensive Evaluation in Therapy
00:18:43
Speaker
boys have between the father and the mother, the competition for the mother. And you have a theory that this is behind the things you observe in the patient. So you explain everything with that theory. right And if it doesn't fit, you can run into trouble. Or do you have a more contemporary example, Farrah, about the way that narrative fallacy can run amok in psychodynamic therapy, where sometimes we may be flying blind? Yeah. I mean, I think it always can. But but I do think that when a new patient comes in, there are certain things that I think even an analyst would use the term low hanging fruit. Even an analyst. Yeah. Would, would say, okay, let let's, you know, there are really easy things to check. When was the last time someone saw a primary care doctor? How was their thyroid? How, you know, these very basic things. And I think that's the easiest place to start with
00:19:42
Speaker
a test that you can where you can get some ah you know objectively correct answers. um so and You can spend 10 years treating someone for depression and you find out that their thyroid function is off. Correct. That's really, really bad. I think so too. I would say as as a psychoanalyst, as i trained as a psychoanalyst, I know people debate whether they there should be an evaluation or not, or whether you just kind of let the process flow. Well, I think a big part of it is what do people think they're coming in for? Most people when they come in for an evaluation are expecting that the professional is going to get the information that they need.
00:20:25
Speaker
So a patient doesn't come in and I say, well, why don't you tell me what you think is important? Because then I'm going to miss something that I think is important, whether it's a safety issue, a medical issue. you know all of these things that could be going on. The safety issue being like risk for suicide right or homicide. Right. So those are the things that I think set the set the blueprint for the work that we're going to do. And while I don't use like formulas or mathematical models, I do think that there is some structure to it. So there are a lot of considerations.
00:21:01
Speaker
you know family of origin, current living situation, when and how symptoms arose, what is someone's baseline. And then we can sort of put together a picture of where we want the treatment to go. And that's something that should be collaborative. So I'm the expert, I can say, here's what I think is possible. But for someone who's never been a happy-go-lucky rainbows and sunshine person, we just really want to get them back to maybe enjoying the chess game the weekly chess games that they used to enjoy. And so I do think it's a matter of trying to restore some level of wellness,
00:21:42
Speaker
having that balanced life, enjoying what they can what they can. Sometimes it's transformative, sometimes it's not, but I do think that one of the issues with, I don't know that I would say every case, but a lot of this idea where we don't do an evaluation, I think that's dangerous. This could easily get into a debate of kind of about psychoanalysis. I don't think we want to go down that path. At at least I don't think I do. No, no. But there's an idea that in pure psychoanalysis, you wouldn't get any information. And I think clinically, certainly, that is hands down not a proper clinical approach.
00:22:23
Speaker
What I would say, just as an aside, is if if that's how you work, if you're a pure analyst who is not interested in sort of medical evaluation, then that should be stated as part of the beginning of the treatment that that's not what I'll be doing. We're here just to engage in a dialogic process. We're not here to make sure you don't have a thyroid problem. Right, which is fine. But I think when people go to a tarot card reader. They go to so you know someone who's going to read their astrological card. They have different expectations. When they go to a doctoral level clinician who has, let's say, institute training, they may have a different idea. I agree. That's why I agree 100%. It should be explicit.
00:23:04
Speaker
Yeah. Yeah. And I do think how someone works and what informs their work, you know, my sort of low hanging fruit model versus someone else's, you know, like award winning formula, you know, my style may seem really sort of like nebulous and vague. I don't know, but it's what works for me. Well, there's a range. but So let's assume that we've done a proper evaluation and we're within a psychodynamic framework where we've excluded the low-hanging fruit, where we've done due diligence. Alexei, I'd like to turn it back to you to think about how
00:23:45
Speaker
The concept of narrative fallacy applies once you're within you know a process and you've you know you again you've safeguarded against these obvious what might be considered opening blunders to use the chess analogy further. Thank you for the chess analogy. I love that. But also I think a phrase that helped me connect these dots is, pun intended, is ah when we're theory driven as clinicians, more so than data driven, then we're in danger territory with narrative fallacy.
The Risks of Theory-Driven Practice
00:24:15
Speaker
So if I'm heavily invested in the edible dynamics, and this is how I think about the panic disorder, then that's, you know, but I have been ah receiving a lot of pushback from my colleague psychoanalysts. I do not wish to do a straw man out of psychoanalysis. I know Mark Psalms is a very contemporary, sophisticated clinician, and of course,
00:24:33
Speaker
you know how she model be ruled out the you know they exist in practice in their license and so they studied but i have an example from psychiatry would that be okay with you very briefly if i show some examples so this is actually from a textbook written by two very senior psychiatrists william campbell from northwestern and robert m. burba I think from medical um school in Yale. And the very popular term is teaching psychiatric residents is biopsychosocial. And there's four P's, predisposing factors, precipitating factors, perpetuating factors, and protective factors. I'll just read you an example of a formulation.
