Transference Focused Psychotherapy, Borderline Personality Disorder, Narcissism, with Frank Yeomans, MD

In this episode, Dr. David Puder interviews Dr. Frank Yeomans, a leading expert in Transference-Focused Psychotherapy (TFP) and personality disorders, to explore the treatment of Borderline Personality Disorder (BPD) and Narcissistic Personality Disorder (NPD). They discuss object relations theory, identity diffusion, splitting, and the therapeutic relationship in TFP. Dr. Yeomans shares clinical insights on working with paranoid, devaluing, and omnipotent transferences, highlighting how therapists can navigate idealization, devaluation, and therapeutic neutrality. They also compare TFP with other psychodynamic approaches and discuss the role of aggression in mentalization and personality integration. Learn how TFP helps patients develop a stable identity Understand the differences between BPD and NPD treatment Explore the role of transference in psychotherapy Tune in for a deep dive into psychodynamic therapy with one of the field's top experts! By listening to this episode, you can earn 2.0 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-234-transference-focused-psychotherapy-borderline-narcissism-frank-yeomans Link to YouTube video https://youtu.be/nC9iu8vMjZ8

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

• 0:14David Puder?

  All right. Welcome back to the podcast. I am joined today with Dr. Frank Yeomans. He is an MD/PhD prominent psychiatrist, psychotherapist specializing in personality disorders. We'll be talking about borderline personality disorder, transference-focused therapy. He had his undergraduate at Harvard, graduated at Yale, residency at New York Presbyterian. He has had a number of professional roles. I'm just going to highlight the most pertinent to this discussion. He's the president of the International Society of Transference-Focused Psychotherapy. He wrote two books that I want to emphasize. Transference-Focused Psychotherapy

• 0:54David Puder?

  for Borderline Personality Disorder: A Clinical Guide in 2015, and a primer on Transference-Focused Psychotherapy for Borderline Patients, co-authored with Kernberg. I think both of these were, right?

• 1:06Speaker 01

  Yeah.

• 1:07David Puder?

  Am I correct about that? Okay.

• 1:08Speaker 01

  Yeah. I should also give credit to Clark and co-authored with Kernberg and John Clark.

• 1:13David Puder?

  Very good. Thank you. So today, we wanted to talk about borderline personality disorder. We've talked about it from the perspective of mentalization-based therapy. Prior on this podcast, we've talked about it. We've talked about transference-focused therapy a number of times. So it's great to have you on here to kind of hear it from you directly. So thanks for coming on.

• 1:34Speaker 01

  It's a pleasure. Thank you for inviting me.

• 1:36David Puder?

  And so I thought we'd start and talk about like, what is maybe for those who are less familiar, and we're really speaking to an audience here of mental health professionals, people in training, they probably have heard about transference-focused therapy. I imagine they all know what transference is, but I'm hoping to really, in this discussion, pull out some of the nuance of the uniqueness of the approach. On the podcast, we talked about reflective function and how transference-focused therapy uniquely improves reflective function. So I'm wondering if you could just kind of introduce broadly transference-focused therapy and where it is today in terms of research.

• 2:15Speaker 01

  Certainly, I'd be happy to try to do that. Invite. Turn into a lengthy answer. But when you said, going back to your statement, most people are familiar with transference, that's probably true. But there's also a common misperception, misunderstanding of transference, which is that it's the past being repeated in the present. That leaves out the mind. Because what is actually being activated in the present when transference occurs isn't an accurate version of what happened in the past. It consists of the activation of mental images, internal representations of people, experiences, relationships,

• 3:00Speaker 01

  that are laid down as memory traces in the mind, but often become modified and sometimes exaggerated by the processes of the mind and unconscious processes that we think about when we think about a psychoanalytic approach. So there are fears, there are desires, there are anxieties, there are wishes. All these have an impact on the way the memory traces are laid down into the internal representations. So when I talk about transference in general, I'm going to refer to the title of one of Körnberg's early works, which is Internal World and External Reality. The idea is that in the course of the development of any individual,

• 3:45Speaker 01

  they internalize images, as I said, representations of themselves interacting with others. These become paradigms or templates for later experiences. So transference is, first of all, it's a universal phenomenon. We all transfer onto each other. Anytime I meet somebody new, my first encounter with you, there are traits, aspects of you that will activate in me memories of...

• 4:19Speaker 01

  And this is largely unconscious, but you know, I'll think of, you know, he kind of reminds me of X, Y, or Z. So I'll project onto you characteristics that may or may not really fit who you are. The challenge in adapting to reality is taking in who the other is. So you get a precise, an exact sense of them that might be different from your initial reaction based on some kind of images that are activated in you. So it might help at this point to give, I think, what I think is a fairly dramatic example. And it's actually the clinical experience that convinced me to work with this approach.

• 5:03Speaker 01

  I had just finished my training as a psychiatrist and was working at a hospital, but also started a private practice. And one of my first patients was a man with a combination of borderline and narcissistic personality disorders. We can talk about each of those later if you'd like. But in any case, like a lot of patients with narcissistic personality disorders, he had kind of an angry, aggressive, devaluing stance toward me a lot of the time. He was kind of a tough cookie, to put it in plain English. In any case, in one session, this guy, who was usually angry and critical, told me a

• 5:46Speaker 01

  story that's something that happened to him when he was a kid, five, six years old. It was a very sad story and it brought tears to my eyes, which is not what usually happens when I'm in a therapy session, but can't happen. Anyway, so he noticed that and he said, "You have tears in your eyes." And I simply said, "Yes." I didn't know what else to say. Then he looked at me very closely. He kind of scrutinized me and said, in all seriousness, he said, "You're mocking me." So that is an example of transference, where the internal representation, the other who is mocking you, so prevailed over what seemed like kind of clear evidence to most people that I was sympathizing with him, that his transference onto me

• 6:31Speaker 01

  was what we call a paranoid transference. The other person doesn't like me, is critical of me, is mocking me. And if your transferences are so strong that they prevent you from getting an accurate take on reality, then it makes it hard to adjust to life and have success and satisfaction in life. And our patients tend to have those kind of distorted transferences where the internal image prevails over the external data that they're taking in. So in a more typical case, it's the patient who just assumes, when, say, you look at the clock, there's no one to end the session, that you hate them and want to get rid of them. And that's a transference

• 7:15Speaker 01

  triggered by a minor external event but leading to a massive projection.

• 7:21David Puder?

  Can I, can I ask you about this, um, so this, this comment? He said, "You're mocking me." He's seen, he's seen you, you, you're feeling emotionally distraught. So he's unable to empathize with your true experiences. His reflective abilities about you and what you're really doing are off, very off, right? Was the, was the paranoid transference there? Was the, um, the fear that you're mocking him, was that tied into the, the, the actual trauma of what happened to him when he was five years old? Like, was in that five-year-old instance of him going through that conflict, was there some aggression maybe that was disavowed?

• 8:04David Puder?

  Or was there some that now is pointed at you, his therapist?

• 8:08Speaker 01

  I think that's very likely the case, but it's a good point to bring up because a lot of therapies, and this is one way in which transference focused psychotherapy differs from more classical psychoanalytic psychotherapies. A lot of therapies would jump to the past and say, oh, in that experience, did you feel your parents, who were the people involved in the interaction, as I recall, you know, were criticizing you unfairly, putting you down, mocking you? You know, then let's try to distinguish then from now. In transference psychotherapy,

• 8:48Speaker 01

  we would consider that focus on the past to be an avoidance of what's happening in the here and now. Because we think it's more effective therapeutically to work with what the patient is feeling in relation to you, rather than say, hey, let's look at the past 30 years ago. So you can, let's put it this way, to say, okay, you know, you took in these ideas that people who are supposed to care for you are mocking you because your parents seem to have done that. This man is going through life on a daily basis, misperceiving others. So we do not try to correct the distortion. If it would work, I'd be happy to correct the distortion.

• 9:33Speaker 01

  I'd be happy to say to him, no, please trust me. You know, I'm sympathizing with you, I'm not mocking you. But it doesn't work to say to somebody who's incapable of trust, to say to them, please trust me, they're not going to.

• 9:46David Puder?

  Right.

• 9:46Speaker 01

  So you have to enter into the projection. You have to be able to carry the projection so that you and the patient can look at it together. So instead of saying, no, please understand, I'm not mocking you. My response, I mean, this was ages ago, would have been something along the lines of,

• 10:06Speaker 01

  "That sounds like a terrible experience to come to therapy for help and to wind up with a therapist who's mocking you. Let's think about that together. I'd like to hear more about that." First of all, your willingness to entertain the negative projection, the negative transference, usually is an implicit sign, maybe you're not so bad, because anybody who is really negatively inclined to would have said, "Oh, no, no, let's not go there." So my willingness to say, "If I'm mocking you, let's think about it," opens up reflection.

• 10:43David Puder?

  Okay. So like, let's, how would you feel if I pretended to be this patient and we kind of go into this scenario right there and see what happens?

• 10:54Speaker 01

  We can give it a try.

• 10:55David Puder?

  Let's give it a try, okay. So you had just said to me that statement, so I'm gonna go from there, okay.

• 11:04David Puder?

  Well, yeah, I'm here, I'm paying money to be here, and like, I'm telling you this awful, awful event that happened to me when I was five, and all of a sudden, like, you're like, mocking me, and I'm just like, what the heck?

• 11:21Speaker 01

  Well, I guess it's not just at age five, but right now, your life is full of really awful events, including what's happening between us, and I can understand your depression when a helper, or the so-called helper, seems to be the opposite. It must be awfully frustrating to seek help and to encounter the opposite mockery.

• 11:56David Puder?

  Well, I feel like, I feel like you, you know, somehow you're, you're doing this kind of psychotherapy gymnastics around me right now. But I can't believe I caught you

• 12:10Speaker 01

  Yeah.

• 12:11David Puder?

  mocking me.

• 12:12Speaker 01

  So I'm trying to weasel out of what in fact I think of you really, which is kind of a negative, critical mocking stance. I'm trying to put the veil over that and retreat to my pretend position of, you know, sort of being a concerned caretaker. That's what's going on?

• 12:36David Puder?

  Yeah, exactly. Like how, you know, I tried to call you and then it took like three days to hear back. Just the other week. And, and this is just another example of this. It's like, if you really cared, you would have called me back that day. I was in absolute crisis.

• 12:56Speaker 01

  Well, just parenthetically, I wouldn't let three days go by. So I'll have to find a way to adapt to your, your comment here.

