Pod Insights Psychiatry & Psychotherapy Podcast Nancy McWilliams on Shame, Transference, Personality Disorders & Becoming a Better Therapist About this episode In this in-depth interview, Dr. David Puder welcomes renowned psychoanalyst and author Dr. Nancy McWilliams to discuss essential clinical topics from her seminal books Psychoanalytic Diagnosis and Psychoanalytic Psychotherapy. Dr. McWilliams shares practical wisdom on working with shame in therapy by emphasizing self-acceptance over mere self-knowledge, along with powerful insights into transference, countertransference, and projective identification. The conversation explores how different therapist personality styles influence clinical work, strengths, and vulnerabilities. Additional highlights include building love and trust in the therapeutic relationship, protecting the therapeutic frame, setting early boundaries, and real-world guidance on handling stalking and boundary violations.
By listening to this episode, you can earn 1.5 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program
Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-273-nancy-mcwilliams-on-shame-transference-personality-disorders-amp-becoming-a-better-therapist
Link to YouTube video https://youtu.be/-wvPUZeK-jQ
Transcript 14,105 words · 7 speakers
Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.
0:13 David Puder? Welcome back to the Psychiatry and Psychotherapy Podcast. I'm your host, Dr. David Pugh. Today, I am happy to announce that I have Nancy McWilliams back for a second time. She authored several of my favorite books, Psychoanalytic Diagnosis, Psychoanalytic Psychotherapy, and, most recently, Psychodynamic Diagnostic Manual, Third Edition. We originally recorded this as part of the psychotherapy cohort that I lead every year. This year, Dr. Reger and Dr. Stokes also led cohorts, and they were a part of this interview as well. None of the contributors have any conflicts of interest to report for continued medical
0:54 David Puder? education that is apprehended through my website, psychiatrypodcast.com. In this episode with Dr. Nancy McWilliams, we covered things like shame, personality styles, and countertransference, like how different personality types, schizoid, depressive, hysterical, narcissistic, how they uniquely have countertransference with patients. We talked about projective identification and how to handle intense, sometimes overwhelming, countertransference. We also talked about stalking and about boundary violations and how to maintain a therapeutic frame.
1:35 David Puder? So let's get into the conversation with Nancy McWilliams. So we've been going through your book, Psychoanalytic Psychotherapy, and then Psychoanalytic Diagnosis will be like the second half. So people are pretty familiar with you and your thoughts, and we have some kind of general questions. We'll start, and then I think we'll have time for people to ask, jump in and ask questions as well.
2:09 Speaker 01 Okay, that sounds easy. I don't have to prep.
2:12 David Puder? No prep. Ali, do you want to jump in and ask the shame question?
2:19 Speaker 02 Sure. There's so many places to begin, but I think with the with the chapter that we read most recently and what we've been talking about a lot is, you know, there's a there's a quote that really stood out. The idea that self-knowledge is one goal of psychoanalytic treatment, but a more profound goal is self-acceptance. And how challenging this is when a patient, you know, is deeply ashamed. I mean, of course, we all have parts we're ashamed of, but but particularly a patient that is is driven
3:01 Speaker 02 by so much shame. And how there's a this is a multi-part question, and we can take it in any direction you see fit. And so I'll say it, and then we can we can take it from there. How do you help patients talk about shameful aspects of themselves? And how does exploring and sharing the shameful parts lead to a positive outcome? Particularly, how do you do this when a patient does not believe there can be any acceptance of the shameful parts? Like, it's really disbelieving of that. And maybe
3:43 Speaker 02 provide an example of how you frame this this rationale to a patient who who doesn't buy in or can't can't fathom ever, you know, really talking about it or accepting it?
3:55 Speaker 01 Well, you know, I suspect I'm going to say this in response to a lot of the questions today. It often depends on your knowledge of the individual patient, and I would probably do it differently from one patient to another. But to try to generalize.
4:16 Speaker 01 I do several things. One is that I sometimes say very explicitly, you know, "In one way, I'm an old-fashioned Freudian. I think this process doesn't work unless you're trying to say everything, even if it's socially inappropriate, even if it's hostile, even if it's critical of me, even if it's something you're ashamed of. If you find it hard to say something, you don't have to push yourself to say it, but you could at least flag it to me that you're having trouble bringing something up and we can look at why." And that often gives an opportunity to go into who shamed them?
4:58 Speaker 01 How did they learn that this idea was shameful? Some patients need you to explicitly make a distinction between feelings and impulses on the one hand and actions on the other. If they were brought up by parents that shamed them for feelings, or even in a religious community that said they were good thoughts and bad or impure thoughts, I will sort of take that on directly and say, "That's not my understanding of what you should judge yourself for, because everybody's got very bad thoughts. The question is whether you
5:39 Speaker 01 act on them." If you're trying to cleanse yourself of bad thoughts, you are in for a lifetime of disappointment in yourself, because we are mammals, we have aggression, we even have sadism, we have all kinds of very unpleasant aspects of ourselves: envy, resentment, disgust, contempt. Those are normal feelings. And it sounds like something in your background made you feel like it wasn't. Okay to have those. I don't mean to enact them and to treat people with hostility,
6:19 Speaker 01 but even to have hostility. So I sometimes do a certain amount of that to try to, to really reframe how they're thinking about whatever part of themselves is so shameful in their mind. But I also will use humor sometimes, or just, I haven't seen much positive come from simply trying to tell somebody that they shouldn't be ashamed, you know, that, that really constantly talking about how, well, everybody isn't that normal, everybody has that. I might say that kind of in passing, but I, I find that reassurance never works.
7:00 Speaker 01 And instead, I'll attack the self-shaming part of them. Like, where did you get the idea that you're uniquely bad somehow? What makes you so much worse than all the rest of us? You know? Because they can take that in. Oddly enough, when you attack the self-attacking part, they kind of feel they can listen to that because they, they get that you're attacking something about them and they feel they deserve that. But you're attacking their self-attack. So I do a fair amount of that. Oh, I forgot, you're too shameful to even join the human
7:43 Speaker 01 race, you know? One of these days, you might want to rethink that. That kind of thing often moves it along. Just naming it helps. Sometimes, am I picking up that you're ashamed of what you're telling me? Sometimes people tell you behaviors that they've done that they should be ashamed of. I mean, shame, shame is not entirely a crazy emotion. It's one of the ways that tribal cultures and larger cultures help people not to act out destructive parts of themselves. They, they shame them for behaving in certain ways.
8:24 Speaker 01 They can over-shame them and that's a problem, but you don't want a shameless culture. You don't want people to behave shamelessly. So.
8:34 Speaker 01 Sometimes I differentiate between, well, it seems to me that, you know, that it's reasonable to feel ashamed of your doing that, although I hope over time you can forgive yourself for that because you're not the first person who's done that, as you well know. Shame is harder, actually, to get rid of than guilt. Because with guilt, you can, guilt is very difficult for other reasons, but with guilt, you can, um, you can do something to compensate. You can apologize, you know, but since shame involves being seen in all your ugliness, you just wanna crawl into a hole in the ground. It's not something you wanna call attention to and try to undo.
9:20 Speaker 01 It's like, oh, God, the ugliness of who I am has been on display for everybody to see. So it's a, it's a particularly toxic affect. And sometimes people don't even want to name it because they can't bear to feel that exposed. There are some patients, especially people in the psychotic range, where I am more self-disclosing, more conversational. And I will say, you know, something that I think they're ashamed, for example, an example would be, um, one of my patients who was very paranoid and which, you know, had been
10:05 Speaker 01 humiliated about all kinds of things in his life. He confessed to me in a shamefaced way that he had struggled with irritable bowel syndrome. And I said to him, oh, that's such a difficult thing. I, I had a long siege of that when I was in my twenties. Unfortunately, it was one of the things that my analysis changed. And he said, you admit that you had that? That's such an ugly condition. And I said, yeah, but a lot of people have it. You know, and to, to just acknowledge something that is, um, without the shame that I think the patient is ashamed about, like, yeah, I see we have a, I see we have a break coming up.
10:49 Speaker 01 And, uh, actually, I hate separation, so I always get anxious around separation. So we'll, we'll have to pay some attention to that.
