I’ve been in psychotherapy, on and off, since I was 16 years old. That’s 51 years as a patient. My guest on this episode, Dr. David I. Joseph, has been on the other side of that equation for just as long — 50 years as a psychiatrist and psychoanalyst. His book chronicling his journey in the mental health profession, Listening for a Lifetime: The Artful Science of Psychotherapy, is available on Amazon, including Kindle Unlimited.

When I read it, I recognized my entire mental health life on those pages.

Know Who You’re Talking To

Before we got into the book, I asked Dr. Joseph for a primer — one that I wish I’d had 50 years ago. What exactly is the difference between a psychiatrist, a psychologist, and a psychotherapist?

His answer: “A psychiatrist is someone who’s gone to medical school and then done specialty training in the field of psychiatry,” which means training in both the brain and the mind, including the ability to prescribe medication. Psychologists focus on how the mind functions. Their training centers on providing psychotherapy, not pharmacology. And not all psychiatrists are equally equipped to do deep psychotherapy work — some are, some aren’t.

That explanation paralleled my experience. In my time in the system, I found that psychiatrists often moved quickly to the prescription pad. Dr. Joseph, to his credit, agreed — and contextualized it. He was trained in the late 1960s and early 70s, when psychiatrists still received serious education in psychotherapy. Today, many don’t. And the economics make it worse. As he put it, a 15-minute appointment and a prescription generate more income than a 50-minute conversation. Knowing that matters when you’re choosing who to see.

A Book Built on Aphorisms

Listening for a Lifetime grew out of Dr. Joseph’s decades of teaching and clinical practice. His students and colleagues kept telling him he had a gift for distilling complex psychological truths into short, memorable phrases. After the third person said he ought to write a book, he did.

He spent about a year and a half collecting these aphorisms — phrases he had developed over the course of his career that condensed the essential experience of both therapist and patient. “I decided that I would organize the book around these aphorisms because I wanted to make it understandable, readable, substantive. I didn’t want to dumb it down.”

The cover of the book, by the way, is a photo of his actual office. His story is that real.

Being a Patient Is Hard Work

Dr. Joseph said it plainly: “Being a patient is hard work.”

He’s right. And the hardest part is opening up about the things you’d rather leave buried. I told him I’ve been in situations where I refused to go there — where something was too painful to bring to the surface and I just covered it over instead.

His response was not what I expected. He doesn’t coax anyone. “I never coax anyone to do anything,” he said. And he reframed the whole thing for me. It’s not that talking about certain subjects is painful. “It’s risky to talk about certain subjects because you’re going to make yourself vulnerable.” That distinction matters. Risk is something you can evaluate. Pain feels like something that’s just happening to you.

What a Bad Therapist Looks Like

I’ve had a lot of therapists over the years. Some great, some not. I gave Dr. Joseph two real examples.

The first: after my brother passed away suddenly in January 2024 — he was 66, they found him in his chair — I found a telehealth therapist through my insurance. I told her my brother had just died. She had me fill out a questionnaire. Session after session, we went through the questionnaire. She never once said she was sorry. When I mentioned my brother again — the details, the shock of it — she moved on to page two. I had to drop her.

Dr. Joseph’s reaction was unambiguous. “I would say that this is a lousy psychotherapist. I would no more give a patient a questionnaire before I’d met them and talked with them a long time. I never have given a patient a questionnaire and never would.”

The second example: a psychiatrist who started avoiding me — not returning calls, not available for appointments. When I finally got in to see her, she told me, to my face, that I had been “so draining.” I later found she was going through something herself — possibly a divorce however her approach had already hit my psyche hard. My first thought was that I was actually that bad — that I had broken my own psychiatrist.

Dr. Joseph’s take: she couldn’t make herself available in the way I needed, and the professional thing would have been to say so and refer me to a colleague. The failure wasn’t mine.

Where the Problems Start

I brought up my own tonsillectomy — I was four years old. My parents turned and walked away. Someone put a mask over my face. I remember smelling and tasting the anesthesia, and then it went black. I’ve always believed that’s where my attachment issues began. They walked away and I developed a mistrust.

No therapist I saw ever made that connection. I found it myself, years later, by watching my own patterns.

Dr. Joseph validated the experience and expanded on it. Young children interpret abandonment as their own fault — what did I do wrong? That moment becomes part of the mind and the brain. You can’t erase it, but you can reduce its grip. “You can make it have less impact. You can understand it in a different way. You can adapt to it differently.” And you can always be triggered again if circumstances line up. The goal of good psychotherapy isn’t to remove the memory — it’s to make you less vulnerable to it.

He also took my hypochondria example and ran examined it. Growing up, my household was full of tension — money problems, my father working multiple jobs, multiple kids. My mother was often stressed. But when one of us got sick, she turned into a different person: nurturing, present, sweet. At some point, without knowing it, I started manufacturing symptoms to bring that version of her back. I carried that pattern into my marriage. It wasn’t conscious. It was survival logic from childhood.

As a psychoanalyst, Dr. Joseph framed it this way: “our prior experiences shape how we’re likely to respond in the present, but we’re flexible people. We can learn until we’re dead, and we can change until we’re dead.”

Psychoanalysis vs. CBT

I’ve always had mixed feelings about cognitive behavioral therapy. My late brother was a patient of Albert Ellis, one of its pioneers. The approach felt like: your mind is causing the problem, stop letting it. Don’t dig into the why. Just override it and move forward.

My issue with that: if I don’t address the root, it keeps coming back. No matter how many affirmations I layer on top of it.

Dr. Joseph offered a more nuanced view. CBT and psychoanalysis overlap more than their practitioners like to admit. CBT works through desensitization — it can help someone stop fearing spiders, but it won’t tell them why they were afraid. Psychoanalytic psychotherapy, done well, helps you metabolize what you’re dealing with so you can relate to it differently. It’s not about avoiding the thing. It’s about changing your relationship to it.

One of his aphorisms that stuck with me: “someone’s thinking or behavior seems irrational because we don’t understand their rationale.” The problem isn’t that you’re thinking wrong. The problem is that nobody took the time to understand why you were thinking that way.

The Chemistry Question

One of the chapter titles in the book reads: Chemical imbalances are the spices of life.

I asked him to explain it. He said the phrase “chemical imbalance” gets thrown around as if it explains everything about depression. It doesn’t. He made the point that, in a sense, he and I were having a mild chemical imbalance durin...