• 13:05David Puder?

  Sure, sure.

• 13:07Speaker 01

  So it's important that this is coming out so clearly now. I guess you felt this for a while, but didn't bring it up. And again, I want to try to sort this out because it's a pretty sad situation in life. When even the person who's supposed to help turns his back on you, doesn't care enough to call back. And now it seems like I've, a kind of mockery you see in me has broken through. One thing that's implicit in all of this is the view that I'm dishonest. You know, maybe we should think about that because you seem to feel that I'm pretending to be one thing

• 13:51Speaker 01

  and I'm really another. And let's, let's open that up, please.

• 13:58David Puder?

  Yeah, I mean, there's part of me that's like, I know a couple of weeks ago, I would have, I think it, I don't think it, I thought I saw you that way at all. I thought you were the greatest, you know, doctor ever. But somehow, all of a sudden, it seems like you're just like all the other shitheads in my life that have preceded you.

• 14:23Speaker 01

  Yeah, I can see that that's confusing. And I do remember when you seemed to think I was a good guy. So therapy is about trying to figure out things that are confusing. Maybe you've figured out or decided once and for all that the good guy thing was nonsense and that, you know, I'm a, like everybody else. Don't like you, reject you, internally mock you. But on the other hand, there seems to be a little bit of that first part, which by the way, might not be the whole story either, because that seemed to be a little too good to be true.

• 15:08Speaker 01

  But in any case, I think you're struggling with something. It's not totally out in the open what you're struggling with, because I think it's not fully in your awareness. But at the same time that you have this negative feeling toward me, you're still coming here. So that's kind of contradictory. And we should work to figure out how to sort out that confusion.

• 15:33David Puder?

  You know, I haven't told you a dream that I had this week about you. And I think it might relate. I had a dream that we had ended a session and I had left, but the door was cracked. And I overheard a phone call with you and some colleague on the phone. And you were laughing about me with this colleague. And then when I woke up, I felt like it was so true, like it actually had happened. But then I was, I felt just absolutely betrayed.

• 16:11David Puder?

  And that was the end of the dream.

• 16:12Speaker 01

  When did you have the dream?

• 16:14David Puder?

  Last night.

• 16:15Speaker 01

  Oh, just last night.

• 16:16David Puder?

  Yeah.

• 16:17Speaker 01

  Okay. Oh, well. It seems like it's the same thing as what.

• 16:24David Puder?

  What we're talking about.

• 16:25Speaker 01

  Yeah, you feel as materialized here. That in spite of my. What you see as facade of interest in you and wanting to help you. But in. My mind, the honest reaction I have is to think you're.

• 16:43Speaker 01

  Kind of a pathetic human being and. You know, like I say, talk more about that.

• 16:52Speaker 01

  I might go into, you know.

• 16:55David Puder?

  Should we pause here and kind of reflect on what's going on?

• 16:59Speaker 01

  Because what I'd like to do is I'm trying to. Understand what in your mind would be to my thinking you're a pathetic human being.

• 17:08David Puder?

  Oh.

• 17:11David Puder?

  I mean, I think it's like a deep. Fear, you know, I mean, and you know. Uh, you know, when I was. Some of the early situations that I had. Where I felt some level of betrayal. And I think I. It's a, it's a fear. That I have.

• 17:30Speaker 01

  Well, being betrayed and being pathetic are not exactly the same thing. I can understand. You're feeling betrayed, but what I see now is a kind of feeling pathetic. Where. You, you know, we've seen so many instances where you disqualify yourself. Attack yourself. Put down an effort you've made. And I think kind of. What's happening between us as you see it goes on in your mind.

• 18:01Speaker 01

  Within you. You know, there's you against you. The way you, me, the way you see me against you right now.

• 18:10David Puder?

  Hmm.

• 18:13David Puder?

  Yeah, and so I think I'm confused because it seems like you're not against me right in this moment. You're curious about how I'm observing you. I don't, do you think, okay, let's pause.

• 18:27Speaker 01

  Let me get finished. I say, well, that is another possibility. It's very important to figure out which of the two possibilities seems more real. But anyway, you, okay, that's that's enough. Yeah.

• 18:39David Puder?

  Okay. Well, I, I think I'm curious because you've done this a lot. Like, what would the patient say at this point? Would they, would they, they soften, you know, in their kind of observations? Would they get more reflective? Would they dig in?

• 18:55Speaker 01

  I would say more often than not, no, because defenses are very strong. When I say defenses, I mean, especially when we're talking about people with borderline level personality disorders, splitting defenses where, which we should discuss at some point. The person can't get in touch with their own aggressive feelings and see all the aggression on the, in the other. As this man is seeing all the aggression in me, I'm trying to get him to see there's some aggression in him, which in fact, he turns against his self,

• 19:33Speaker 01

  himself. But to answer your question about what patients usually do, usually they say, oh, you're just, you know, what, what will they say? You know, you're just running circles around me. You're just trying to use the psychobabble to cover up what I know is true. So you can't expect every intervention to lead to increased insight, but you just have to continue with it, stay committed.

• 20:01Speaker 01

  And assume instances like this will happen again and again. And that when you're lucky and you've accumulated enough mutual experience, one of those moments will lead to the person thinking about what you're saying and beginning to reflect and take it in. We have some research along those lines. One of our colleagues, Yogesh Kavidi and his other researchers, published a paper about what leads to change and to the reflective functioning you mentioned, and it is what in his paper he calls bids for reflection. In the traditional TFP literature, we call it confrontation. A lot of people say that's not a good word.

• 20:46Speaker 01

  It implies a hostile confrontation. But it really means doing what I tried to do with you in the clinical vignette. Say, we've got this and we've got that and they don't seem to fit together. How can we reflect on them? So, short answer to your questions. Most usually, the patient continues with their defensive projection. But if you keep going, eventually they begin to reflect.

• 21:11David Puder?

  Yeah.

• 21:14David Puder?

  Oh, yeah, I think it's, I think there's a couple of things that I was trying to embody. The idealization early on in treatment. And then this kind of became into the devaluation, right? So I think this is a lot of what clinicians have seen. It's like initially, the patient is like, you know, you're this all good, perfectly nurturing, you know, figure who really gets me. You truly understand me. Finally, I have a clinician that has enough expertise to help me. You know, you hear like a bunch of these string together and you start to get a little bit worried as an experienced clinician like, oh, okay, there's something deeper going on here, right? And then, and then the devaluation, right? So this is, he's currently in the devaluation where it's now you're malevolent and competent,

• 21:59David Puder?

  cold, rejecting. And this is partly what you consider like borderline level of functioning, right? So not neurotic level of functioning, not psychotic, but borderline level of functioning. There's a lot of this idealization devaluation.

• 22:10Speaker 01

  Yeah, but let's talk about the basic theory because to understand what's behind idealization devaluation, I think we have to take a little review of object relations theory. Is that okay?

• 22:23David Puder?

  Sure.

• 22:24Speaker 01

  Okay. So object relations theory is a branch of psychoanalytic theory that emphasizes the self in relation to the other. Early Freud posited neurotic conflicts based on an internal struggle between an impulse, a drive, and a prohibition against the drive. So, you know, somebody wants to have sex, but they think it's bad and they get a symptom and, you know, I'm simplifying. But in any case, some later analysts came along, and the one I'm thinking of in particular is Meneli Klein, and said, "Well, people do have drives. They have sexual drives, they have libidinal drives." And libidinal means more than sexual.

• 23:09Speaker 01

  It means affiliative, you know, attachment related, you know, wanting to have or satisfying relations with others. So there are libidinal drives in the broad sense, and there are aggressive drives. Anger, wanting to strike out, wanting to, combination of assert oneself and defend oneself. Not all aggression is bad. It can involve competitiveness and assertion and competition and creativity. Anyway, the idea is that if you have those drives, libidinal ones and aggressive ones, you don't just feel a drive, you feel a drive in relation to the object of the drive.

• 23:51Speaker 01

  If you're feeling you want to connect to somebody, you have the idea of with whom you want to connect, or if you want to, you know, have some kind of competition with somebody, there's an object of that. So, given that emphasis on the connection of the drive to the object of the drive.

• 24:08Speaker 01

  We can then look at infant development. And the newborn takes in a lot of experiences and it's complicated because of neurobiology and the myelinization of the brain and so on and so forth. But, and you know, there's still a gap between the analytic theory and neurobiology, although the gap is narrowing. So, in this theory, in the early year or year and a half of life, as it is positive, experiences with the caretakers are, by the infant, seen as either perfectly satisfying or totally depriving.

• 24:52Speaker 01

  Because there's no concept of object constancy. If you're being, you know, caressed and fed and kept warm and cozy, you're in heaven. But if you're uncomfortable, you're cold, you're hungry, you're soiled, and the caretaker isn't there, you don't have this feeling, "Oh, I know she'll, mom will come around, you know, just give her a little time." You don't have that object constancy. You're in pain, you're suffering, and you perceive the other as the source of the suffering. So you're either in heaven or in hell. The other is totally caring for you in an ideal way, which doesn't correspond to reality, by the way.

• 25:32Speaker 01

  Or the other is persecuting you, not just unavailable, but persecuting you. So, in object relations theory, the early makeup of the mind is divided between the segment of the mind that's about positive, ideal experiences and negative persecutory experiences. Interestingly, this corresponds to some neurobiology, because it seems like the brain areas where positive affect is located and the brain areas of negative affect are different brain areas that require cortical intervention to bring them together. And we think therapy can help with that. So in any case...

• 26:16Speaker 01

  If you go through life where things are either perfect or terrible, you don't adapt well to the complexity of life, because life isn't that way. So to go back to your concepts of idealization and devaluing, patients often come in projecting, "I finally found the ideal therapist. This guy knows everything, everything's going to be perfect." Now, that positive side of the split internal world is just as pathological as the negative side that's all about paranoia and rejection and harm, because the positive side doesn't correspond to reality. You never find the perfect caretaker.