11:01 Speaker 01 Just to model that stuff that somebody else might feel ashamed of is all in the human condition helps people. But ultimately, I think that that any kind of therapy, and perhaps especially psychodynamic therapy, is it's exposure therapy. It really is exposure on a grand scale. The person tries really hard to tell you everything and finds themselves with all kinds of feelings about that, and you you accept them. You don't
11:42 Speaker 01 make a big deal out of, well, you know, that's okay, don't you? You just say, yeah. So you wanted to kill so and so. Can understand why. And try to make it just a natural thing. But I don't think people are surprised when therapists are nice to them if they've seen mostly cooperative, pleasant parts of the person. But they're very moved when they've shown you their ugliest parts, including their hostile parts toward you, and you're still welcoming them. That actually makes a difference. Does that cover the general territory of?
12:25 Speaker 02 Absolutely. Yeah. Yes.
12:29 David Puder? I think with that, I was thinking about a type of transference I've seen lately where it's like they can almost fragilize the therapist and imagine that they would really hurt the therapist's feelings if they said something mean or if it was a negative transference. How do you, how does that relate? Or how do you sort of address that or notice it maybe even?
12:54 Speaker 01 Sometimes I don't see it. It's one of those transferences that actually makes me angry. Because in my personality, I'm invested in, "Bring it on." I can tolerate it. And if you're trying to be nice to me because I would fall apart, I feel insulted. You know? I remember, um, once, years ago, one of my patients, she was in analysis with me. And she was, um, there was a book party for me when one of my books came out.
13:31 Speaker 01 And, um, I think it was a book party, but at any rate, she wasn't on the list of invitees because she was in treatment with me, but she heard about it. But she didn't know whether it was a surprise event for me or not. And she didn't ask anybody. But she got it in her head, and this fit with her transference toward me as somebody that, like her depressive mother, she had to take care of. She began, you know, seeming very blocked in treatment. And I'm, you know, turning myself into a pretzel, trying to figure out what's going on. She's not talking about this. She was hurt that she wasn't invited.
14:16 Speaker 01 She was envious of the people who were invited. And she didn't want to talk about it because maybe it was a surprise and she'd be blowing the surprise. And when I found out, which I finally said to her, "I give up. There's something that's bothering you, and I don't know what it is. What is going on?" And she finally confessed. And it was a very interesting enactment because she could have asked somebody, "Is this a surprise party for Nancy?" She kind of... Grabbed on to the opportunity to feel like she was taking care of me because that was familiar to her. She knew how to relate to a mother figure that way. But my irritation
14:59 Speaker 01 with her was quite obvious to her when she finally confessed what would have been going on. Because I, I felt you've been making me work like a dog to try to figure out what's going on. You haven't been, you know, following the basic rule of just free associating and talking about everything. I've sometimes had a patient tell me, oh, I want to talk about this novel I've read. Have you read it? And if I say no, oh, then I don't want to spoil it for you. And that irritates me. Listen, I'm, I'm your analyst. You're supposed to talk about everything. I don't, I'm not, so, so you spoil it for me. Big deal. That's not as important to me as that you keep talking about the things you're interested
15:40 Speaker 01 in. So I, I think I have a particularly reactive countertransference when people are taking care of me. When my husband died about 20 years ago, it was, the news went around my grapevine with like a flash. And I called everybody the day after he died and said I was, you know, I'd had a death in the family and I was going to take three weeks off and then we would resume in such, such a time. And I had a lot of patients who would come in and they'd go, oh, how can I talk to you about my trifling problems when you're
16:20 Speaker 01 going through this bereavement? And I, I pretty much had to say to them, listen, I, I really appreciate that you want to take care of me at a bad time for me. But if you really want to take care of me, let me do my job. Yeah. So I, I, I, I react badly to, to patients who think I'm fragile and they have to leave certain things about themselves undisclosed with the rationalization that I couldn't bear them.
16:52 Speaker 03 And I'm curious, you know, what is it about maybe you as an individual that has that countertransference response? Is it, is it something that's happening situationally in your life or is it more of a personality, your personality style?
17:07 Speaker 01 No, it's a personality thing. I lost my mother when I was nine and when latency age kids lose a parent, their role in the family tends to, I mean, teenagers will act out, younger kids will regress. Latency age kids will tend to try to show, I'm okay. Who, who needs a mother? I'm going to be self-reliant. And I was actually, when my mother was dying, I, I was told, you're, your mother is dying. You're going to have to be more self-reliant than a lot of kids your age are. And it's not going to be easy, but we trust you to do that.
17:47 Speaker 01 So that became part of my self-esteem, that I'm tough. You don't have to take care of me. So my, my poor husband, my, my current husband complains about this a lot because he will do something for me and I'll say, did I ask you to do? Is it because, because I immediately think, he thinks I need that rather than, I've gotten better over time. But he's also gotten good at saying, I have an idea that I think might be helpful for you. Do you want to hear it?
18:24 David Puder? So, so every like four months, right? Email you and ask you to come back on the podcast, you're not offended by that, by that continual?
18:33 David Puder? Question.
18:34 Speaker 01 No, I'm flattered by it. But if you said, oh, Nancy, I know you're so busy, but you know, could you possibly, I'd rather you be very direct and say, we'd love to have you on the podcast again. Here's what I have in mind, and I can either tell you whether I can or I can't do it.
18:52 Speaker 01 There's some way in which, for me, as a person who was an ambitious female, really before the feminist movement appeared in the 1970s, there's some way in which I'm,
19:09 Speaker 01 I easily feel that especially men are telling me, they're there. Don't bother your little head with this, because in the 50s, that was the way men actually behaved toward women.
19:24 Speaker 02 So, you know, speaking to like your ability to sort of rely on your own, you know, self-knowledge of your personality, but your counter-transference to to sort of pick up on what might be going on based on your personality. I wonder, can you speak to sort of like strengths and vulnerabilities of different personalities of therapists?
19:51 Speaker 01 Yeah.
19:53 David Puder? Shall we start with one in particular, maybe?
19:55 Speaker 01 Sure. What would you like to start with, David?
19:59 David Puder? Maybe Schizoid?
20:02 Speaker 01 All right. Schizoid people tend to be quite good therapists, or at least good at psychodynamic therapy. They're extremely sensitive people. And if your main defense is withdrawal into your mind, or maybe withdrawal into a fantasy world, you don't have to distort. So schizoid people don't tend to use defenses like repression, reaction formation, the more distorting defenses. They see a lot of stuff that other people are defended against. So they naturally get the unconscious. Psychoanalytic therapy makes sense to them.
20:46 Speaker 01 And they have a conflict about closeness and distance, how close to get to other people. They often appear to be very distanced and aloof, but if you get to know them, there's a longing for closeness that coexists with that. And being a therapist is a nice resolution of that conflict because you get closer to your patients than anybody's ever been. And yet, you don't have to take your hair down all the time. And you're protected by the fact that the session ends. There are very clear boundaries. And so you get a lot of your needs for intimacy met without the feeling of risk that goes
21:29 Speaker 01 with most social situations where you get easily overstimulated and impinged on. So there are a lot of people with schizoid psychologies in psychoanalytic work. I think Winnicott had this psychology. He's always described as shy and quirky and not very sexual. Even his concepts, like the third or the space, transitional space, going on being. Impingement is something that he emphasized a lot, which is a very schizoid kind of experience
22:10 Speaker 01 of often a depressed parent who's impinging on you, too overstimulating. So the downside of being a schizoid person and a therapist would be sometimes you can get overstimulated. And you need time to refuel. Often, my schizoid colleagues tell me that at the end of the day, they want an hour to themselves. They don't want to see anybody. They don't want to have to talk to anybody.
22:44 Speaker 01 People with my psychology, which is more hysterical, are also extremely sensitive people. And I think we're good in the role if we can get past some of the hysterical defenses, like a kind of performative style. And as you, I've already said here, we are reactive to gender issues. And we have to keep paying attention to that. But those two psychologies are very tuned in kinds of psychologies to other people, even though they look very different. Depressive psychologies are the most common psychologies for therapists to have.
23:29 Speaker 01 At least that's what a study in Australia found out. And that's been my experience of, I have a big streak of that. And most of my colleagues, I would say, are pretty depressively organized, meaning that they tend to be self-critical. They use interjection rather than projection. If somebody criticizes them, their first assumption is, oh, there must be something right about that. They don't tend to do the paranoid thing, well, that's your fault, you know. They, if their patients get better, they credit their patients' hard work. If their patients don't get better, it's their fault. And they like being close to people.