00:25:10
Speaker
ah that is described here as advanced, right? And it's it's necessary to cover the four Ps. Here it goes. Jane Doe is a 30-year-old female who presents with acute suicidal ideation in the context of a job loss. She notably has a past history of childhood trauma and abuse. The patient has genetic vulnerabilities from mental illness in her family history, a history of anxious temperament, ongoing substance use, and subtherapeutic mit medication levels. So I haven't said anything sort of super surprising just yet, but let's pause here and look at how this is constructed. This is the beginning of a formulation in the second paragraph. First, they talk about, this is how people are taught, genetic predisposition to let's say depression, right? Let's just pause here.
00:25:57
Speaker
And I'm not an expert here. Michael Levin is is one of my sort of heroes. I'm quoting him. He said, the path from genotype to phenotype is not entirely null. The morphological thing, how the organism constructs this hand with five fingers, is most certainly not in the DNA. DNA is hardware. So he can manipulate the morphology on the level of cell collective, not in the genes. He can make a worm be two-headed without touching the genome at all. And then he can put it back to be in one head. But we have a genocentric story that has been perpetuated for a long time. I have people tell me I have chronic cough and that's genetic. And we're very comfortable with this thing that's in genetic predisposition for depression. But it is a story, right?
00:26:39
Speaker
Then they're saying subtherapeutic use of sertralin, 75 milligram, I think it was for this patient. So there's another story there, which is a monoamine theory of depression. And several psychiatrists recently challenged me and said, what are you talking about? This this story has been dead for 20 years. This is a textbook, right? and And a person is thinking, well, why are they doing 75? They should be doing 200. But again, that's the story that a chemical imbalance or a certain disbalance, let's say, in several neurotransmitters and neuromodulators is influencing the depression. That's a story. And that story is a narrative fallacy because we're talking about a molecule of serotonin, which is very micro level. And then we're talking a macro phenomenon of depression in the patient's brain that has transits, contextuality, emergent properties.
00:27:25
Speaker
I would jump from one to another very quickly while skipping all the levels nobody can show me a causal chain of events from a molecule to depression it doesn't exist but we think this way and then people prescribed this way.
Groupthink in Medicine
00:27:37
Speaker
Well, there's a lot of groupthink, for one thing, is for narrative fallacy, like people all have to believe in it. There's the social construction. like It's real because we think it's real. When people talk about like inadequate medication dosing, you don't need to have a narrative fallacy about genes or serotonin theory.
00:27:57
Speaker
you need to believe that higher doses of medications will often work better. And then you can look at data that says psychiatrists all prescribe differently, which is kind of true. But by and large, the majority of us probably think if a patient isn't responding to a lower dose of medication and they're tolerating it, meaning they don't have bad side effects, we should try a higher dose up to a certain level. But that's not based on any particular backstory. And people don't think about whether it is or not. They just think, OK, go up on the dose. Same thing with blood pressure. If blood pressure is low, try to increase the dose of the medication, assuming maybe we've worked on lifestyle factors as well, exercise, weight loss. And that's a debatable point.
Applying Narrative Fallacy to Psychotherapy
00:28:44
Speaker
My real question would be, has it come up when you're actually doing psychotherapy?
00:28:51
Speaker
Right. And I think psychotherapy has multiple stages or ah things. And my paper is specifically about one component of psychotherapy, which is case formulation. We make sense of what's going on with the patient. And there's different schools of doing it in psychoanalysis, at least four or five schools. And, you know, I've studied thoroughly Mark Salms' approach in in our field in neuropsychoanalysis, his way of formulating cases. And there's what what I presented is a small component of a psychiatric case formulation. But essentially, it's a story form. There is a narrative where we connect the dots. We we talk about causes. And this this is the part to which you know the narrative fallacy applies. It certainly doesn't apply to how I'm listening to the patient in the moment, or you know maybe feeling my countertransference, or other things that therapists do. But when they formulate a case, which I think, if we're really honest, the vast majority of therapists
00:29:44
Speaker
do, do. We formulate cases. We think about what is going on and why does it happen all the time. Right. So this is the component. And if we look at every- The story also has to change, right? In theory, yes. In practice, I have seen very few case conference where the presenter had original formulation and then they worked for 10 sessions and they changed the formulation. Well, let's ask Farrah for a sec, because you do a fair amount of therapy.