• 27:00Speaker 01

  No matter how much you're in love with your partner, they're not going to be perfect. So you have to accept that. But people with splitting, when we talk about splitting, we mean the splitting between the all good and the all bad. People with splitting expect perfection, and for a while they might continue with you with the illusion that they've found that. But inevitably, there'll be disappointment and then it flips into the devaluing. So let's talk about what happens in successful psychological development. In success... Oh, by the way, that split organization is called the paranoid schizoid organization. It's called schizoid because it's split. Why is it called paranoid? Because in that mental organization,

• 27:45Speaker 01

  where aggression and libido, fondness and aggression are totally divided, the person experiencing aggression is not comfortable seeing himself or herself as the source of the aggression. They tend to project the aggression and see it as coming from outside. So as soon as you begin to get close to somebody, you're nervous, because you think something bad is going to happen, rejection, harm, so on. So in successful psychological development, we move from the paranoid schizoid position, that radical separation of positive and negative and the projection of anything aggressive on others,

• 28:29Speaker 01

  to what interestingly Melanie Klein called the depressive organization, which doesn't sound great, who wants to be depressed? But it's more specific than that. If you integrate those two radical polarized extremes, two things happen. One is you have to give up and you have to mourn your belief that you can never find the ideal other, or that you can ever be the perfect ideal self. You have to give up on thinking anybody can be ideal. And that's kind of a sad awareness. The second thing that happens when you begin to integrate your positive and negative emotions is that you begin to have awareness

• 29:13Speaker 01

  and take some responsibility and consciousness for the aggressive feelings you always saw as outside of you. So it's a painful trajectory from splitting and projection to integration and mourning the ideal object and accepting that one has one's own aggression. I'd like to give you a clinical example in a minute. But does this help understand why patients come in with the idealization and then inevitably switch to devaluing when you don't meet their perfect expectation?

• 29:45David Puder?

  Yeah, I think the thing that I would love to hear from you kind of like how it fits into this is the idea of identity diffusion.

• 29:55Speaker 01

  Yeah.

• 29:56David Puder?

  Can you integrate that into how you... Does that fit somewhere into this?

• 30:00Speaker 01

  Oh, it's perfect. In fact, it's good you bring that up because in our model of the mind of personality and of personality disorders and its treatment, identity is the core concept, whether the identity is integrated or fragmented and diffuse. It's important when we talk about identity to think about how we mean it. Because a lot of people, when they think about identity, think about identifications. You know, what's my gender? What's my sexual orientation? What's my ethnic affiliation? What's my nationality? What's my sports team? What are my interests?

• 30:43Speaker 01

  So there are all kinds of elements of identity. And when we talk about identity, that's not exactly the level at which we're talking. We're talking about identity.

• 30:55Speaker 01

  As the ability to be in touch with, grasp, and manage the full range of your internal emotional states. In other words, does your identity allow you to assume and connect with the full range of who you are as an emotional being? That's a different level of identity. It's a very core sense of identity. Do I have an integrated identity? Means, have I gone beyond the paranoid schizoid position, where everything was polarized and fragmented,

• 31:39Speaker 01

  so that I could not have a stable emotional existence? I was buffeted back and forth between idealization and devaluation. I don't have that core sense of emotional stability, where I get it. I can be loving, I can be angry, I can adore somebody, I can be rageful with somebody. So, our sense of identity integration is to be integrated emotionally, not to reject, split off, and project parts of your emotional self.

• 32:15David Puder?

  Okay. So, I've been, I've been reading, thinking about identity diffusion. I was reading about this guy, Solomon Akhtars.

• 32:25Speaker 01

  Yeah.

• 32:26David Puder?

  Six characteristics. And is it this, is this, is this what we're talking about? The same thing, or is that slightly different? His six characteristics were temporal discontinuity of the self, lack of authenticity, feelings of emptiness. Emptiness is kind of different than loneliness, because there's a hollowness.

• 32:46Speaker 01

  Yeah.

• 32:47David Puder?

  Just feeling like, just like a shell. A lack of identity around gender, a lack of identity around sexuality. So it's kind of like a diffusion beyond just like, like, who am I? What am I doing in the world? Is this kind of what we're talking about? Or is it?

• 33:06Speaker 01

  Dom, Victor is a really brilliant guy. And I haven't read exactly what you're talking about. I would agree with the first part. I wouldn't talk as much about the second part. The emptiness. Can you mention the first three things you said? One was emptiness versus loneliness. So I want to talk more about that.

• 33:27David Puder?

  Like, the discontinuity in the self.

• 33:32Speaker 01

  Yeah, and it's continuity in time, yeah.

• 33:34David Puder?

  So it's like, a quote from him is like, the past, the present, the future are not integrated into a smooth continuum of remembered, felt, expected existence for these patients.

• 33:45Speaker 01

  Yeah.

• 33:46David Puder?

  So that's one of them. Temporal discontinuity, discontinuity of the self, like a chronology of how they see their life, a lack of authenticity. Here's a quote, act as someone else they know would act, not in a manner that genuinely is their own. So they kind of like put on different faces, so to speak. Feelings of emptiness is like this, like hollow, shell-like.

• 34:14Speaker 01

  Yeah.

• 34:15David Puder?

  Lack of capacity to fantasize for a person or experience in the midst of like, a lonely person may fantasize for connectedness with someone that like they don't have that fantasy for that other person.

• 34:28Speaker 01

  No. But let me, yeah, I want to say, I think that's a nice delineation of what we call identity diffusion. And it has to do with the development of a core sense of self. If you remain split and you're flipping back and forth, I love this person, I hate this person, which by the way, has internal correlates, which is I love myself, I hate myself, as I was trying to point out in our patient role play, that he was very rejecting of himself. At the same time, he saw me as rejecting. You don't have that ballast, that core, that integrated foundation on which to build.

• 35:13Speaker 01

  You're just flipping back and forth between two states that never come together. That leads to emptiness. That leads to a sense of not development over time, but just time passing without development. Dr. Kernberg has an interesting article about what he calls the destruction of time. Because if we consider time from the subjective point of view, what is our experience of going through life and the passage of time? Kernberg's idea is that we sense time as we build and grow as a self,

• 35:56Speaker 01

  as we enrich who we are, we add to our sense of who we are, we become more complex and we add to what we've done and what we plan to do. If you haven't yet achieved emotional integration, you can't develop because you don't know whether you're loving or hating. You can't combine the two. And if you're always jumping back and forth between two things, you don't have that foundation upon which to build. A lot of my patients say to me, you know, the worst part of having borderline personality disorder is not the acting out when I'm maybe hurting myself or having a rage attack or something like that.

• 36:39Speaker 01

  And we should get back to the experience of aggression in the borderline patient. The acting out isn't the worst part. The worst part are those moments when I'm sitting alone by myself and I feel totally empty. We have to, therapists, try to empathize with what that is like. It's pretty horrifying, pretty scary. And a lot of the acting out is to escape from that core feeling of emptiness. And if you do have that feeling of emptiness and unclarity about who you are, then you are going to mimic other people. You know, I'll do what this one does, I'll do what that one does. So I agree a lot with what Actar says.

• 37:20Speaker 01

  I want to invoke another title of one of Kernberg's books. He has a title called "The Inseparable Nature of Love and Aggression." And I think that relates to this concept of integration. A lot of my patients who are stuck in that kind of naive belief that you can find the ideal, say, "I know I'm getting better because I'm going out with this guy and we were having a really good time." But then, I don't think I can sustain it, or I ruined it all because I got angry at him. I felt angry at him. And I say, "Well, yeah, but let's look at that." Do you feel you can really know somebody in depth, have a lot of shared experience, and it's all going to be positive?

• 38:05Speaker 01

  If that's your goal, you're not going to have any deep relationships. Because in intimacy, deep connectedness is going to include negative feelings as well as positive ones. That's a more concrete example of integration.

• 38:20David Puder?

  In one of your Youtubes, I forgot which one, but you said something like, "The strongest identities are based off of religion, philosophy, or art."

• 38:31David Puder?

  Did you say that?

• 38:32Speaker 01

  No, I didn't, but I'd be happy to talk about it.

• 38:34David Puder?

  Wait, who, I swear, I was... Who said that? Okay, was that...

• 38:39Speaker 01

  I don't know who said that. I think you might have... Here's what I said about religion, philosophy, and art, which is that that's where you can idealize.

• 38:51David Puder?

  Oh.

• 38:52Speaker 01

  Yeah, I said, "When I just went over the object relations theory, where you go from the split organization, paranoid schizoid, to the integrated, more complex organization, where you give up the idea of perfection and finding the ideal in another person." I want to emphasize that I'm not totally cynical. I don't think you're not allowed to have ideal beliefs, ideal values. They might be embodied in a spiritual system, an ethical system, an artistic pursuit, an aesthetic pursuit. So I think ideals are laudable, but look for them where they might exist

• 39:36Speaker 01

  and not in another person or oneself.

• 39:40David Puder?

  Okay, thank you, thank you for that clarification. So, okay, so it's like, is someone inevitably always going to be in the depressive position? Is that where they stay forever?

• 39:52Speaker 01

  Well, first of all, when somebody advances to the depressive position, that really enriches life. As I said, you lose the idealization and you have to take responsibility for your aggressive feelings, but then you're in much closer contact with reality. You can really engage with others more fully. You can engage with your work, your projects more fully. So, when patients make that shift to the integrated depressive position, we help them work through the sad feelings about mourning the ideal object and usually the guilt feelings about having their own aggression.

• 40:35Speaker 01

  And we try to help them see they can, what we call, sublimate or direct or manage their aggression so that it can have positive applications, not negative ones. But, when you mentioned the transition from the paranoid schizoid split position to the integrated depressive one, unfortunately, that's not a development that necessarily takes place once and for all. People like you, I assume, and me, I hope, who are in the integrated depressive level, under certain circumstances, we can regress back to splitting if we're under enough stress

• 41:19Speaker 01

  or if we just want the pleasure and simplicity of splitting. Because splitting allows you not to think as much. Splitting is simple, but in a way, it's reassuring. When your mind functions according to splitting, you know what's good and you know what's bad, there's no ambiguity. So, if, for example, you go to, up here in the Northeast, it would be a Red Sox Yankees game. For two hours, you can allow yourself to regress, to forget about all the complexity of the world. You know your team are the good ones, the other team are the evil ones. And you can enjoy that for two hours. The problem is that...

• 42:03Speaker 01

  Political leaders can appeal to splitting when they say, "We're all good. The only problems are outside of our group. Everything bad is outside." That's just like the borderline patient who says, "Everything bad is in the other. I don't have any bad traits." So I think there's a seductive splitting. You don't have to think as much and you're told what's right and what's wrong.

• 42:33David Puder?