24:11 Speaker 01 They, they feel, it's a very attached kind of psychology with sensitivity to attachment and separation, sensitivity to other people's pain, and a feeling of some pleasure when they relieve pain. They tend to be people who are trying to help the depressed part of themselves by helping the depressed other, even though you can have a depressive psychology. And I've never had a clinical depression. Narcissistic therapists have to work harder, I think, to try to really get inside their patients' experience.
24:56 Speaker 01 But they can be, they can be quite good therapists over time. Sometimes their perfectionism works on their behalf.
25:06 Speaker 01 I guess one of their vulnerabilities would be a vulnerability to thinking when people have an idealizing transference toward them that they are enjoying it too much, you know, that this is, this is how they should be treated. So it's harder for them to find the devaluing side of the patient's feelings. Psychopathic people should not be therapists because they don't see others as subjects, they see them as objects to manipulate. There have been only a few psychopathic therapists that I know about in psychoanalysis, at least, you know, from my inferences about what their psychology was. Interestingly,
25:50 Speaker 01 Ernest Jones was pretty psychopathic. He was, he was very close to Freud, but Freud privately called him "the liar from Wales" because he was such a moron. Masochism is, in one way, it's a plus if you have a kind of masochistic tendency because you will roll with a lot of stuff. But where you run into trouble as a therapist is setting limits on people and modeling not being masochistic, because it's not really helpful for masochistic patients if you're being self-sacrificing and being more and more giving with the idea that at some point they'll see how good you are and they'll be able to take in that
26:35 Speaker 01 you're better than the people that have persecuted them in their life. And that's, that's always a loser. It's much better, for example, if your patient runs into trouble with money, to say, "I can really understand why you would want a lower fee, but I've gone as low as I can go with my fee. That's how I make my living," and let them get angry at you. That's much more therapeutic than saying, "Oh, you poor thing, I'll reduce my fee," and then you end up resentful, especially when they drive up in a BMW after you do that, or when you can see that you're reinforcing their masochistic pattern. What they learn is, you know, the worse off I am, the more I'm going to get stuff from
27:20 Speaker 01 other people, and you don't want to set that tone. Paranoid people, I haven't known too many therapists who are essentially paranoid. Edgar Levinson used to say that he felt he was essentially more paranoid. He was a very big influence to the interpersonal tradition in psychoanalysis. But usually, if people feel they're paranoid, they don't announce it. But paranoid people, even though they suffer a lot internally, they are also very sensitive. The risk they take is that sometimes what they think is understanding a patient is
27:59 Speaker 01 projection of what it would mean if that were them saying the same thing. Who am I leaving out?
28:09 Speaker 02 Obsessive?
28:11 David Puder? Hypomanic dissociation.
28:14 Speaker 01 Okay, and obsessive.
28:16 David Puder? Obsessive.
28:18 Speaker 01 Obsessive people can be very good therapists because they have such integrity. I mean, they're trying very hard to be the best kind of therapist they can be. That's important to their self-esteem. But they do tend to join the patient in intellectualizing. So I periodically have to talk back to my own obsessive side when I'm explaining something rather than exploring something. Hypomanic, the only person I know who's a therapist who's called himself hypomanic, actually, he called himself hypomanic with obsessional defenses, is Sama Noctar.
29:03 Speaker 01 And I think he's quite a good therapist, but I think he also probably overextends himself easily. I don't know too many examples of that, though. Usually, hypomanic people have trouble with the sustained relatedness that is required for psychotherapy. It wouldn't be their first choice of profession. And it does involve using a lot of denial, and if you're using denial, you've got an additional obstacle to understanding people. If you're brilliant, like Sama, and that doesn't get in the way.
29:47 Speaker 01 But for most of us, it would get in the way.
29:51 Speaker 01 Dissociative? There are a lot of dissociative therapists. A lot of therapists are trauma victims. And they, they get easily triggered. And I think the important thing for them is to try to figure out what triggers them and not work with patients like that. So if, for example, you have a sexual abuse history, you don't want to try to treat pedophiles. You may have to during your training, but once you have control over who you see, you, you just don't want to re-traumatize yourself. It's hard enough being a therapist. But they certainly have a feeling for how trauma can take you over.
30:33 Speaker 01 Some of the best people in the movement to try to understand dissociative patients have significant trauma in their own background. And that was what partly made it possible for them to see this group of people that the rest of us weren't seeing yet. I'm thinking of people like, I don't know his personal history, but I would say Richard Cluft, Cornelia Wilbur, Frank Putnam, Ira Brenner, Christine Courtois, a lot of people in the, that originally put dissociation on the map in the 1980s were people who knew something about it.
31:12 Speaker 01 Judith Herman, I think, was not traumatized herself, but she identified, it was important to get women talking about this. In the 80s, we saw this perfect storm of the feminist movement where we were listening to women's experience. The Vietnam vets were starting to talk about their trauma finally 20 years after it happened. And people began realizing how much trauma there was out there. But Judith Herman's book was a groundbreaker where she basically said, suffering sexual
31:52 Speaker 01 abuse is, does the same thing to your psychology that combat trauma does. And it's a, it's a, Jennifer Freed later called it betrayal trauma.
32:05 Speaker 01 So she's, she's the one that reframed it. I remember a time when people would talk about incest as if it were like this forbidden satisfaction of some edible desire, rather than the drastic exploitation of a child's helpless dependency by a predatory or clueless parent.
32:28 Speaker 02 How do you, and we don't necessarily have to ju- jump here, but how, how do you work with, you know, a really, someone who really uses dissociation as a defense? Or has like a dissociative transference?
32:45 Speaker 01 I don't know if there's such a thing as a dissociative transference exactly. I think in different self-states.
32:53 David Puder? Let me describe the dissociative transference as kind of like what we're thinking, because we've talked about this.
32:58 Speaker 01 Okay.
32:58 David Puder? Prior as a question. It's like when you may be making an interpretation or something towards them, it's like they space out during that.
33:08 Speaker 01 Oh, okay.
33:09 David Puder? So it's like, it's like their brain doesn't even register what you, the therapist, said maybe during something, you know?
33:18 Speaker 01 Yeah. Well, that does happen a lot when you're working with dissociative patients, and I will just try to name it. Are you still here?
33:28 Speaker 01 I feel like you zoned out. Did I go somewhere that you're not ready to hear?
33:34 Speaker 01 And I do a lot of basic grounding. Can, can you, you, you look like you've, you've gone into another place. If they're outright D I D, I say, am I talking to somebody other than who I was talking to before? And sometimes they'll say, yeah, why are you trying to help her? She doesn't deserve it. You know, you've got this split going on. And.
34:02 Speaker 01 The literature on working with dissociative patients is pretty clear. You always act as if all of the parts of the person are in the room. And they are all hearing you, whether or not they're identifying as the person talking to you at the moment. So, for example, when a hostile alter personality emerges, they're often angry and even a little threatening. Listen, I know you are trying to help Marie. And I don't, I think she's scared of you, but I understand you're trying to help her and you're afraid that I'm trying to hurt her.
34:46 Speaker 01 So I get it, but you're not allowed to threaten me. So with frankly DID people, I do accept the premise that their experience is that they're different people at different times. With more ordinary dissociation, like people zoning out on me, I sometimes miss it for a long time because people learn to pass. They learn to cover. One woman that was a frank DID patient that I worked with for several years told me when she stopped treatment that, you know, she was somewhat disappointed that she wasn't as gloriously integrated as she had hoped originally that she would become.
35:29 Speaker 01 But she said, "It's such a relief not to have to dissimulate and lie anymore." You know, "I used to spend all my time, people would confront me with stuff I'd done in another state of mind and I didn't remember it and I would try to develop a cover story. So, "Oh yeah, I guess I was angry that day, sorry." And now I can just say, "You know, sometimes when I'm under a lot of stress, I dissociate and I don't remember what I did. What did I do? I'm really sorry I did it." And it took a tremendous weight off her that she wasn't having to constantly pretend not to have this tendency.
36:14 Speaker 01 So again, it would, it depends upon the patient, but I often begin to, to know that there's a dissociative process going on when I zone out. When I think I'm listening and then I realize I've been thinking about what to buy at the grocery store instead of really hearing what they're talking about. I bring myself back and I will say something like, wow, I, I think I was just zoning out a bit. Are you, are you fully here? Somehow you and I think we're both up in the clouds. So again, it, it depends on the person.