Dynamic vs. Structured Psychotherapy Approaches
00:30:10
Speaker
I do a fair amount of therapy. Lexi, you practice psychotherapy. We probably practice eclectically, like we use dynamic, meaning more open-ended, like let's figure out what the meaning is as some more structured approach is, like let's look at how you're thinking about it and maybe modify that. And I'm thinking about what you're saying, like session to session, like what is my explanation for what's going on?
00:30:32
Speaker
For me, at least, I find you know that it shifts a fair amount, but it may be grounded in something like any one of a number of different theories, from trauma theory to a biological hypothesis to a non-trauma developmental theory to a model of you know pragmatic action in the moment. But Farah, can you help us out here a little bit and and bring it into like the practice of therapy? Well, I guess the only way that I can do that and is by saying I don't really formulate cases in any like static and unchanging way. I don't ever write things up. I don't really listen or go to like seminars and case conferences because I think it is so hard to let's say question ourselves and that's why I seek out supervision
00:31:30
Speaker
I sort of share what I'm thinking with the patient. It becomes collaborative, dynamic, and changing. And so I guess it's hard for me to look back at, oh, well, what did I think when I first met this person? What do I think now? like yeah I think i'm I'm conscious of how that evolves over time, how my narrative changes, but maybe that's not common. Like, I don't know, Alexei, if you're saying this this is what you recommend, people be conscious of how they construct narratives and continually ask whether they're filling in the gaps, whether they need to update their model, whether there's evidence that goes against what they're sure of,
00:32:04
Speaker
really having to be very open-minded. And supervision helps with that because you get all these different people giving you a different take on it, which really helps loosen up the narrative.
Emotional Deprivation in Teens
00:32:13
Speaker
um Let me give an example. you know This could apply to many, many different people. Someone with a history, say, of significant developmental neglect, I can think of many people I've worked with. Their material needs are met. They're growing up in a family which is emotionally destitute. And I just saw a study that came out, like it was you know in the papers yesterday, that a good amount of American teens say they don't receive adequate emotional support. Only one in three say they do. And parents think that they're providing more emotional support than the teens are perceiving. And so you know it's quite common that people grow up where it looks like they have what they need, but maybe they're being starved out emotionally in some way.
00:32:50
Speaker
and Patients will come in and they they feel like they can't move forward in their lives, right, in any one of a variety of ways. And so it's very common for people to feel stuck in their personal lives, work, romantic relationships, friendships, stuck with, you know, an addiction or an eating disorder, just un it and unable to like, Okay, move forward, but they also don't quite know like what the problem is. They don't have a narrative for it or you can supply a narrative which may not be accurate,
Narrative Coherence in Therapy
00:33:22
Speaker
right? It may be incorrect, um like a trauma narrative may be incorrect. It may not be due to the trauma, but sometimes having a fallacious narrative helps them move forward a bit. But then you find after a time inevitably, almost inevitably, they get stuck again because it only got you so far.
00:33:39
Speaker
And then you run into the same kind of what's the real causality here. And then there's an idea that if you can understand what's really going on, then maybe you can make a deeper type of change or a more enduring change. So that still is somewhat abstract. But does that make sense as a general process? Or is that also maybe a fallacious narrative? I think it's a very sophisticated example you're bringing, Grant, and you know i'll I'll probably try to make a strong statement and take some risk by doing so.
Critiquing Static Diagnostic Tools
00:34:08
Speaker
It's in the paper as well. I think there's a fundamental issue with the process where we're content with the audio verbal method of data collection. Patient told us something, we thought about it using our audio verbal thinking, and that's that. So what I think we're dealing with when we're talking about psychopathology is dynamic phenomena.
00:34:26
Speaker
Let me bring a metaphor, a waterfall. Let's say I'm looking at Great Falls, right, from an overlook. What is happening in front of me is turbulent dynamical system. And when we put it into words, we take a picture of it. You're a photographer. If I take a picture of the waterfall, I can tell you you know where the the rocks are, but it tells me absolutely nothing about the flows. So when we use words, we determine things, we stabilize things, you know we put them in buckets, you know and there's a long history of determinism and psychoanalysis in and psychiatry. We use deterministic tools. Look at the differential diagnosis tree.