  And I think there's a, I mean, if you look at both sides of political spectrums, it's very common that the person will adopt all of the policies of one side, right? It's very rare to find someone who's nuanced and parses out different policies and can see good and bad. So I think we all, do we all kind of enjoy and revel in at times this splitting as well within our sort of tribe, right? And is that a natural process?

• 43:05Speaker 01

  We can until the system breaks down because in that tribe mentality, people are not taking responsibility for themselves, but only blaming the other. And then when you get enough of that going on, somebody's gonna get into violence and it's gonna fall apart.

• 43:26David Puder?

  Okay, so I think, I think this is like a really good aspect I like about depth therapy is you get the person to a place of taking some responsibility rather than just blaming purely all of their situations they found themselves in. But do you find that also like, there's this kind of overexaggeration of like, all of, all of life's issues that you have are because of the traumas that you've faced, right? And, and does this kind of like push against transpherous focus therapy, which is kind of like, hey, we're taking responsibility for...

• 44:04Speaker 01

  You're bringing up a very big issue and a controversial one, an area in which we sometimes get accused of being insensitive and unempathic. So let me give you a clinical example first, and then I'll get back to that trauma question. Because when we talk about taking responsibility for one's own aggression, we should speak for a moment about the concept of acting out. Everybody talks about acting out, but the true meaning of the term has been lost. At this point, when clinicians say, "Oh, he or she acted out", it usually kind of means they misbehaved.

• 44:48Speaker 01

  But the definition of acting out is to put into an action an emotion one cannot consciously stay with, that one cannot tolerate in oneself. So you discharge the emotion through action instead of feeling it and thinking about it. So here's my example. A patient of mine came to therapy saying that even though she made a suicide attempt, she wanted me to understand she didn't have a psychiatric illness, that all of her problems were caused by her monster husband who made her life so miserable that any woman married to him would sometimes rather be dead. And unfortunately, that can be the case.

• 45:32Speaker 01

  At the beginning of therapy, I had to consider that that might be an accurate description of her life. Anyway, a couple of months into therapy, she comes into a session and says, "I told you how awful my husband is. Can you believe he forgot our wedding anniversary? He knows how much that means to him. He's awful, he's callous, he's cruel." In the meantime, before that session, I had received a phone message from the husband who said, "Doctor, I don't know what to do. I forgot our anniversary, and I know that's bad." And I know that, you know, is something my wife cares a lot about.

• 46:12Speaker 01

  But she got so angry at me that she picked up the TV and threw it across the room at me. So in the session, I said to my patient, I said, well, I can understand your hurt feelings and how bad it was that your husband forgot your anniversary. But he left me a message that you threw the TV at him. You know, I said that calmly, not condemning her in any way, staying neutral. And she said, what else could I do? I was upset. It's different to say, I was upset than to say, I was rageful and angry. She felt a discomfort that I believe was rooted in her rage and anger.

• 46:57Speaker 01

  But she didn't want to feel, I'm rageful and angry. I want to get rid of this emotion. So I'll throw the TV and then I'll sort of get it out of my system. So if we see acting out as the discharge of something one cannot think about, our job as therapists is first and foremost to get people to think about what's in them that is too difficult for them to think about on their own. Now, how does that tie into trauma?

• 47:26David Puder?

  Wait, can I, can I ask this sort of a side question on this? How do you feel when the, the family member calls you and gives you information like that? Because sometimes it can put us like in a difficult position, right? Sometimes I'll get like an email from a mother or father, you know, and it's like, you know, sometimes it is a little bit like, okay, what is reality here, right?

• 47:50Speaker 01

  Oh, very much so. But I'm glad you asked that. In TFP, we're, even though we're based on psychoanalytic concepts and techniques, we are more open to contact with other persons in the patient's life. You know, classic analysis is analyst or the therapist in the patient. That's like totally hermetically sealed. But But patients with severe personality disorders, in the initial evaluation, we emphasize you have to evaluate a person and discuss that the nature of the treatment will be and what the conditions of the treatment will be.

• 48:32Speaker 01

  You have to have all of that in place before you begin the therapy. So anyway, part of that assessment in our practice increasingly involves bringing in the parents, if it's a young person who's very dependent on the parents, or the partner, if it's somebody who's living with somebody or very close to somebody. And why do we do that? We do that because, first of all, most people don't understand personality disorders. Most people, and I think this is a problem with American psychiatry. I think so too. Yeah, most people just think about symptom disorders. It's a depression, it's an anxiety disorder, so there's got to be a medication for it.

• 49:13Speaker 01

  Well, you can be depressed because of the way your mind works, not because your neurons aren't firing right. So if we, one of our steps of beginning treatment is after our assessment, to have an open discussion with the patient about our diagnostic impression. If it is personality disorder, we say that, we explain it in simple English, we emphasize the new understanding of personality and personality disorders, that it centers around difficulties in the way one thinks about and feels about oneself and about others. That's in the alternative model of the DSM V. And then we bring in the family with the patient present,

• 49:58Speaker 01

  and we have the same discussion, why do we do that? So first of all, they won't have unrealistic expectations that there's just a medication that hasn't been tried yet, or ECT, or TMS, or something like that. And secondly, because there's a...

• 50:15Speaker 01

  Common misconception that you can't expect much from a person with a personality disorder. And we don't find that to be true. We think you can expect a lot. But I don't mean to say this in the sense of putting a burden on the patient, but opening the patient up to their potential. So they don't see themselves as medically disabled for the rest of their lives.

• 50:37David Puder?

  Yes.

• 50:37Speaker 01

  They can get better, as many do. They can have a much more productive life. So anyway, having had.

• 50:44David Puder?

  I think that's, I think that's so important because especially, I think people think personality disorder, you have this for life. And I think that a lot of people with BPD or borderline low functioning, they take on illness as a narrative about themselves. And then, you know, what you're challenging is that identity of illness.

• 51:06Speaker 01

  Yeah.

• 51:07David Puder?

  And like, I am an ill person. I will always be an ill person.

• 51:10Speaker 01

  Yeah.

• 51:11David Puder?

  Which is why I get, I've turned so many people from bipolar to unipolar and personality disorder, because it's like, it's like, no, like, there is hope. Right? You're not, you don't need to be on medication your whole life. If you have a personality disorder, actually, the new standard with the APA, American Psychiatric Association, the borderline personality disorder is not, medication isn't going to treat borderline personality disorder. It may treat some of the comorbid issues, but not actually borderline personality disorder.

• 51:40Speaker 01

  That's the most important message from this whole discussion. I hope your viewers have stayed with us long enough to hear what you just said.

• 51:49David Puder?

  So go on, go on. I'm like, we're on the same team.

• 51:52Speaker 01

  That's very important. Anyway, after having had this initial contact with partner or parents, whoever it may be, with patient present, as I said, you leave it open that if those parties think there's something important to communicate to you, they can provide you that information. The patient usually says, you're violating my confidentiality. And I say, no, because I'm not telling them anything. I'm just letting them know if they have a concern, they think I should know about, they can tell me. And that doesn't mean I'm necessary to believe them. You know, maybe, you know, they'll say something and. You'll say that's not accurate and maybe it'll be their issue and not yours or ours.

• 52:36Speaker 01

  So anyway, that I hope is an answer to how we would deal with information from a third party.

• 52:42David Puder?

  Yeah, that's good. Okay, I think we were now.

• 52:45Speaker 01

  Trauma.

• 52:46David Puder?

  We're talking about trauma.

• 52:48Speaker 01

  Yeah.

• 52:48David Puder?

  And the reason why I'm bringing this up, because I've been thinking a lot about complex PTSD, BPD, and the odds ratio. When you go into like adverse childhood experiences, when you go into like when a child has four to five, the odds ratio of either one of those is like 20. It goes way up. And so I personally see it's like, it's like not enough to have a lot of aces to develop BPD. But it's like a part, it seems to be a part of that process.

• 53:24Speaker 01

  Yeah. Well, it gets complicated. So first of all, let's think about what Freud called the complementary series. It's a basic concept where he sees two main contributors to psychopathology. One is temperament. And sort of emotional raw material one is born with. Some people have much more fiery and intense temperaments than others. So temperament could be the main factor in the development of a personality disorder. But the other part of the complementary series is developmental experience. And the adverse childhood experiences you're talking about can be a good example of that.

• 54:08Speaker 01

  So in Freud's model, he says, you know, any individual might have their own proportion of the temperamental contribution to the pathology and the developmental. But let's go back to what you said about complex trauma and borderline personality.

• 54:27Speaker 01

  Let's rewind to the 1990s. I was running, I was the unit chief on an inpatient unit where we had all patients with relatively severe borderline personality disorder. And we like to invite people who might contribute to our knowledge to come and talk to us. And at that time, and it is kind of a resurgence of it now, there's a very strong emphasis on trauma as maybe the most important factor in the development of personality disorders. So Judith Herman, who writes and researches, you know, trauma a great deal along with her colleague

• 55:09Speaker 01

  Bessel van der Kolk, came and spoke to us and her work is really good. But I think she and we are not on the same page about borderline personality disorder because she said, you know, you guys don't understand borderline personality disorder is a misconception. All of these patients you have are trauma patients and you should see them and treat them as trauma patients. What is the difference there? The difference is what you said about most trauma models, I'm not saying all because I'm not totally versed in trauma models, but they would not see any contribution of the patient's own aggressive feelings.

• 55:51Speaker 01

  They would see aggression in the patient, not as the patient's innate inherent stuff, but as the result of traumatic experiences which have been introduced into the patient's mind from outside. Mentalization-based therapy is sort of a good example of this. They talk about the alien self. Their model of BPD is somewhat different from the TFP model. It's interesting because both are considered psychoanalytic models. But I think TFP goes deeper in terms of looking at the core, deep conflict in the mind between libidinal feelings and aggressive feelings, loving and hating.

• 56:35Speaker 01

  Whereas in MBT, they say... What happens is that the borderline patient has had experiences of trauma growing up. So they have in their mind an internal image of aggression that has been introduced to their mind from the outside, and that is, to use their word, colonizing their mind. And as you help them to think and reflect more clearly, to mentalize their internal states and the internal states of others better, that alien aggressive element just kind of goes away. I consider that a little naive. I think that everybody, you, me, and everybody I have ever encountered,

• 57:20Speaker 01

  you know, part of the human nature, part of human nature is to have some aggression. We wouldn't have survived as a species otherwise. The problem is, how in touch with that are you? And how do you manage that? So I think what happens with BPD patients is, as we know, um, let me just give a little reference to research, and then I'll get back to the clinical example. Studies have shown that about 70% of patients with BPD have had experiences of trauma. But first of all, if you look more carefully, as Joel Paris up in Montreal did, the trauma isn't all major trauma. But I think more importantly

• 58:05Speaker 01

  is to reference a study that shows that if you start by looking at the general population and you look at the subgroup of the general population who have experienced trauma, and you study that group of trauma-experiencing individuals, the majority of them do not have psychiatric conditions. So you can't say trauma equals the development of psychopathology. We think it has to do with the way trauma is processed. And we're not saying that trauma doesn't have an impact. But let me reference a patient of mine who is a...