36:53 Speaker 03 Yeah, we have a group member, Ariel, has a question specifically about transference. Ariel, why don't you go ahead and ask Dr. McWilliams directly?
37:01 Speaker 04 Hi, thank you so much for being here today. I actually have a question that came up at a time when I was going through some counter transference, some really, really difficult projective identification issues, to the point of becoming physically ill, seeking medical help. I would just share really quickly that reading your psychodynamic diagnosis book, there was a very specific passage which actually really helped me in my processing of this. And that led me to asking a question that is, I'm curious to learn about your most intense
37:44 Speaker 04 experience or experiences with projective identification and counter transference. More specifically, how did it feel for you? What about it affected you so deeply? And what is your most effective strategy or tool that helped you process and work through it?
38:02 Speaker 01 Oh, well, I'll just go with what came to mind. I mean, I've worked with a number of patients who are so intense that they activated me a lot. But one that is particularly memorable to me was I had a somewhat paranoid patient who was very sensitive to any indication of rejection. And he had very rejecting parents. And he was one of these people who scans you all the time. And it's exhausting because you keep feeling like if your face twitches in a way that he thinks is negative,
38:47 Speaker 01 he's going to go right into, what are you thinking? You were critical of me. I know it. You may not know that you're rejecting toward me, but I know you are. I mean, he was poised to project into me his whole internalized drama that he's going to be rejected. And one day, he came to the office and the door was locked. My husband had thought I was finished for the day. And I had an office with a separate entrance. Then there was a stairway and it went up to a second floor office.
39:29 Speaker 01 And my husband was just securing the doors at night and thought my day was over and locked it. But I didn't know that. And I hear the patient at the door. And I went down. I said, I'm so sorry. I don't know how that got locked. And he said, oh, okay. And I thought, with his whole rejection thing, I better investigate this. So he sat down and started talking about something else. And I said, you must have had a reaction to coming through the door and finding it locked. And all of a sudden, he looked terrified. And he later explained to me that
40:13 Speaker 01 And this is, this is the way you can get sort of screwed up in your own mind when you're working with a person for whom some virtually psychotic reality feels like the reality. He said, "When you brought it up, I couldn't think of any reason for you to bring that up, except if you knew it was true, that you were rejecting me." Right? And, and he gradually let in the idea that somehow there were professional reasons for my checking with him about that. It didn't have to be that that was the actual feeling that I had toward him, that I didn't
40:55 Speaker 01 want him in my, in my office, that I basically hated him. And this interaction happened several times over the course of a long treatment, where he was sure he knew better than I did that I hated him. And through projective identification, I wouldn't say that I felt exactly hateful toward him. What I mostly felt was the terror that was behind his hatred. I was terrified that I was going to lose him as a patient, that I was going to hurt him, that, that I was going to do more harm than good.
41:38 Speaker 01 And one time when we went around on this, he was so certain that I was being naive and self-deluded, and he knew what I really felt, that I started to cry. And that's what broke it. I didn't do it in a deliberate way. I just, I said to him, "I don't, I don't know how, your conviction is so..."
42:10 Speaker 01 Complete that I somehow hate you. I feel helpless because everything becomes evidence of that. And he later told me that the fact that I actually cried about it made him believe that maybe I wasn't just rationalizing. So, you know, there's nothing in our textbook that tells us if you're out of all other things to do, burst into tears. But, you know, sometimes the things that that actually get to patients are not the things that are in the rulebooks. But that was a particularly challenging case. Very, I really loved this guy.
42:55 Speaker 01 He was a very tender hearted person. But his conviction was was pretty psychotic and he saw it everywhere. I had another patient that I got out of it with a similarly outside the book experience. I had this patient who was pretty narcissistic, who had had a depressed mother and came down every morning to see her sitting at the kitchen table with a cigarette in one hand and a coffee cup in the other hand staring into space. And, you know, she was almost never fully alive, you know.
43:38 Speaker 01 And in the transference, he used to come in and say something like, oh, you look really tired today. And I would wanting wanting to analyze it as a transference, I would say something like, gee, I'm not aware of feeling tired. Is there some reason why you might want to tend to see me that way? And he'd say, oh, you know, I'm a very sensitive person. You may not know you're tired, but I can see that you're tired. I, you know, so he would always sort of one up me by, he was a sensitive person. He would, he would walk in and he'd say, oh, you look depressed today. And I would say, gee, I'm not aware of that.
44:21 Speaker 01 What's going on with your perception of me as depressed? He's, oh, I know you're depressed. You just kid yourself, you're depressed. So what actually moved that treatment along was I was pregnant.
44:37 Speaker 01 And he hadn't noticed. And I got into my sixth month before this super perceptive guy noticed. And I had to call it to his attention. We went through the usual thing. I know you want to look at this as a transference, but it's about you. It's not about me. And I finally said to him, if you're so fucking sensitive, how come you haven't noticed I'm six months pregnant? And he stared at my belly and he said, oh, my God, you really are. And that was the first time he rethought the possibility that maybe his conceit that
45:18 Speaker 01 he always knew better than I did what my state was, might be affected by his own psychology and not just mine. So a couple of times I get rescued by some reality because it's so hard for people to believe that what they are projecting on you might be their stuff and not yours.
45:40 Speaker 05 We're gonna, I'm gonna pull in Dr. Latal here. I wanted to know your thoughts on the relationship between love and trust within the therapeutic relationship, both from the therapist's point of view and from the patient's.
45:57 Speaker 01 Well, I, I think one of the things that drives people crazy is not only not being loved, but not having their love accepted. If you're a child whose parents seem indifferent to you, who don't light up, who don't respond to your love of them, you're going to get damaged by that. And to the extent that the therapy relationship is curative, just because it's a different relationship than what you've had previously with authorities.
46:36 Speaker 01 You have to be welcoming to the patient, all of the patient's feelings about you, including their love, without breaking any boundaries. And they have to have evidence that you care about them, that you're really interested in them. I don't typically tell patients that I love them, but they can tell that there's love in the relationship just by my commitment to them. Trust usually takes a bit longer. Patients will find it easier to love you than to trust you if they've been betrayed in their history or horrifically neglected.
47:17 Speaker 01 So epistemic trust is the core to any kind of secure attachment, and it takes a while to build. There's empirical evidence that if you're, if you've got one of the insecure attachment styles, it's pretty robust. I mean, if you're three years old and you're in the strange situation paradigm and you test as having avoidant attachment, when you're 33 years old, you'll probably test as avoidant attachment on the adult attachment inventory. But there are, at least Philip Shaver's empirical work
48:01 Speaker 01 has demonstrated that if you are in a loving relationship, like a good marriage or partnership, if you have a really close other in your life, for at least five years, you start to test more securely attached. If you have intensive therapy, that can happen over two years. So at the end of the second year, you actually do see shifts in attachment style toward a more secure attachment, and that's basically the evolution of trust.
48:44 Speaker 01 When patients know that they don't trust me, often they do know that at the beginning. I say to them, I'm aware that there's nothing that I can say that is going to make me more trustworthy in your eyes, because from what I hear of your history, nothing has given you any foundation for feeling that other people are trustworthy. But I am hoping that I can be trustworthy enough that over time you'll actually take it in that I can be trusted. But you don't have to trust me now. In fact, you can't choose to trust me now. I'm quite aware of that.
49:19 Speaker 05 I think it answers about 80% of my question. The other piece is like, do you feel like you need to have some sort of trust for your patients? Or how does that work for you in a long-term relationship?
49:35 Speaker 01 If your patients aren't trustable, you certainly have to set conditions in which they can't act out in ways that are problematic. For example, I've had colleagues whose patients were fascinated with them and befriended their children on Facebook and tried to get interesting information about their therapist from the kids. One patient of one of my colleagues joined AA because she learned that the therapist's son was in AA, and she became his sponsor and then came into treatment announcing that she was the sponsor of the therapist's son. And...