00:35:01
Speaker
Look at the terms we use, like major depressive disorder, right? But if we were to consider the phenomenon we're dealing with as a dynamical systems, and we were open to formulating it as a dynamical system, then we would get somewhere else. And there's a very, very small number of psychologists and psychiatrists that try to do that. It's called Society for Chaos Theory in Psychology and Life Sciences. The vast majority of us don't go there. We are content with using words such as, I have ADHD or I have a major depressive disorder recurrent, you know, and we may update it and saying, you know, oh, no, it's not. It's a bipolar disorder, not a major depressive disorder. And we may say, yes, there was trauma and other things, but it's still we use inherently mathematically static tools, words, narratives, paragraphs to describe the waterfall. That I think is one of the issues.
00:35:50
Speaker
that that's That's one of your, um part of your mission is to sort of fight against that type of excessive crystallization. I don't think anyone on this call is going to is going to say that that isn't a valid critique. I think I might say there's also dynamic uses of language that don't crystallize experience and probably the the better, in my opinion, psychodynamic therapies don't call it too soon. And the general i think even the classical ones would say not to interpret too soon but nevertheless you see it because people want to make themselves feel better i want to ask you about because we're talking about the quote unquote talking cure. But before i do that um far i'm wondering how your.
00:36:35
Speaker
taking in what Alexei is saying. This is a man who obviously has a bone to pick. Well, I have, you know, the same bone to pick. And it's an important bone. I pick it a different way by just sort of disregarding, you know, I think it's funny every once in a while, people will say, well, I really want to know, like, I want to talk about my diagnosis. But you're not trying to change the system, right? You're trying to do yeah the right work. yeah The right work at the right time. But that's like, you know how how do we ever know? We just give it our best shot. But I try not to get distracted by things like diagnoses. You hold it lightly. What? You hold it lightly. Yeah, I hold it lightly, if at all. I mean, what we're on the fifth version of the DSM.
00:37:30
Speaker
said a lot of things in its various forms that I disagree with. yeah I think it's done as much damage as it has done good. So I'm very, very lucky that I live in a city and that I'm able to practice in a way to say, hey, that's not important to the work we do. Neither is you know a lot of the other academic stuff um that i I do feel very fortunate that I you know ah not not part of that sort of establishment.
00:38:03
Speaker
But um you kind of give it a miss. so You kind of do what you know is right. And I think we could we could make the same criticism of structured therapies, which, you know, even more kind of crystallize things and give people tools. Because I think the backstory here, no pun intended, is that people can really be harmed and are harmed. Right. That's why this is important. It's not because you love, you know, you do, but it's not because you love the thinking and the math. It's because there's people's lives on the line. Exactly. I'm not here to exercise aesthetic pleasure and just shuffle chaos theory and mathematics. ah we We are too far from resting on laurels. you know Acute PTSD patient has much higher probability of completed suicide. 30% of them don't get better than any kind of therapy with any kind of medication.
00:38:53
Speaker
ocd treatments don't usually lead to lasting improvements and we're not very good if we're talking about dynamical theory psychodynamic therapy with ocd and and we have a lot of work to do so i think one of the issues in the field is again determinism. and just putting things in buckets. Continuous buckets like autism spectrum disorder or discrete buckets like major depressive disorder. We don't usually, we we we are stuck in determinism. We're behind physics by about a hundred years. But we don't have to go very far to see people who do things differently. Right in your city, in New York City, Beatrice Bebe, who is an analyst, works with mother infant diets. She takes a video recording of a complex dance between a mom and a baby. There's no words exchanged.
00:39:36
Speaker
but she has a lot of information from it, and it's a dynamic. She talks about the pace of attunement between a mom and a baby. And this is an example of using dynamical tool for a dynamical phenomenon, for a flow. This is sort of like using a video camera to document a waterfall as opposed to a camera, which is a static tool. We're missing all of this data when a patient sits across from us and tells us a story, and then we think through a story form of what happened to them. You couldn't possibly think of all that data, you know, like you said, the working memory of a human in a computer. So I'd i'd love to end on a science fiction note. and i've And I've read some science fiction like where therapists have a dream machine or something like that. But if we were to go beyond sort of the spoken word, what what would you what would you want to see in a community based psychotherapy practice?
Updating Theories for Better Therapy
00:40:24
Speaker
Not in terms of necessarily like workup, like neuroimaging statically, but would you want dynamic real-time information like being fed to the patient and the therapist? We can pay more attention, for example, to nonverbal information, but would you want like an AI, for example, reading interpersonal interactions, looking for areas of synchrony or disconnect, pointing it out to the therapist if they're missing something that might be important emotionally? or letting the therapist know the patient's pupils dilated and you know you wouldn't have picked that up, but it might mean this. like If you had your druthers, like what what would your be on your wish list for practicing therapy with better narrative better narrative hygiene?