• 58:45Speaker 01

  Actually, a lovely young woman in her early twenties, who was lovely except when she was making serious and violent suicide attempts. In a session in my office, she banged her fist on the arm of the chair and said, "I'd rather be dead than think I have anything in common with that awful abusive father of mine." And I said, "I think you just defined your problem beautifully. You'd rather be dead than think you have anything in common with him." Whereas, as a matter of fact, you almost undoubtedly have something in common with him, because we all have some angry, aggressive feelings. Part of who we are. I think your problem is that when you feel

• 59:27Speaker 01

  the first emergence, the slightest inkling of an aggressive feeling in you, you can't think about it, accept it, and work with it. The slightest inkling of an aggressive feeling in you activates the internal representation of a totally abusive father, and then you think you don't deserve to exist. So the problem is that the trauma introduces into the person's mind images of aggression that are excessive and not easy to tolerate.

• 59:58David Puder?

  Yeah, I'm following you. I have a couple of thoughts. One of the thoughts is, I've studied micro-expression, so I look at like, small moments of flashes on the face of people as they talk to me. And often, you know, anger is given a bad rap. People don't like to think that they are angry. People don't like to imagine that they are angry. And my conception of anger has shifted over the years as I've watched people.

• 1:00:26Speaker 01

  Yeah.

• 1:00:26David Puder?

  Because they not only flash micro-expressions of anger when they're frustrated at their spouse or in an argument, but they flash it as well when they're talking about what they're passionate about, a book that they're writing, an artistic endeavor, it's a passion project. And so I've reconceptualized anger as it's the energy to overcome an obstacle, to move towards a goal. And so I agree with your conceptualization that we have this drive, right? Which I would say is aggressive, this aggressive drive, a drive that's maybe competitive. Maybe at its worst, it's envy to a place that it doesn't allow friendships.

• 1:01:09David Puder?

  Maybe at its best, it's a drive that allows people to accomplish worthy things that improve society, improves your family, improves yourself. So that's my first thought on what you said. The second thing is, when I think about, we've talked about BPD on prior episodes and we talked about some early studies by Chess, Thomas, Rutter, Earth, 1963. They did a study of 141 children that they followed. And it was this longitudinal study where they classified people as easy, slow to warm up and difficult. And 10% of the kids were difficult from a very young age.

• 1:01:50David Puder?

  And the difficult ones, they described as, quote, "often irregular in feeding and sleeping, are slow to accept new foods, take a long time to adjust to new routines or activities, and tend to cry a great deal." And they followed these children. And the difficult children accounted for the largest proportion of kids that had behavioral problems later on. And so it was Dr. Cummings, who has been on my podcast a number of times. He was emphasizing that a lot of the kids that potentially develop BPD have this kind of like temperamental sensitivity, higher aggressiveness, right?

• 1:02:33David Puder?

  And then if they don't go through traumas, maybe they don't develop BPD. But with the right, with the wrong environment, lack of empathy, lack of connectedness, maybe a disconnect between parenting styles, disconnect between personalities, maybe they develop something that looks more like BPD. Maybe they, you know, we know that. Attachment disorganization has something to do with it. The beta is pretty small. Emotional dysregulation in adolescents has much higher beta. So I'm kind of like agreeing with you and kind of adding on this layer. So coming back to like this idea of aggression and a positive sense of like personal responsibility.

• 1:03:17David Puder?

  Taking ownership is sometimes disavowed and someone ends up in this kind of like victim, hero, persecutor.

• 1:03:28Speaker 01

  Yeah.

• 1:03:29David Puder?

  The trauma therapy ends up in that place where the patient is always the victim. The therapist is always the hero. And the bad things in life is always the persecutor that happened earlier in life. And that's, it's a very seductive place to live. But it's also, it kind of leaves them in that illness narrative, which I think keeps them stuck.

• 1:03:54Speaker 01

  Yeah, there's so much going on. First of all, I really endorse this emphasis on micro expressions. That's when a lot of what is split off and not in awareness comes through in facial expressions, nonverbal communication. Second, that was Stella Chess's work you're referring to?

• 1:04:15David Puder?

  Yeah.

• 1:04:15Speaker 01

  Yeah, I haven't thought about that in ages. I'm very glad to hear you refer to that because it should be given more importance in the current days. Or maybe it's just me, but I haven't thought about that in a long time. But getting back to what you just said about therapist, hero, patient, victim, abuser, outside, that's where we sort of upset the apple cart, if you will. Because we don't accept this hero role in TFP. And this is where the role of therapeutic neutrality comes in. We're often criticized these days for what you call neutrality. Can I talk about that for a minute?

• 1:04:59David Puder?

  I noticed it in our back and forth. It's like you were not, it's like, it's like you weren't overly reassuring, right? And you were like curious.

• 1:05:10Speaker 01

  Yeah.

• 1:05:11David Puder?

  And I was almost about to like push you on it in the role play, but I decided not to shift gears and be like, I feel like you're really distant right now. You don't really care. It looks like you're almost bored.

• 1:05:20Speaker 01

  You could be quoting a session I had yesterday, but go ahead.

• 1:05:24David Puder?

  Ah, so, so go, go ahead.

• 1:05:28Speaker 01

  But that's the point. We stay neutral and that doesn't mean indifferent. We care a great deal about our patients. We are, we react emotionally to our patients. We tend to keep our emotional reactions inside and to reflect upon them. That gets to countertransference and how one can use that. But if you're not explicitly endorsing, and I'll use the word validating because that's so important in DBT, the patient, often you're considered suspicious or negative. And then you just don't get this hero treatment that you would get if you said, yeah, it must be terrible to have had that dad who was so awful.

• 1:06:12Speaker 01

  I mean, I wouldn't say, I wouldn't necessarily not say that. I mean, it was terrible to have that dad. But then I might say, but if we only talk about him in the past, I think we're missing something that goes on in your current life. And that's when you sort of stop from totally supporting a projective defense and you begin to be open to a deeper look inside. And that's when you're not the hero anymore because you're seeing something that connects with the patient's doubt about themselves. But they had doubts about themselves before they came into your office.

• 1:06:56Speaker 01

  They just want you to reassure them they shouldn't have any doubt. But instead of that, we're saying, what are your doubts about? What is there in you that you're concerned about? Maybe if we thought about it, you could sort of get to know yourself more fully.

• 1:07:14David Puder?

  Okay, so what if, what if like, um, okay, so like, what if I had said

• 1:07:20David Puder?

  to you in that role play, uh, Dr. Yobin, I feel like as you're responding to this to me, like, I sense there's so much dispassion and I would expect you to at least react a little bit to me saying that you were making fun of me. Like, it seems like you're just kind of apathetic to that accusation.

• 1:07:45Speaker 01

  Uh, um, again, I'm channeling a session from his, uh, I'm trying, it's a tough position because you're being, oh, I don't, let me, let's say.

• 1:07:59David Puder?

  Go ahead, go ahead.

• 1:07:59Speaker 01

  So, yeah, so essentially, you're experiencing me as a combination of indifferent and neglectful.

• 1:08:09David Puder?

  Yeah, it's like, for some reason, that feels more true than you being the abuser. You know, it feels like, it feels like you're, it's a form of abuse. To just neglect me and to be apathetic.

• 1:08:24Speaker 01

  So what you would like is for me to heartily endorse the position you're taking and just say, if we could just get you beyond what your parents did to you, you know, you'd sort of deal with life better, be able to have better relationships, feel better about yourself. Is that the model you have in mind?

• 1:08:53David Puder?

  It's like, it's like I'm talking to a door and like, I just want some, well, something other than this. I mean, it's just like, even, even the speed at which you said that, it's like lulling me into some sort of like hypnosis or something. I don't know if that's like part of what you're trying to do.

• 1:09:11Speaker 01

  Well, I don't mean to be sarcastic, but the kind of thing you're asking me for, you've had a number of times over kind of long periods of therapy. So first of all.

• 1:09:28David Puder?

  Yeah, and I know, and I know they're all, they were all like, I hate them all, you know, like, they're all, well, some of them had some decent parts, but most of them were like all, you know, just quacks, they were quacky.

• 1:09:42Speaker 01

  But let's get back to here.

• 1:09:43David Puder?

  Okay.

• 1:09:44Speaker 01

  You know, I'm speaking slowly, so I'm a robot without any feeling about you. And I'm just kind of, that reflects my lack of interest. Am I getting it right?

• 1:10:00David Puder?

  Yeah, uh, like, do you, I don't know, maybe, maybe I'm just one of a hundred patients of yours and you like, you know, it's just like, okay, here we go again, you know?

• 1:10:13Speaker 01

  That I get.

• 1:10:16David Puder?

  What do you mean you get? What do you mean? What does that mean? You get it?

• 1:10:20Speaker 01

  Now I get why it's so depressing, your life. I mean, I don't think I'd say-

• 1:10:27David Puder?

  Yeah, it's like you're the person who's supposed to care the most. And when I sense that you don't care at all, it's like, it's like a dagger into my heart.

• 1:10:35Speaker 01

  Well, I, I can understand if you feel that after coming here now for three months, twice a week, that I don't even see you, that you're, I kind of just have this boilerplate response to the person who came before you and the person who came after you. That would leave a person pretty sad and desperate. So there I do get it.

• 1:11:02David Puder?

  Yes.

• 1:11:04David Puder?

  Thank you for that. Yes, it leaves me sad. It leaves me desolate.

• 1:11:10David Puder?

  It leaves me feeling like, what, what the heck am I doing here?

• 1:11:14Speaker 01

  Yeah.

• 1:11:15David Puder?

  Like, did I choose wrongly? Am I crazy to think that you'll be able to help me?

• 1:11:19Speaker 01

  Well, that's the question. What are you doing here? Because, like I said before, um, in spite of all the dissatisfaction and, and I guess pain you're experiencing here, you keep coming. So I just wonder if there's something else going on.