50:23 Speaker 01 Yeah, it's I have another colleague whose patient joined her swim club because she wanted to hide in one of the cubicles and look through the slats to watch her therapist undress. Therapists, and I don't think we get good training in this at all. We get a lot of training about how to be empathic, but most therapists are naturally empathic. That's why we went into this field. We don't need a lot of training in how to care about people. But we need training in how to set limits that ensure that we have the conditions of labor under which we can practice. So you have to set limits with your patients. Look, you are not allowed to befriend my kids on Facebook. You are going to have to
51:08 Speaker 01 tell my son that you can't be his sponsor anymore. If you want to continue, we'll have to stop the treatment. I don't want my life to be overlapping with yours. That gets in the way of my doing my job. And we have to stick with that. We don't have to absorb everything that some desperate patient inflicts on us. I've had a couple of colleagues who were stalked, and they put up with it too long. And in one case, the person's office was burned down by the stalker. So if you have a patient who starts to stalk you, it's
51:46 Speaker 01 a serious thing, and you got to immediately set boundaries on it, or refer the patient to a higher level of care, because that's a dangerous psychology.
51:59 David Puder? So maybe you could define, like, what is stalking behavior? If there's any others that clinicians should be concerned about? And then, what, maybe if there's any nightmare stories that I know people have reached out to more than the, maybe you've probably heard more of these stories than the average clinician. Any stories come to mind in particular?
52:26 Speaker 01 The stalking stories are usually, by the time they get to me, they've elaborated in ways that are really hard for the therapist to get out from under. So it is a good thing to know something about the psychology behind that. I don't know why they didn't put it in the DSM, because it's a well-known syndrome, erotomania is what it's typically been called. And it's really an obsessional preoccupation with another person that includes attraction and hostility. The hostility is often unconscious. But it's a paranoid syndrome.
53:06 Speaker 01 In erotomania, I believe that you really want me. That's the projective identification of my own craving. But it's paranoid in that it's denied in the self and it's seen as coming from the other person. If you weren't so wonderful, I wouldn't feel this way. And it can be so powerful that even people who've brought stalkers up on charges, like if they've gotten a legal prevention on the person coming in their orbit and the person disobeys the ordinance and it gets to court.
53:48 Speaker 01 Reed Malloy, who's an expert on this, told me that the stalker so firmly believes that they were encouraged, that this was really what the stalkee wanted, that they can often persuade a judge and a jury. Because you can see how it would happen. The therapist, therapists are nice people. And when you realize somebody's impinging on you much too much, you might... This is... This happens to non-therapists too. A kind thing to do would be to say, "Listen, you're a very nice person, but I don't want to have that kind of relationship with you." And then their defense attorney gets on the stand,
54:29 Speaker 01 gets you on the stand and says, "Didn't you say you're a very nice person?" And the stalker is sitting there going, "I was encouraged, you know? I was seduced."
54:42 Speaker 01 And it's really a powerful paranoid condition. It was first, interestingly enough, it was identified in women who would have these reactions to men of higher status. It was thought to be a female disease originally because people would get preoccupied with the local duke or earl, you know, back in the 1700s. And they would follow him and make his life miserable. And celebrities, of course, often have at least one stalker. That's our contemporary version of that. But therapists become important to patients, and if they have that dynamic, you can be in real trouble.
55:27 Speaker 01 So you have to sense it early and then set limits on it really clearly and have consequences for the limits. You know, I told you not to befriend my kids on Facebook. It's come to my attention that you have a, under a different name, under a different social media handle, you've done it again. I'm sorry, we have to stop. And you leave it there. The self-protection that we have to pay attention to as therapists has been pretty much minimized in our training, I think.
56:02 David Puder? Do any questions on this specific topic from anyone? Anyone have any concerning people? They can just jump in the chat and I'll bring them in or raise your hand.
56:14 Speaker 03 Or maybe even tendencies that are concerning. So maybe if they don't necessarily fit this full psychological profile, maybe there are certain behaviors that have been exhibited throughout treatment that are concerning.
56:28 Speaker 01 Give me an example and where would you start getting nervous with a patient? What would be some of the behaviors?
56:36 Speaker 03 I would say if there's overt behaviors that start to infringe the frame, where I've established parameters, I've established boundaries.
56:46 Speaker 01 Yeah, exactly what you said, violations of the frame. If they start calling you in the middle of the night, if they happen to have been in your neighborhood. And I think we are reluctant to set limits very early because we want to understand them first. There's a book by a woman, I think it came out about 15 years ago. It's called You Know You Really Love Me. It's her description of having been stalked by a patient. Ian McKeown wrote a novel about being stalked by a gay guy that became obsessed with him or with the character in the book. So that was interesting because it was the same gender.
57:28 Speaker 01 Often it's, you know, often it's a heterosexual phenomenon, but it can be a gay phenomenon, too.
57:36 Speaker 01 I think we're seeing more of this in recent decades. There are a lot of desperate people out there that want to glom and cannibalism.
57:48 Speaker 03 Can you explain cannibalism from a transference perspective, just so the group understands? Because I don't know if everyone understands that.
57:55 Speaker 01 I just mean that you feel consumed by a patient like this.
58:00 Speaker 03 Completely consumed.
58:02 Speaker 01 They put the emphasis on the dependency and the erotic attraction, the love. And it's not that that's not there, but it's all merged with a lot of aggression. You know, you're good enough to eat, so I'll destroy you.
58:21 Speaker 03 And it's so hard to put into words of how that feels.
58:24 Speaker 01 Yeah.
58:25 Speaker 03 To be on the other end of that.
58:28 Speaker 03 So Nancy, obviously, there's been an uptick on autism diagnoses in the last several years. And I think, you know, from a psychoanalytic perspective, what are some of the ways that you distinguish autism from schizoid personality? Perhaps the overlapping features? Because I know, you know, as a clinician and then working with a lot of other clinicians, particularly who will come to me for consultation, and I'm not directly working with the patient. A lot of times, they'll present the patient as an autistic patient, but then it sounds and feels more like a schizoid personality structure. So if you could just share with the group, if there's any process that you have to distinguish the two, that would be great.
59:15 Speaker 01 Yeah, they, they look a lot alike superficially. They, both groups are highly sensitive to stimulation from outside. They may have certain rituals that deal with the stimulation. The main difference is in two areas. I, I think they may have a sort of similar neurological pathways that, that are operating. But, two things. A schizoid person may withdraw from other people a lot, but it's not because they don't understand what's going on in the other person.
59:58 Speaker 01 They read social cues, they just don't want to comply with them because of their conflict about it. So, a schizoid person may have trouble, like, hugging his child, because that feels like a lot. But they know children need to be hugged, you know, they get it. An autistic person, you may have to tell them, you know, it's good for children if you hug them once in a while, and they'll go, "Oh, okay," and they can do the behavior. That, that's one thing. How, how much do they really read social cues? And how much, how much is they're not reading it, versus how much are they reading but
1:00:40 Speaker 01 finding it too hard to play their role? The second thing is, schizoid people live in this world of imagination that's very rich, and autistic people, and, you know, I do think there are some overlaps. And I, as we learn more about neurodiversity, I think we're gonna learn a lot more about all the different ways you can, all the different brains you can have. But, my grandson is on the autistic spectrum, and he, he had trouble with other children. That's how we first sort of... Notice it because other kids had an imagination.
1:01:22 Speaker 01 And so when he was three, some other kid would come up to him and say, I'm a lion. And my grandson would say, you are not a lion. You are a kid. Yeah, okay. And his mother had to teach him about imagination. The kid is imagining himself being a lion. And now, now that he's older, he will say to his mother, oh, is that that imagination thing? So again, he's a, he's a, he's a loving kid. He's a warm kid, but he doesn't get those processes. Schizophrenic people, again, can have extraordinary imaginative lives.
1:02:05 Speaker 01 And they're quite clear what the difference between that and reality is. They can play in a way. So those are the main difference that I've, I've noticed. But, you know, I think our diagnoses are, all of our diagnoses are problematic because the DSM and ICD have gone in the direction of trying to define everything based on what's externally observable. And sometimes what's most important to people is the internal experience, which they don't always share right away.
1:02:39 Speaker 03 Wonderful. Thank you.
1:02:41 Speaker 02 Why don't we open it up to some of the group members? What do you think?
1:02:47 David Puder? Let's do it. Carrie Pond, I'll bring you in here.
1:02:52 Speaker 06 So one of the things that I would love to hear your thoughts on is, I think this kind of, this question came from a little bit working with couples, but then also kind of in the therapist-patient dyad. I'm curious if, what your thoughts are about like combinations of particular personality styles or like how they might interact. Yeah, kind of reading through psychoanalytic diagnosis and kind of understanding kind of styles within individuals and the defenses that come up. I'm just kind of wondering if you have any, any thoughts about particular combinations or ways in which things might combine and certain styles might pull on certain like aspects of our own kind of psychology if we're hybrid or just kind of anything in
1:03:35 Speaker 06 the interactive kind of dynamic between people realm, if that makes sense?
