Both of my clients who had received a diagnosis of ADD prior to starting therapy and are now taking meds continue to help me understand the psychological origins of this difficulty.

Later in a session, when talking with one patient about how distracted he gets and the ways he procrastinates, I made the parallel: his urge to “move on” from guilt or remorse, putting those feelings out of his mind, resembles the way he “moves on” when he comes up against boredom or frustration.

When I thought about how upset he looked at the beginning of our session — and how rarely he brings much emotion into our work — I realized there’s a lot more pain than I had thought, but that he distracts himself from it so effectively that the pain doesn’t seem to exist.

Distraction as a mechanism of psychological defense; as a “habit of mind,” so to speak, it clearly bears on his ADD symptoms.

Alan talked in session about his disappointment over the job interview, odds that he won’t get an offer, and feeling “depressed” about it. We’ve discussed depression before but something about what he was saying felt different this time.

He mentioned attempts to rouse himself into action, then sinking back into lethargy. At one point, he was lying on the couch, then got up to clear off his desk. Alan had been neglecting that particular chore for a very long time: his desk was dirty and stacked with old papers, books, cups, etc. He described it as a complete mess. He did his best, then fell back onto the couch, feeling despondent about his future.

The messy, long-neglected desk jumped out at me from all the other details in the session; I felt the little mental “click” that happens when you suddenly understand something in a new way.

I’ve now uploaded the third installation in my series on psychodynamic psychotherapy, which you can access through the video frame below. This one covers early manifestations of the transference and includes a lot of examples from recent sessions in my practice.

It’s a useful counterpart to my earlier post on the subject, fleshing out the ways that an understanding of the transference can shed light on a person’s “outside” relationships and internal dynamics.

Can I ask a favor? I know that everyone dislikes receiving endless email notifications from all the websites we visit, but the number of people who subscribe to my channel has an impact on my standing in the YouTube community and how my channel ranks; if you watch the video and like it, would you mind subscribing? Many thanks.

As he left the office last night, Naomi’s boss gave her some instructions that struck her as ridiculous, betraying a lack of understanding for the flow of work during the evening shift. As she talked about him, she sounded scornful. Because she felt so angry, she wound up doing virtually nothing, which in the end made her feel “guilty” because she’d wasted time that she might have used to develop other projects.

She went on to talk about one of her colleagues, a highly ambitious man a few years her senior, who has recently enjoyed some rather public success. Whenever one of his projects receives attention, he gets very excited and tells everyone at work about it. Naomi said she looked down on him for caring so much, that it really wasn’t such a big deal. Again she sounded scornful.

Just before our session, David had his monthly consultation with the psychiatrist in charge of his medication. Prior to that meeting, David had spent hours researching his various meds, their indications and side-effects, new drugs on the market, etc.

He presented a written report with all this information to the psychiatrist during their consultation. “He basically did what I told him to do,” David said to me, at the beginning of our session (meaning that the psychiatrist wrote the prescriptions that David had suggested to him). Then he mentioned how much he enjoyed doing medical research and would like to start a business doing this kind of work for other busy psychiatrists, even though he has no medical degree or background in science.

As David continued, he explained to me what he needs at this juncture in his life: community, a sense of purpose, etc. He had various ideas about what he ought to do and outlined some plans. He sounded very pragmatic and upbeat, in contrast to last week when he felt despondent about the possibility of real or lasting change. Throughout the session, he sounded very sure of himself.

Things I heard myself say during sessions yesterday:

I think you feel so screwed up that there’s no hope you could ever do anything to get better … that you might as well throw yourself onto the trash heap.

Sounds like you’re saying none of these apartments will make things any better — one’s as good as another — because wherever you go, you’ll take yourself and all your pain along with you.

I think you feel completely alone in the world, and that no one cares about you.

Seems like when you get to that point, you want to give up and hand yourself over to the snakes, because you feel that there’s no goodness left anywhere in the world, inside or out.

This is the second installment in my video series about what to expect in psychodynamic psychotherapy, focusing on what happens during the early weeks.

In addition to developing a deeper understanding of the client’s past and current emotional issues, these sessions involve a fair amount of education about the process itself: how it is the job of the psychotherapist to make the unconscious conscious; encouraging clients to begin thinking of themselves as a collection of parts, more or less like distinct individuals cohabiting and relating to one another; and explaining what kind of change is possible and how it occurs.

Janice continues to struggle with this new awareness of having a mouth. It isn’t only symbolic or metaphorical — a way to describe coming alive to her needs; she feels it on a quite physical level, too. When I returned from my vacation break, she talked about feeling as if her mouth had been cut away from her face. Now, she feels as if her mouth is like an ugly wound, full of blood and shit.

In today’s session, she talked about the very old feeling of wanting to murder her husband for the way he chews. As a result of our earlier sessions, she has come to realize that the smacking sound he makes turns him into a “smug mouth” — the mouth that “has it all.”

The smug mouth has no needs but instead gloats over what it already possesses (the breast-mouth, all in one, as she later pointed out). Janice connected this to hearing my last radio interview. She made clear up front that she knew I hadn’t actually sounded that way, but she heard me as saying I was so incredibly wonderful, such an amazing person, and that I had it all. She wanted to kill me, too. Like her husband, I’m a smug mouth with no needs of my own, and a superior feeling that I have everything already.

During our first session, I began by telling Deanna that the lead-up to the appointment had felt like chaos — the “forgotten” session, her difficulties in getting the forms to me in a timely way, taking days to reply to emails, the incomplete information on the new client questionnaire, etc. She agreed right away and I suggested it was a good place for us to start our discussion.

Deanna went on to tell me that her physician had finally refused to continue seeing her because of so many missed appointments; she begged him to let her continue coming and promised she’d make the next appointment … then went on to forget that one, as well. This led her to discuss a lifelong history of problems with self-discipline, respect for rules and limits, as well as a feeling that she hadn’t fulfilled her potential.

As a precocious, highly intelligent child, she’d managed to skate through grade school, doing as little effort as possible. When she reached college, she worked extremely hard for the first year but then began to slack off. All this of course reminded me of my own struggles at that age, and the shock I felt when I got to college and found I actually had to work!