• 1:11:39David Puder?

  Why? You're, you're the, you're the person who's supposed to tell me what I'm doing here. Not me. Like, I'm not the professional.

• 1:11:46Speaker 01

  I have a hypothesis. So my hypothesis is that in spite of all surface appearances-

• 1:11:58Speaker 01

  Our repeated meetings have activated some feelings in you, negative, positive, both. But we're seeing the negative ones. We're not really seeing a whole lot of the positive ones. And yet, you're coming here and continuing to do so. So just there's something positive, but it seems really scary to you.

• 1:12:19David Puder?

  I'm embarrassed about how honest this conversation is right now. Like, this is very uncomfortable for me. I usually am not this honest.

• 1:12:30Speaker 01

  Well, do you, would you agree with me that honesty might be useful and helpful in therapy? And what are you?

• 1:12:40David Puder?

  Yeah.

• 1:12:41Speaker 01

  What would you usually hide? I don't think what you would usually hide would be your criticism of me and your saying I'm a robot and don't care and mock you. I think what you might be hiding is that you kind of wish we had a good connection, but that's scary to think about.

• 1:13:04David Puder?

  It's scary to think that you don't care.

• 1:13:08Speaker 01

  Well, you see, that's what.

• 1:13:10David Puder?

  I desperately want to know that you care. Like, do you? Yeah.

• 1:13:17Speaker 01

  Yeah, but I don't think I could say anything that would convince you. I think we have to continue with what you're experiencing here. And what's noticeable, I think you could agree or disagree, is that you feel safer with the negative feelings than with the positive ones. And when you said you were being a little more honest here, I think it had to do with maybe communicating something positive. But that's like really going on thin ice for you because that's not your general experience in life.

• 1:13:50David Puder?

  I think if you were to give me a hug, I think that would convince me that you that you appreciated me.

• 1:13:56Speaker 01

  Well, I disagree. Because you've had that kind of therapy before. And I think to ask for that is to short circuit what you're feeling right now. To short circuit that tug of war in you right now. Can I trust him? I'd like to, but I can't trust him. He's gonna hurt me. I'd rather stick with the tug of war than try to put it to a premature close. And anyway. I'm gonna say, you know, that's just not something I think would be therapeutic, be helpful and could kind of complicate matters.

• 1:14:34David Puder?

  Okay. Okay, let's, uh, let's, let's debrief. Yeah, so, okay, so this is like something that you experience with patients. It's like this, the neutrality kind of can engender. So Nancy McWilliams talks about like it's the, the tetrad of the, the hero, the victim, the persecutor, and then she says the fourth, the, the uninterested observer, right, which the therapist can kind of get pulled into. So that's like another level of transference, right?

• 1:15:05Speaker 01

  Yeah. But the key is to being, maybe the word is too strong, but almost passionately interested in your patient, concentrating on them, devoting your attention to them. And even in spite of your feeling as a patient, that I speak slowly and without any affect, uh, over time, our belief is that that solid commitment to the patient is going to sink in at some level. But I also want to say, I don't want to portray this as simply a corrective emotional experience, but it's important to maintain that focus, that concentration and that

• 1:15:48Speaker 01

  commitment because patients push us out of that position. Patients provoke us by provoking counter-transference reactions where we can get angry at them, we can reject them, we can distance ourselves from them. It happens particularly with narcissistic patients. We haven't talked as much about narcissistic patients, but let's for a moment. Patients with classic borderline personality disorder have almost universally an insecure attachment style, as do patients with other severe personality disorders. But there are different subtypes of insecure attachment. And borderline patients, classic borderline patients,

• 1:16:33Speaker 01

  generally have what's called the preoccupied insecure, which is ruminating about the other person in the interaction. What is he thinking about me? How did he think about the last thing I said? Does he think I'm stupid? If the patient is worried about you and your responses, you have a ton of material to work with. So a classic narcissistic patient has an insecure dismissive form of attachment. You don't matter at all. I could care less about you. So what studies and clinical experience have shown is that when the therapist is subject to that dismissive attitude of the patient's,

• 1:17:15Speaker 01

  most often they mirror it and they back away and they become dismissive and devaluing themselves. That's why I say for you to maintain intense interest and commitment is not a given. A lot of therapists are derailed from that because of the countertransference reactions that are elicited in them from the patient.

• 1:17:41David Puder?

  Hmm, interesting. Okay. So yeah, somehow their detachment as a, as a sort of a mechanism of staying connectedness to mom, right? So it's like the classic picture is mom leaves the room, there's toys, they're distressed, but they're pretending as if they're playing happily with the toys. Mom's comes back and they don't even look at her, you know? But they really are in a distressed state. Their cortisol is high. So in a, that's more of that avoidant attachment style. So you're saying that that occurring in the room, when they are like that, somehow that, this is the way that I'm thinking of it. It's like our mirror neuron representation of that countertransference really wants to distance ourself

• 1:18:26David Puder?

  or become a little bit more disengaged.

• 1:18:29Speaker 01

  Yeah, right.

• 1:18:32Speaker 01

  So anyway, to get back to whether it's a corrective experience, emotional experience or not, your ability to stay committed, interested, and devoted to the patient in spite of all of the storminess and the kind of negative feelings that can arise, and sometimes wishes to distance herself, that in and of itself isn't enough to make the patient sort of reconsider if somebody might really care about them. Because if you take the guy who saw my tears as mockery, you have to do some interpretation before he can take in my commitment in him and interest in him. You have to help him see that he is putting in me

• 1:19:16Speaker 01

  something that exists within him. And like I said when we were doing or discussing the role play,

• 1:19:24Speaker 01

  the mocking person is part of his own mind towards himself that he exports to others. If we get him to see that it exists within himself, then maybe he will be less inclined to automatically see others as rejected and be able to take in their caring about him in a way he couldn't before.

• 1:19:46David Puder?

  Okay. How does the kind of the transference of omnipotent control

• 1:19:56David Puder?

  kind of fit into that? Like where their agenda setting, boundary testing?

• 1:20:01Speaker 01

  Yeah. I'm going to refer to your notes that you sent to me about Tapas. In a way that's totally understandable. You wanted to talk about different types of transferences, devaluing erotic, childlike, regressive, rejecting, and the controlling omnipotent. But the first thing I want to emphasize is that, given the internal fragmentation of the patient's mind,

• 1:20:31Speaker 01

  you can have rapid shifts from one transference to another. You were talking about that to some extent when you talked about going from idealization to devaluing. But you kind of talked about that as though it was like a once and for all shift. But depending on the circumstances, people can, not consciously, but just in effect, hop back and forth from one way of experiencing themselves in relation to you to another. And it can be a little bewildering until you have time to think and observe it. So. Given that understanding that transferences can shift a lot, and that's a lot of material for our reflection and engagement with the patient. The controlling or omnipotent transference makes perfect sense.

• 1:21:16Speaker 01

  It's a manifestation of the primitive defense mechanism of omnipotent control. The individual feels that usually through the way they verbally interact with the other, they have to control the interaction. Why does that make sense? If your mind is organized the way I described in the paranoid schizoid form, then by virtue of your projection of any aggressive stuff onto the other, others by definition aren't safe. They are either gonna disapprove of you, or abandon you, or criticize you, or hurt you. So as you get close to other people,

• 1:22:00Speaker 01

  what's the only reasonable thing to do? Control them. If in your gut you think they're a threat, you have to have control. How does this manifest in a psychotherapy session? Can I give you an example? Because it's take a few.

• 1:22:16David Puder?

  Yes, yes, please.

• 1:22:18Speaker 01

  So a patient started therapy, and she was such a classic example of seeing all the hostility outside of her. Everybody mistreated her, family, people she encountered, you know, the waitress at the restaurant, the checkout person. Everybody she felt was critical and disapproving and rejecting and mean to her. Anyway, so she starts therapy, and for session after session, she comes in and talks nonstop with kind of a pressured speech, which helped me understand why for many years she was diagnosed as bipolar.

• 1:22:58Speaker 01

  Pressured speech, you know, kind of a hypomanic style. Anyway, after the six or eight sessions of this, I did what is the main shift.

• 1:23:15Speaker 01

  If we're considering the difference between TFP and more classic therapies, perhaps in particular, classic psychoanalytic therapies. I shifted from following the content of what she was saying, because all the stories were the same. This person treated me badly, that person treated me badly. You shift from the content to the interaction. This is something that most therapists have a hard time doing, because you're taking the focus away from what they're saying to what's happening. And I said, can we think for a minute about what's going on between us? And she said, you're interrupting me. Yeah, I realize that, but I had something I felt might be useful to think about. She said, what's wrong with you? You told me at the beginning of therapy,

• 1:24:00Speaker 01

  I was supposed to just come here and say everything on my mind. That's what I'm doing, you're interrupting me. So I also said that, you know, sometimes I might have an idea to think about that I like to introduce. So, you know, that's kind of what I'm trying to do now. She, I, what's your stupid idea? She was very angry and devaluing. So this is where I'm going to say in like three minutes, what took 20 minutes to go over with her, because you have to be so tactful. This is where you begin to challenge the patient's defenses of projecting everything on the other. I said, you know, if we think back on all these sessions we had, could we agree that the kind of pattern is you come in and you talk

• 1:24:42Speaker 01

  and there's really kind of no room for me to participate? Or, you know, my job is to sit and listen and take in. What's wrong with that? That's what you told me to do. I said, well, as I said, nothing's wrong with it, but we might want to kind of understand something about it. And let's just start by describing what happens. Would you agree that, you know, your style of speech and talking, you know, without interruption? Let's just say maybe that has a little bit of a controlling quality to it. You have to be very tactful. I was kind of surprised because she said, well, maybe it is a little controlling, so what?

• 1:25:26Speaker 01

  So I said, well, you know, that's up to you. If you want to be controlling, you have every right to be controlling. But I think it might help to think about what motivates that and the impact it has on relations. And in a way that surprised me, she burst into tears. And she said, if I didn't control you, you'd leave me like everybody else does. Perfect example of what I was saying, omnipotent control. If the other is going to do something to you, you have to hold them in your grip. But ironically, it's the holding others in your grip that makes them run away from you.

• 1:26:09Speaker 01

  So that's an example of omnipotent control and how I might work with it with a patient.

• 1:26:16David Puder?

  Wow.

• 1:26:19David Puder?

  Oh, man, stirring up some stuff, yeah.