1:03:41 Speaker 01 Yeah, I mean, most of us have elements of more than one personality style. And you know, if you really want to get to know somebody, you end up learning what their specific story is, what is their narrative? How do they understand the world? What is, what is, what is the theme of their life? And it can often involve combinations. My own personality, as I said, is somewhat hysterical, somewhat depressive. It's very common to have a combination of schizoid and obsessional.
1:04:18 Speaker 01 The kind of person that Jeremiah was talking about, who combines paranoid with psychopathic is altogether too common. And our, and our legal system doesn't help us with that either because the legal system insists that you be one or the other. You, like, you can't be, if you're psych, if you're psychopathic, you're not crazy. Those are mutually exclusive diagnoses, but plenty of people are both psychotic and psychopathic, paranoid to a psychotic degree and psychopathic. Depressive and masochistic tend to go together a lot.
1:05:01 Speaker 06 Do you, would you say those combinations find each other in different people? Like, do you see, I don't, I don't know if you've ever, if you ever worked with couples or, or just kind of in your experience, like, do certain styles tend to find one another and have more hostile or more equanimity in terms of their combination? Or like, in, with your personality, do you have certain styles and patients where you're like, this seems to work really well on others that you're like, wow, this sucks. This is not a good combination, something like that, kind of between people?
1:05:34 Speaker 01 The only combination that I've noticed over time as a common combination is schizoid and hysterical. They have certain things in common, like their level of sensitivity. So in some ways they're similar, but let's say it's a schizoid man and a hysterical woman. They are drawn to each other like magnets sometimes because the schizoid man admires her comfort with other people and her expressiveness. And she admires his capacity to stand alone and reflect. And you know, then they get together and in couples therapy, you get these pursuer distancer dynamics because her way of solving a problem is to move closer to him and his
1:06:19 Speaker 01 is just get out of there. And that's actually something that you can interpret and they can see and they can, she can learn to give him space. He can learn to move toward her when she's upset instead of avoiding her when she's upset. So that's a pretty common one. But I've seen all kinds of combinations. And I think for me, I've enjoyed working with all different kinds of patients. I think the ones I have the hardest time with are people who are profoundly narcissistic because they don't really love. And I don't mean ordinarily narcissistic.
1:07:02 Speaker 01 We all have narcissism, but you know, your malignant narcissists are very, very hard to reach. There's a reason Freud thought they were untreatable and it wasn't until the 1980s that we had literature that allowed us to conceptualize ways that they might be helpable to move more toward the capacity to have I thou relationships rather than like show off or idealize or devalue relationships.
1:07:37 David Puder? Awesome. Thank you so much, Carly.
1:07:39 Speaker 01 I think Grant had his hand up a long time.
1:07:42 David Puder? Okay, we'll do Grant next. Hello, nice to meet you. Thank you so much for coming. I'm a large fan, so I'll probably just get that out of the way.
1:07:54 David Puder? I don't know how to really word this question so that it's the most maybe like socially appropriate, but hearing, I've never been analysis with you, obviously, or any of your, like, the leading minds of psychoanalysis. But there's something about the way that you speak and the way that you write that I find different from the other leading minds. And a pleasant one I find. So I was more curious if that was something that you experience as well, maybe that you feel differently, some like theoretical differences that you feel, and what would those be?
1:08:38 Speaker 01 I don't think it's theoretical differences. I think it's a combination of personality and feminism. I wanted to represent my own voice and not to try to sound like a mansplaining expert. But I think I'm just very lucky. I have absolutely no memories of ever having been shamed. I have some painful experiences in my history, but I was never shamed. I was always supported in my confidence. So I always hated it when I felt people were using obfuscating jargon and not talking like real people. Interestingly, Freud was
1:09:23 Speaker 01 a very good writer and stylist, and he was very down to earth. That's one of the reasons that he became so popular in the heyday of psychoanalysis was that he was very direct. And Theodor Reich, who influenced me a lot, also was, and very self disclosing. And I, from the time I was adolescent, people used to say to me things like, "You're so sincere." So I think that comes from never having been shamed. I think I'm just incredibly lucky that way. It's very interesting to me, with my diagnosis book, frequently people will tell me, what I really like about the book is the stories, you know, when you give a
1:10:06 Speaker 01 vignette about something. And there's one story I really love in that book. It's always the same story. Right? I bet some of you are associating to it right now. It's that I, in the flush of a rescue fantasy, I loaned my car to a psychotic patient and he drove it into a tree. And I think people, people are so pleased to hear that I could be that stupid. Because, but I think that's what we need is mentors who talk about how hard the work is, what kind of mistakes they make, how easy it is to make those mistakes.
1:10:45 Speaker 01 So as a writer, I haven't been particularly self-protective to protect a certain image. And I think people are grateful for that.
1:10:59 David Puder? Yeah, I, I agree. It's, it's, there's something about the way that you model that's, that brings down the authority that analysis has, where you give this interpretation and you're, you know, this professional, but yet at the same time, you're supposed to be creating a space where we're both human. And sometimes I find that when I read, I get, I feel like the, the, you know, the doctor, whoever's writing, have kind of lost sight of that in a way.
1:11:34 Speaker 01 Yeah.
1:11:34 David Puder? And I find when I lose track of that and I'm fighting that because I'm new, I look back at your writings and I just, yeah, so that's why that, that's, that was the stem of my question. So thank you for answering and thank you for setting a good model.
1:11:49 Speaker 01 Thank you.
1:11:51 Speaker 02 Yeah, there's, there's such inherent authenticity, which is, you know, so true to your character, I think. You know, I think that that sounds like it comes quite naturally, that authenticity in your writing. But the, the use of self-disclosure as well allows so many to just feel seen and, and takes away some of the, the shame. I think that, you know, or, or fear.
1:12:15 Speaker 01 Good. Because it's hard enough learning to be a therapist without alienating jargon. Yeah. Go next.
1:12:25 Speaker 06 Yeah, I actually had two questions, but I thought one may be a better segue from the last one. So I'll ask that one first and then maybe throw in the other one if you want to answer that one too. But the one thing I wanted to ask is like, what skills as like a psychoanalyst or like a psychodynamic therapist, do you think can be learned through training or just through your career? And then like, what skills do you think are kind of like inherent to who you are? So it becomes almost like, you know, you kind of are born with like this superpower and you know, because of that, that is what makes you a good therapist or a good psychoanalyst.
1:12:58 Speaker 01 Well, I think an awful lot of what makes people a good therapist or a good analyst is just natural human qualities that haven't been snuffed out, like curiosity about other people, respect for other people. We haven't, we haven't theorized respect a lot, but I think that's even more important than empathy, you know, for people to, to feel you're approaching them with the attitude that you're interested in learning from them, you know? And, and many therapists have that naturally. If you don't have that naturally, you can learn a lot of things. But it's always going to be a little bit of, um, I don't know, a, a performance.
1:13:41 Speaker 06 Yeah.
1:13:41 Speaker 01 I, I, I've had a couple of supervisees over my time that they just don't have the intuition that I think most good therapists naturally have. So, you know, I, I will say something like, um, well, did you ask this guy about what his substance use is? Because he's mentioning all these addictive things in his family. Oh, no, I, I probably should have done that, you know? Whereas it wouldn't be a matter of my going through a checklist of what I should ask. It would have been a matter of my just hearing intuitively that, you know, there's, I should ask about this.
1:14:23 Speaker 01 Some people don't have that. Now, he's got, he's the, the guy I'm particularly thinking about. He's done okay as a therapist. I don't think he's had quite as many successful experiences as some of us, but he's not doing harm to people. But I, I can't imagine his patients don't feel like there's something missing.
1:14:46 Speaker 06 Yeah. No, that's a great way, because I think about it even from like a clinical or like a medical standpoint of there's a difference between a doctor and a caregiver.
1:14:56 Speaker 01 Yeah.
1:14:57 Speaker 06 You know, and the doctor is like the technical, like I'm again going off a checklist of diagnoses and then the caregiver is actually bringing humanity back to the relationship. And so I think that's kind of a beautiful way to put it is just like, you know, understanding that there's a human at the end of it, not a diagnosis, not.
1:15:13 Speaker 01 Yeah. You're treating a person with appendicitis, you're not treating an appendix.