00:41:08
Speaker
I think that tools is a question way down the road. Certainly, I think discussion about video cameras is non-trivial. I know clinicians who use it routinely, such as ISTDP, Intensive Short-Term Dynamic, and people who are vehemently in opposition to a video camera in the room, from psychiatrists to classical psychoanalysts. But that's a question of tools. I think the what what it needs to start with is theory building and how we conceptualize things. If we continue to model you know quantum mechanics with Newtonian physics, we're going to fail. We need to be real about it and say, we need to update our theories and stop putting things into buckets. We need to use the proper, if you wish, you know mathematics. and inter interim in In the language of clinical psychology and psychiatry, we need to conceptualize these disorders differently.
00:41:54
Speaker
They are indeed complex. They do have emerging properties. They do have context. And they do have transients. And none of that is present in the textbooks. you know Textbooks teach us to put things in those shelves. you know And we can shift it from the second shelf and put it to a third one. But they're they're sort of static. static models, and I think this is the starting point to update our theories. Specifically, to bring it home, the foundational block of psychoanalysis is called the principle of psychic determinism.
Freud's Psychic Determinism and Modern Psychoanalysis
00:42:21
Speaker
Freud built an entire system, I'm talking strictly Freudian psychoanalysis, where there's nothing stochastic and nothing chaotic. Strict determinism. He literally said there's nothing undetermined or random in the psychic life. And this is how we have been practicing for 100 years, and we're content with it, and people are holding on to it for dear life.
00:42:38
Speaker
And God forbid you're going to say that it's a chance that somebody saw an apple in the dream. We're prohibited from thinking this way. It means something that they saw an apple in the dream. It's from their unconscious, you know, et cetera. I'm giving a distorted example to make a point. But chance and chaos are taboo words in in classical psychoanalysis. And we have examples of that in psychiatry, in CBT and elsewhere. true Yeah, I think I'm spoiled because I'm an interpersonal relational analyst. And we've been, if anything, overdoing uncertainty sometimes and embracing models like the Boston you know Process of Change group, which I think has has understood the need for a paradigm shift. I'm holding out for an AI, though, that tells me what's going on. And maybe in another episode, we could talk about if there's any benefit to restricting to speech.
00:43:27
Speaker
Yeah, I don't think so. I think that's the main reason why I, and I guess the research is is still out on this, but seeing people in person, body language, I do notice things like dilated pupils. I do notice shortness of breath or clenched fists or those things in the office that I might not might not see But do you ever dance in your chair with the patient? Not yet, but like but I'm open to it if it were the right situation. So I have wanted to dance in my chair. I will say that. I'll move around. I don't necessarily, you know, I'm somber and everything, but I think the motion of the analyst is really important. Yeah. And and sometimes I think it's really fun. I wish
00:44:16
Speaker
quite frequently that i I could get up and move. I think that's the only part of this that feels unnatural. There's that whole movement to walk and talk. Yeah, yeah I would like to. So it's interesting. I don't get much privacy here though, so I don't think. The other thing I'd say is it'd be very interesting, I think, and maybe even more informative to study right the brain and the dynamics of the therapist.
Dynamic Tools in Neurology and Therapy
00:44:41
Speaker
Sort of to study counter transfer and select see in a formal way but also to really understand the the dynamics of the whole system right and not just the patient or person in therapy final words elect see and where can people find you. If they google my name they'll see my website pretty quickly but just a quick example that again we don't have to reinvent something like a i.
00:45:03
Speaker
neurologists, you know, they talk to a patient, they examine the patient, but when they suspect a seizure, they use a dynamical tool, which is EEG. There's a timeline, because it's a transient phenomenon. The seizure may happen here, but not an hour from now. And a lot of therapists are content with not even going there and saying, I talked to the patient, that's it. This is sufficient, and that's all I need, right? So if- That's like the snapshot fallacy. Yes, pretty much. Yeah, snapshot of the waterfall. yeah I'm most grateful. Thank you for this interesting, inspiring conversation. I enjoyed it. It was fun. Thank you so much. yeah Likewise. It was really nice meeting you. Thank you for joining us today. And we'll keep following your work and see how you make change in the field. Very good. i and I wholeheartedly agree that this change is needed. Do we have the technology? Do we have the will? That part is not as clear. But we can start with theory building. I think that's a good place. Have a good day. Thank you very much. Thanks thanks for coming, and thanks for listening. Thanks a lot. Bye-bye. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.
00:46:41
Speaker
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