• 1:26:23Speaker 01

  But I mean, the main point is I had to do with therapists have a great deal of difficulty doing is to say, let's stop listening to what you're saying and let's look at what's going on here. For some reason, that makes therapists nervous. They don't think they have a right to do it. It made you nervous.

• 1:26:40David Puder?

  Oh, no, it's just, uh, it's, it's, uh,

• 1:26:46David Puder?

  there's something about, when I was a resident, I had a really good attending. He was like, you know, the more you tell me about this person, it's like she's talking at you, not with you. And so is that, that kind of like omnipotent control through the speech? Is that the?

• 1:27:03Speaker 01

  Yeah, and that's why, and here I have very strong feelings. That's why a lot of psychotherapy has a real bad name within the world of psychiatry and in the medical world. A lot of our colleagues say, oh, you know, psychiatry isn't really medicine, especially if you're doing psychotherapy. Well, that really annoys me. But when I get residents coming to me and saying, well, I inherited this case and she's been coming to the clinic for 20 years. And then the resident starts presenting. Material and all the patient does is what my patient was doing and she's been doing that for 20 years with one resident after another.

• 1:27:48Speaker 01

  That's a waste of a valuable medical resource. My psychiatry resident's time. He should just be a sympathetic listener. If that's what you want to give the patient, get her a social, you know, a reading group or something like that. But, um, you know, we are trained to help people, not just to absorb, I mean, not just be a sympathetic ear. We're too highly trained and too valuable resource. That resident should be saying, what is it you're doing here with me that we could understand might be related to the fact that you don't have a lot of other people you're close to in your life?

• 1:28:30David Puder?

  Hmm. That's good. Ben, I feel, I feel like I want to get to some other sort of other stuff to kind of, that might relate because I feel like erotic transference can sometimes have that flavor where it's like out of the fear they want to control. Interestingly, I've had, I've done, I've done episodes on transference here and I've had people reach out to me by email saying like, hey, I find myself in this situation. I'm a patient. I have this therapist who's, you know, 50 years older than me, but for whatever reason, like I feel like erotically charged towards them and how do I make sense of this?

• 1:29:11David Puder?

  Sometimes I'll say things like, well, maybe, you know, have you, have you told the therapist this, you know? Or like, um, but I'm curious how you have dealt with this over the years and I know it's like something people might have interest in hearing.

• 1:29:27Speaker 01

  Oh, sure. And it's also important because you have to distinguish between the erotic transference, which is based on loving the benevolations, and the eroticized transference, which has the look of an erotic transference, but that is perverse and destructive. We could talk about both. But basically, that patient you initially referenced, who says, you know, he's fifty years older than me, but I have these loving feelings and sexual feelings. How can I understand that? First off, she should mention it to the therapist. And generally, those feelings are based on what we'll just go back to again and again,

• 1:30:06Speaker 01

  which is an internal representation of an idealized object that doesn't exist in reality, but that the person is projecting onto you. So when a patient, just to give you an example, a patient of mine came in and said, you know, this is going to be our last session. Why? Because I have to confess, I'm in love with you and it's hopeless because you could never feel for me the way I feel for you. And it's embarrassing and it's humiliating. So one approach is to say, you know, I realize how uncomfortable this is, but the great thing about psychotherapy is we can talk about everything, understand things, help you move forward. Nothing's going to get acted upon.

• 1:30:49Speaker 01

  So I said, you know, I know how hard and awkward it is, but can you, you know, you've been coming here for a couple of years. But, um, you know, so I'm sure you have some sense of who I am. But on the other hand, you know, since I don't talk about myself, there are probably a lot of things you don't know. And I'd like to hear more about how you imagine me and how you see me. And she started describing somebody that was so perfect, so ideal, that even as she was listening to herself, she began to chuckle and say, I guess that kind of person couldn't really exist. So that's just a simple simplification, a sort of a reduced version of how one might deal with that.

• 1:31:31David Puder?

  I mean, part of me is like, well, maybe, maybe you are a great human. You know, here you've dedicated your life to helping people and you've written books to help other people learn how to help other people. So like, what's, what's reality, you know? Maybe you are this archetypal male, right?

• 1:31:54Speaker 01

  I think that's idealization.

• 1:31:58Speaker 01

  You know, I mean, obvious, I mean, why should I? I'm thinking about a supervision I did last week. Maybe I'm trying to put the focus off myself.

• 1:32:13Speaker 01

  The therapist, who's a really good therapist, was presenting a case. It had to do with the therapist being made to doubt themselves. But the reason that came to my mind is you're saying, yeah, I have written books and I have, you know, dedicated a lot of my life, certainly not all, to helping other people. But, you know, I have my flaws, I have my weaknesses, I have...

• 1:32:36David Puder?

  Then, then why don't you tell me some of them? I mean, it would be helpful for me as a patient to know your flaws. Why don't you tell me your flaws?

• 1:32:44Speaker 01

  I'm more interested in the fact that you can't imagine them. Because if I just give you a list of my flaws, you're going to go on with this idealization and find somebody else to pin it on. So I think we'd be better off looking at how you manage to blind yourself to anything that might be less than perfect about me and stay stuck in that perfect view. And we should also think about how important it is for you to do that, how much it means to you, how sad it would be to get beyond this idea, somebody could be the way you're imagining me.

• 1:33:20David Puder?

  I, I'm just convinced that if you don't tell me some of your imperfections, I'm, I'm just gonna inevitably not be able to unidealize you. So I think that the only way I can get to more balanced views is by you telling me the truth.

• 1:33:36Speaker 01

  Well, let's look at what's going on right now. Clearly, I'm not so perfect because you're having to increasingly control me to get what you want from me. So if you're putting such increasing demands on me, it sort of implies I'm not going to give you what you want. That in and of itself is a problem, isn't it?

• 1:34:01David Puder?

  But I think the very nature of the therapy relationship is you're not going to be able to give me what I want. It's gonna end sometime and our age discrepancy, at some point, you're gonna die before, you know, what if I need you 20 years from now, you know?

• 1:34:16Speaker 01

  All right, let's get back to here and now, not 20 years from now. You're saying to me, "Tell me an imperfection. If you don't tell me an imperfection, I'm gonna keep idealizing you."

• 1:34:29David Puder?

  Yeah.

• 1:34:30Speaker 01

  That's of interest to me, because if you have to control the other to feel okay in the relationship with them, including me, what does that mean about who the other really is? I guess you're thinking that I'm not so perfect because I'm not giving you what you want, never will, and that the only way for you to get it is to demand it and insist upon it. That doesn't seem like a very harmonious relationship.

• 1:35:00David Puder?

  Touche.

• 1:35:01Speaker 01

  Okay. Always have to stick with what's going on in here and now.

• 1:35:06David Puder?

  Oh, that's good. That's good. Because it's the, that omnipotent control transference there leaking back in, right?

• 1:35:14Speaker 01

  Yeah, anytime you have that controlling, it implies there's no trust of the other.

• 1:35:21Speaker 01

  But let me just think of one more thing. The funny thing about the erotic transference is it's harder for patients to work with than the paranoid transference or the negative transference. Paranoid, negative, sort of the same. So, the therapist comes into supervision, "You know, it's terrible. You know, my patient thinks I don't care about them and thinks I mock them and thinks I secretly, you know, don't like them and, you know, you have to keep in mind, this is a very simple concept, they're not talking about you, they're talking about what they're projecting on you. They're talking about an internal element of their mind that they're sticking onto you. It's not you." "Oh yeah, well, that's perfectly logical, because I'm a nice guy and I don't dislike my patients and want to get rid of them."

• 1:36:03Speaker 01

  Then the therapist, a year later, comes in and says, "This is terrible. My patient is saying she's in love with me," which we don't always get to, I'd say most cases don't get to, an explicitly erotic transference. But then the therapist says, "What do I do?" Now, you have to say, as I said to you, "Look at what they're projecting on you." This therapist thought it's totally unreasonable to think the patient sees them as a bad guy. The same therapist might think, oh, they're in love with me. That's kind of logical. I'm a nice guy.

• 1:36:37David Puder?

  Oh, man.

• 1:36:38Speaker 01

  Yeah, you have to get them to see that's not the real picture.

• 1:36:42David Puder?

  Yeah, yeah. I once had a supervisor who said, she was a, she was a patient at one point. And she said that her, she had some, you know, these kind of feelings towards her therapist. And the therapist turned to her and said, look, I could be a one eyed cyclops and you would have these feelings.

• 1:37:03Speaker 01

  That's interesting. I wouldn't say that. You know why?

• 1:37:07David Puder?

  Why?

• 1:37:09Speaker 01

  That's telling the patient, you're wrong to have these feelings.

• 1:37:13David Puder?

  I think it was more, I think the, the tone was more like, these feelings that you're having towards me are more to do to the process of what's occurring in therapy than the, um, the me as a person.

• 1:37:26Speaker 01

  I could see a moment for that, maybe, but I don't like.

• 1:37:32David Puder?

  Okay.

• 1:37:35Speaker 01

  Your perception of me is wrong because they're like going back to the guy, am I a friend or am I a foe? You want him to struggle with it internally. Instead of saying, your negative view of me isn't really connected to me. It's all projection. That's saying, you know, that's your problem.

• 1:37:57Speaker 01

  And the real problem is figuring out whether to believe in or not what you're projecting. And I don't want to short circuit that process by saying, you know, it's all you, you know, get over it. Problem's in you.

• 1:38:13David Puder?

  You want them to, to be more reflective.

• 1:38:16Speaker 01

  Yes.

• 1:38:16David Puder?

  You don't want to short, short, short, short circuit the reflectiveness of what's going on.

• 1:38:21Speaker 01

  You want to entertain the possibility that maybe you are an uncaring mechanical robot who treats all his patients the same way and has no feelings for any of them. To honor that projection, as I said right at the beginning, paradoxically is a way to increase the patient's nascent, sort of fledgling, little bit of trust in you. When you can say, you know, let's think about that. Let's reflect on what you're feeling. Let's not dismiss it a priori.

• 1:38:56David Puder?

  Okay.

• 1:38:58David Puder?

  So I think, I think there's a couple of questions we should definitely sort of hit real quick before we kind of wrap this thing up. One would be the frame.

• 1:39:08Speaker 01

  Yeah.

• 1:39:09David Puder?

  And I think a lot of the transference occurs in the frame. So I think we could probably devote two hours just to this. But attendance of therapy, reporting thoughts or feelings, the fee. How do you do, how do you do like contacts between sessions? Like what, what if?