1:15:17 Speaker 06 Exactly, you're treating a person with it.
1:15:20 Speaker 01 Um, no, that's. Some people have all the words and none of the music, you know, they just.
1:15:24 Speaker 06 Exactly. No, that's great, thank you. Um, and I think I wanted to quickly circle back because we were talking about like stalking and harassing. And the question I had for that is, you know, are these patients, you know, coming in for like other reasons and then, you know, through that, you know, those sessions that kind of like intense psychopathic transference happens where they exhibit then those stalking harassing behaviors or are they actually coming in for that particular?
1:15:49 Speaker 01 They never come in saying, I worry that I'm a stalker. I've had a couple of people who were worried that they were a stalker, but they weren't stalkers, they were just obsessionally concerned that there was something wrong with them and that that was what they grabbed. Um, no, they always come in for anxiety or depression.
1:16:09 Speaker 06 Wow, and then that is what would come out, like there'd be like something that would happen from there. And then would you be able to like tie that through, because you know, when we talked about Scheller, he talked about patterns. And so would you be able to see in other instances in their life, you know, as we're talking about it, where that behavior is common or coming up again and again? So it's not just.
1:16:30 Speaker 01 Well, that's one reason I think it's important to take a history.
1:16:33 Speaker 06 Yeah.
1:16:34 Speaker 01 What went wrong with each relationship that's been important to you? If they've been in therapy before, what ended the therapy?
1:16:42 Speaker 06 Yeah.
1:16:43 Speaker 01 Because that's going to happen to you and whatever happened there. And you have to make it come out differently or figure out that maybe this person needs a higher level of care. I think we're seeing more in our outpatient clinics and private practices of this kind of behavior, partly because we don't hospitalize dangerous people anymore, the way we used to be able to do.
1:17:06 Speaker 06 Got you. Thank you so much, also a huge fan.
1:17:10 Speaker 03 Heidi, you had something.
1:17:12 Speaker 01 Hello. Hi. I'm newer in the field, but I wasn't trained very well in personalities. So your book on personalities diagnostically, the one thing that was really helpful, and I just wanted to say thank you for this, was in working with a schizophrenic patient, you had talked about normalizing how scary their thoughts are. Mm hmm. And I did that with my client and to see his like relief and his like, and the way he could move towards me and the way he opened up to share more with me, it was really valuable. So, so thank you. Good. That population, the psychotic population, they have been so badly treated
1:17:54 Speaker 01 over the last 50 years. I mean, when we got the antipsychotic medications in the 50s and 60s, we were so impressed with how they could calm a person in a state of absolute terror and aggression and misery. They were so impressive that, you know, we started saying, you know, you're going to need to keep this medication going for life. And, and we started telling them that they, they had a condition like diabetes where they just had to get on these medications and we didn't, we stopped offering them therapy and we
1:18:32 Speaker 01 started offering them groups to manage themselves that mainly were groups to keep them on their medications. And I'm not at all anti-medication, especially for somebody with acute psychosis, but we over-medicated them and we haven't given them any therapy. And even if you're on antipsychotic medication, you have stuff you should be able to talk with somebody about. So we, we've really, we've made no progress with that group at all. And now they're learning that, you know, long-term excessive use of antipsychotics damages the brain as much as or more than untreated schizophrenia.
1:19:16 Speaker 01 So we have to develop, we have to refine our effort to try to, and these are people we all went to kindergarten with, who, you know, who lost their minds in a particular way. Freud says that, that the mind is like a crystal. You know, if, if it gets whacked, if it undergoes certain kinds of stress, it, it will fracture along the lines that are, you know, inherent to that crystal. And I think that's a beautiful metaphor. Some of us under stress dissociate, some of us become neurotic, some of us become borderline, some of us become psychotic. But we're all human and we all need relationship.
1:19:55 Speaker 01 So that, that group is particularly underserved and mistreated, I think. They're told that they've, they've, you know, they have schizophrenia as if it's an alien condition that infected them, that they just have to medicate forever. As opposed to they've had a hard life and they lost their mind.
1:20:15 David Puder? Yeah, it really helped me dispel my misunderstanding of what schizophrenia was and, and how it had, and look at where that came from. And, you know, to your point, it was the, the monsters that they had been created out to be years ago with institutionalization and so forth. So, yeah, thank you.
1:20:37 David Puder? Hello. Hi. I'm a huge fan too. But there has been a search in the use of gender-affirming care. And I wanted to hear your views on it.
1:20:48 Speaker 01 Well, I mean, I'm not even sure I like the term gender-affirming care because very often patients' problems are they don't know exactly what to affirm. They are very conflicted about who they are. They are, uh, some people know that they're a man trapped in a woman's body or vice versa. And they've always felt that way. And they're pretty easy to, to help. They just need somebody who will witness their effort to put their physical body into parallel with who they know themselves to be. An awful lot of other people are harder to help because
1:21:32 Speaker 01 They worry that they're trans, they don't know if they're trans, maybe they're gay, maybe they're trans. They need to have a place to talk about all that without a therapist having an agenda for them. And I worry about the immediate agenda that you should get surgery and hormones as much as I worry about the agenda that you shouldn't. You should, you know, you should make your peace with the gender that you were assigned at birth. I think we have to open space for people. For so many years, we were pathologizing homosexuality, and it was just a matter of majority people thinking that anybody who was different from us heterosexuals must be pathological.
1:22:15 Speaker 01 And that was, that was very, very damaging. And I think it's more complicated with trans people. For example, in dissociative identity disorder, sometimes people have, often they have alter personalities of another gender. And so they're, they're trauma victims. And you need to figure out what each personality is doing in the system with them before you make any global decisions about who they should decide that they are in terms of their gender. So it's very complicated, but you have to give the patient space to tell you their story.
1:22:58 Speaker 01 I've known people whose lives got immensely better once they transitioned. And I've known some that transitioned and were very disappointed about it because they believed that it would solve all their problems to, to make the transition, and they discovered that life still hurts. So I just don't think we should get enthusiastic that we know more than a patient does about what they need.
1:23:25 David Puder? Great. Gotcha. Thank you. Okay. Um, one of my questions for you is like with ideal, with the transfers of idealization. When is it too much and or when is it like a nice amount of idealization? That's like kind of a non-threatening like, okay, I'm gonna let this just, I'm not gonna analyze this. Versus when is it like too much? Where it's like? You have to kind of address it and then how do you address that?
1:23:57 Speaker 01 Um. Again, this really depends on the patient and the combination of the patient and the therapist. But there was a big conflict about this in the eighties in the general. The general discussion about how you treat narcissistic patients. When they idealize you, do you, uh, there were really two different viewpoints. Heinz Kohl said, "Idealization is a normal part of development. If the patient's idealizing you, you just accept it. They slowly have to go through a developmental process that they weren't able to go through.
1:24:39 Speaker 01 They um, didn't either had a, they either had a parent who wasn't good enough to idealize in the first place. The way children need to idealize their parent at around age three or so, where they, they think you hung the moon. Or they had a parent who was very defensive about being de-idealized. When the kid got to an age where they realized that their kindergarten teacher knew more about asteroids than their mother and starts, you know, putting you in perspective. If they were able to go through that, they're not gonna turn out narcissistic. If they got stuck, um, they need to go through idealization and then de-idealization with you. And you don't have to interpret it. It just happens during the therapy.
1:25:23 Speaker 01 That was Kohl's position. Kernberg's position was, um, not that, uh, idealization is, you know, and I mean, I think he would say some kinds of idealization are normal and people go through that. But he, he felt if you were diagnosable as a narcissistic personality, you'd gotten off track. Um, and you were using idealization to defend against, let's say, envy.
1:25:50 Speaker 01 And so he would interpret that. He would say something like, I think you want to believe that everything I do is right. Because if, if you saw me as sort of struggling to understand you, you would be terribly disappointed in me. Or if you, if you feel like I'm idealizable, then you're struggling with envy toward me. That, and you notice that every time I talk, you interrupt me, or you tell me you already knew that. I think that's, you know. Interestingly, Kernberg worked with more of the devaluing narcissists and Kohut more
1:26:34 Speaker 01 with the idealizing narcissists, because they were in different settings. But I, I've had patients that make Kohut look good and patients that make Kernberg look good. There are some patients that you, you can't analyze their idealization as a defense. You simply have to put up with it. A, a pretty, a pretty common evolution in therapy, in my experience, is that people start out with a very benign idealization. It's not bothering you that they idealize you. It seems to be actually helping the treatment, that there's a kind of a natural wish to
1:27:18 Speaker 01 do well for you. But there comes a point where suddenly it bothers you. And you can tell that the person doesn't want to feel certain other things, and they're using it as a defense. So it started out as a normal developmental thing, but now it's a defensive thing that doesn't feel good. And when that happens, I think it's always valuable to talk to a colleague about it. But I think you should trust your countertransference. It's telling you something. Maybe the person has moved on, has grown, and now is capable of not idealizing you, but they're hanging on to it because that, they're used to it, you know?