• 1:39:27Speaker 01

  Can I go into an example of that?

• 1:39:29David Puder?

  Yeah, go ahead.

• 1:39:30Speaker 01

  Okay, because that's so important.

• 1:39:34Speaker 01

  Our position in TFP is that therapy takes place in the sessions and communication outside of the sessions is something we don't do, except for two reasons. One is practically is like rescheduling, or if you're having a true emergency. Now, we can go back to what a true emergency is, but anyway. Let me give you this example. A therapist comes into supervision, mid-career therapist, analytically trained, doing a kind of a typical psychodynamic therapy with a forty something year old woman who is depressed a lot of the time, not successful in her work and not successful in her love life, can't get an intimate relationship going.

• 1:40:18Speaker 01

  Anyway, in the course of the therapy, the lady starts sending emails to the therapist. It begins as a trickle, but it becomes a flood. So the therapist comes for TFP supervision and says, you know, what do I do? I don't know what to do with all these emails. He hadn't yet established the frame that you and I have been talking about, like limiting communication. So in the supervision, I said, well, I think you should say to the person, you're gonna... Recommend some modification in the form of therapy you're gonna do, you're gonna make it more structured, you think that would have, you're gonna explain to her, you think that would have more benefit?

• 1:41:01Speaker 01

  And part of the increased structure would be that these communications between sessions stop, and as I said, you know, only occur under two circumstances. So that evoked, and by the way, if you want to evoke transference, just stick to your frame of treatment. All my supervisees say, "All your patients have strong transferences too." My patients just talk about all kinds of other stuff in their lives. They don't have transferences. You want transference, go back to the frame. Be careful about the frame. So anyway, the therapist says to this lady, "Yeah, okay, so this, you know, revision in our model of treatment is that, you know, we don't have all those email contacts." And that evoked, "What? You're abandoning me?

• 1:41:45Speaker 01

  You don't care about me?" And this allowed the therapist to analyze what was central to their interaction and to her pathology. She was finding in him, through her behavior, that I can send an endless number of emails to my therapist, and the godlike, perfect-giver therapist will accept them and take them in and maybe respond to them. That was the enactment of an unrealistic internal image of the perfect provider. Why was her life a failure? Because she was going through life expecting to find a boyfriend who would be that perfectly giving. Why was she a failure at work?

• 1:42:30Speaker 01

  She expected herself to be perfect in ways that were not realistic. She was always critical of herself. So when the therapist said, you know, "We can't..."

• 1:42:42Speaker 01

  You know, continue with all these emails. That brought to the forefront what had been enacted, which was pur wish for somebody perfect. And what needed to be analyzed was the fact that this wasn't going to happen. And the way they were doing therapy was perpetuating an illusion rather than looking at it and understanding it and moving beyond it.

• 1:43:04David Puder?

  Hmm. Okay. That's good.

• 1:43:08Speaker 01

  Yeah.

• 1:43:08David Puder?

  That's good. Okay, let's, um, I, I, I'm not going to say too much on that. I just want to kind of, as we're kind of wrapping up our time.

• 1:43:16Speaker 01

  Yeah.

• 1:43:17David Puder?

  I want, and, and I really appreciate it. And I'm, there's a lot of things here that I think is going to be of, of great value to, to my audience. And thank you so much for your time and, and thoughtfulness and everything. But I, I wanted to see if there's anything else that kind of like, is on your mind that's, you feel like you just want to definitely talk about it. And then, yeah, is there anything else there?

• 1:43:40Speaker 01

  The one thing I don't think we've talked about enough, or one of a number, but the main thing is the difference between a classic narcissistic personality disorder patient and a classic borderline personality disorder patient. I referred to this a little bit when I talked about the difference in attachment style, the borderline preoccupied versus the narcissistic dismissive. But if we look at the internal structure of the narcissistic patient, at the core, we find the same identity diffusion, the same kind of stew of unintegrated representations of self and other, you know, idealization, devaluing, feeling good, feeling bad, having

• 1:44:23Speaker 01

  dependency wishes, rejecting them, having fears, having desires. All that turmoil of unintegrated affects exists in the narcissistic patient. But The narcissistic patient unconsciously in their mind create a structure that seals over and hides or prevents access to that inner turmoil. We call that structure the pathological grandiose self. It's a self story, a narrative of the self that provides a sense of unity and integration of the self, but it doesn't correspond to reality.

• 1:45:07Speaker 01

  It reassures the patient that they're okay, but it doesn't hold water. Simple example, the failure to launch young adult. The guy who finished college because of his own self criticisms and insecurities can't get involved in any kind of work. So he kind of retreats to the basement or the attic of the parents' home and says, I'm writing a novel. So what sustains his self esteem? I'm a novelist. I am writing a novel, so that's my purpose. That's my, what defines me. But years can go by and nothing much happens.

• 1:45:49Speaker 01

  And they're falling far behind the curve. They hold on to their identity as the undiscovered novelist for dear life. And when they come into therapy, you have to help them move beyond their grandiose narrative and get in touch with all the painful longings and insecurities that they have, that they're defending against by this narrative that seems to reassure them, but doesn't have grounding in reality. It's harder to work with narcissistic patients than with borderline patients.

• 1:46:28David Puder?

  One of the things that the mentalization people said that really kind of like was like an aha moment for me. And I think you just reset it in a different way. But it was like people with BPD, they crumble when there's an attachment injury. Boyfriend breaks up with them, they get suicidal. NPD, they crumble when there's a self image injury.

• 1:46:54David Puder?

  Lose a job, wake up to the reality that no one will read their novel.

• 1:47:00David Puder?

  You know, like the incongruencies. That's kind of what you're saying and or would you put some?

• 1:47:06Speaker 01

  That's an interesting, I hadn't thought of it exactly that way. I think that's makes sense.

• 1:47:13Speaker 01

  But in that formulation, what I don't find is what in our model we see as the protective, pathologically protective of the narcissistic narrative, because the way you just formulated it, the borderline patient is going to get in touch with all their anxiety and distress when there's a relationship failure. And the narcissistic patient will get in touch with it when there's a kind of a functioning or performance failure. But in our experience, the narcissistic patient, the very ill ones, managed to avoid those moments of crisis by an entrenchment

• 1:47:57Speaker 01

  in an error that can go on unabated for years. And so it's not as easy to access their distress.

• 1:48:05David Puder?

  Hmm. Okay. Because the in the midst of the losing of the job, the narrative psychologically stabilizes them.

• 1:48:16Speaker 01

  Well, you know,

• 1:48:16David Puder?

  To some degree.

• 1:48:17Speaker 01

  Yeah, but first of all, if it's the kind of narcissistic patient I usually do, they don't have the job to begin with. But so they lose their job. And instead of saying, I'll give you an example.

• 1:48:31Speaker 01

  You know, I guess there's something wrong with the way I performed there. It's like, you know why they fired me? Because I'm the only person there who is truly honest. They all would compromise. I would never make compromises. That's the only reason that firm makes any money. All the other people there would look the other way when something wasn't done right. I don't have that, you know, I'm above that. So sure, they didn't like me. They didn't like me because of my level of honesty, not because there's anything wrong with them. The problem is with them and their lack of honesty and their compromising nature. So you see how the narrative, the narcissistic grandiose narrative repairs the injury instead of opening it up.

• 1:49:15David Puder?

  Yeah, yeah, that's really good. But it's still that like borderline level of functioning with the splitting, the good-bad split with the identity diffusion.

• 1:49:27Speaker 01

  When you help the person see beyond their grandiose narrative, when this lady began to see, maybe it's not so simple that she's just morally superior to everybody else in the world. She begins to get in touch with longings to connect to other people, wishes for dependency that she's never been able to act on because she's too afraid of getting rejected. And the mid-phase of working with narcissistic patients is extremely painful and distressing to them. And you have to overtly empathize with that and say, you know, you're getting in touch with stuff now that's making you feel worse than when you began the therapy. I'm sorry about that, but I don't know any other way to really get better, except

• 1:50:12Speaker 01

  to get in touch with all this stuff that I think was there from the beginning, but that you were fending off.

• 1:50:18David Puder?

  I really appreciate your time. I know we're wrapping it up here. If someone was listening to this and they were like, you know, I really want to do a training in that, like, you know, what is the pathway to become someone who's a certified transference-focused therapist?

• 1:50:36Speaker 01

  Well, I hope people might want to do that. I do find it a helpful form of therapy for many people and an interesting way to do our work. So I would direct the person to two organizations. One is a group called TFP New York. You can just Google that group and we can direct people towards trainings. And the other one is the International Society for Transference-Focused Psychotherapy. The website there is ISTFP.org. And on that website, there's also a lot of information about trainings. But we're very eager to train people. We enjoy it and we find the people who come for training usually find it rewarding.

• 1:51:19Speaker 01

  So I hope, and maybe you could post those websites.

• 1:51:23David Puder?

  Okay, that's good. And then I think, I think we should just say this for the record, because you're going to have a lot of people who reach out to you who want you to be their therapist. Do you have openings at this point? Or if, if a patient was listening to this, they were like, I need this type of therapy, where do they go?

• 1:51:38Speaker 01

  Yeah. First of all, I don't have any openings. And at this stage of my career, I'm devoting myself more to teaching and supervision. And to practice, so I'm sorry I don't have any openings. But I would go for referrals to the TFP New York website or to something I mentioned to you, David. It's a wonderful organization, part of the Department of Psychiatry here at Weill Cornell Medical Center, called the Borderline Personality Disorder Resource Center. Website is bpdresourcecenter.org. And over the years, we have established a database of clinicians, not only in this

• 1:52:19Speaker 01

  country, but in many other countries, who are trained to treat borderline personality disorder. Because even with all the advances that have been made over the last decades in understanding BPD, how to treat it, and teaching more and more therapists about it, there is not an adequate number of therapists for this patient population. So if you're looking for a referral, go to bpdresourcecenter.org, or if you're looking specifically for TFP, you could go to TFP New York.

• 1:52:52David Puder?

  Awesome. Thank you so much. Appreciate you. Love to have you back on.

• 1:52:57Speaker 01

  Well, I have a feeling that could happen because you make the two hours go by very quickly with interesting questions and comments you add, so thank you.

• 1:53:04David Puder?

  All right. Well, thank you so much for your time.

• 1:53:06Speaker 01

  You're welcome. Bye-bye now.