1:28:03 Speaker 01 So I don't think you can generalize about which way to go. Some people are too fragile to do anything other than be who they want to think you are. And other people, you do them a big disservice if you let them leave therapy thinking that, you know, you're so brilliant because when somebody's idealizing you, inevitably then they're seeing themselves as less than. You want them to end therapy not thinking that they had the best therapist in the world, but that, you know, their therapist was good enough and a good process ensued and therapist didn't make too many mistakes and they're moving on.
1:28:46 Speaker 01 Yeah, that's good. That's helpful. I didn't have a lot of idealizing patients when I started my practice. I had a lot more devaluing patients, you know. You look pretty young to be a therapist or, you know, where did you get your training? Or did you read that on page 52 of your manual? I mean, I get a lot of that kind of low-grade devaluation. And I had to learn to, for patients who needed to do that and it wasn't analyzable yet, I had to learn to roll with it and say things like, yep, I guess, I guess I just am not a good enough therapist or, you know, you are, you are a genius at finding everything
1:29:29 Speaker 01 that I do wrong. It's really impressive. And modeling that I'm not threatened by the fact that they're de-idealizing me or devaluing me. It detoxifies it some to be able to roll with it that way.
1:29:48 David Puder? Okay, we have a question on frequency of visits. I think, I think that Sheddler kind of has a stance of like, it has to be two to get the, but I'm like, I'm a little bit more loose. Like, I see a lot of weekly patients. I have one twice a week patient. What's your take on this and has it changed over time? Like, frequency of visits?
1:30:14 Speaker 01 I used to do a lot of three or four times a week psychoanalysis, but that was back when insurance companies happily covered that. That's hard for patients to do now. And so I think we've all adapted in the field. And it's really different from one patient to another. Some people do quite deep work at once a week, and some people, you can see them four times a week, and they never get to the stuff that you think they need to deal with. So I don't think there are rules about that. We've wasted an awful lot of ink with the frequency wars in psychoanalysis. What is real psychoanalysis? Is it three times a week or four times a week?
1:30:57 Speaker 01 What's the minimum number of times you have to see to make a difference? I think it's fairly common for people to say as a general rule, and perhaps this is what Jonathan actually said, as a general rule, it works better to see people twice a week. Because when you're seeing them twice a week, they're not spending the whole, you know, half the session giving you the weekend review before they get into their stuff. If you hurt their feelings on Tuesday, you know that on Thursday you can try to repair that. You don't have to worry that they're, for a whole week, they're dealing with you having made a mistake or they're having brought something up at the last minute that you didn't handle well. So I prefer to see people twice a week.
1:31:41 Speaker 01 But I've had some patients that did well on once a week. I loved seeing people three and four times a week. It really deepened the treatment. And I learned a lot about the depths of certain kinds of psychologies that way.
1:32:00 Speaker 02 You want to do one more? What do you think? Sure. Serena, go ahead.
1:32:08 Speaker 02 Bouncing off that topic, I was wondering if there are any ways you change how you worked with patients to work better with the once a week structure.
1:32:19 Speaker 01 That insurance companies are so hyped about.
1:32:24 Speaker 01 Probably.
1:32:27 Speaker 01 And I don't know how much of it is the difference in frequency and how much of it is just relaxing into the role. You know, I have a colleague who says, we all start out as principalists. We're trying to, you know, put into practice certain principles. And we're following certain rules that we've been taught as how you're supposed to be as a therapist. And as we mature, we become consequentialists. We, we, in other words, we judge what we do by what we expect the consequences to be. Okay, so we don't tend to have rules about, you always self disclose here, you never self disclose there. You kind of feel if I were to disclose such and such here, what would be the consequence?
1:33:09 Speaker 01 And, and so you make your, you make your decisions in a looser way based on accumulated experience with what you can expect the consequences to be. So I don't know how much of it is that I just have loosened up. Also, when you get as old as I am, you've, you tend to feel like, listen, life is short and you got to get going. And I think I, I think I move in on stuff a little faster than I once did. So I don't, I don't know how to separate those things out. But I do think I'm more interactive at once a week, a little more self disclosing, a little more likely.
1:33:50 Speaker 01 And I've been influenced by the relational movement to say more about, you know, what's going on between you and me? Not how are you feeling about me? But do you, do you think you and I are, are involved in something, in the reenactment of what you've been describing in this time? Because here, you're saying this, I'm doing that. It sure looks like, you know, the past has come into the present here. So I, I own more of my own accountability for what's going on than I once did.
1:34:23 Speaker 01 Because at once a week, you can't. You can't be quite as anonymous because you don't know what they're doing with what you've let sit out there without engaging with it as much. It's hard to describe, but I think I'm more active, more self disclosing. Like, I'm finding myself anxious here. You know, you're telling me this without any anxiety and I'm feeling anxious. What do you think is going on? It feels like I'm carrying your anxiety.
1:35:00 Speaker 01 I wasn't trained to do that, but that's often a less toxic way from the patient's perspective of saying, you're defended against feeling your own anxiety. You know, that would be a one person way of saying it. A two person way of saying it is, I'm feeling something that I don't think you're letting yourself feel. All right.
1:35:26 Speaker 05 One last question. Amanda, you're up. Okay. Um, I wrote mine in the chat. I wanted to know what general advice you have for working with child and adolescent patients. So like specifically like countertransference, transference, and even self disclosure, like building trust with adolescents. And I found that I've been a lot more moose, but trying to keep that balance by like, you know, being authentic, but also keeping within the frame.
1:35:59 Speaker 01 Yeah, I think, I haven't worked with adolescents or children for a while. I did it early in my career for maybe 20 years. Then I was, I had my own children and I was sitting on the floor playing with Synchronos enough. And, and also it's, it's harder work, working with kids and adolescents. My colleague Beverly Stout in Atlanta does, has a whole practice of working with adolescents and kids. And She's a person of incredible energy, more than me. But when you're working with kids and adolescents, you're inevitably working to some degree with the parents.
1:36:41 Speaker 01 Because whatever the role of the child is in the family system, as they start getting better with you and changing, the family system tends to, you know, fight back. They're used to them being the identified patient. And if you don't help the parents and the family to adapt to the change in the patient, they are, I've seen very often the patient gets yanked out of treatment. So it's twice the work, really. But you have to, they, the parents have to feel like you're not blaming them, that you're, that you appreciate their genuine concern for their child,
1:37:26 Speaker 01 that you respect them. And, and they are going to be highly alert to any talking down that you might do to them. So being very conversational and flexible with them is important while keeping the, the regular boundaries about time, the email, all the other things that we set boundaries about. Thank you. You're welcome.
1:37:52 David Puder? Thank you, Amanda. Okay, well, thank you, Nancy, for your coming on and your time. And we really appreciate you. Really good.
1:38:02 Speaker 01 This is really fun, and thank you for these thoughtful questions.
1:38:06 David Puder? Yeah.
1:38:07 Speaker 03 Thank you so much. Thank you so much.
1:38:09 Speaker 01 My pleasure.
1:38:10 Speaker 03 When I, I have to say, so we all have our own little cohorts. And my cohort was very, very excited about having you on. I don't think I could even put it into words. So we're very grateful for you showing up today.
1:38:23 Speaker 01 Well, thanks. It's not too hard to do. I really like talking to other therapists. It's an isolating profession.
1:38:32 David Puder? Absolutely.
1:38:32 Speaker 01 We need each other.
1:38:34 David Puder? This is wonderful. Thank you so much for your time. And yeah, we'll leave it there for today, guys.
Previous Murderbot: Schizoid Personality, Neurodivergence, and the Search for Humanity in AI Next Mentalization-Based Therapy (MBT) Explained: Practical Techniques to Improve Clinical Outcomes in Borderline Personality Disorder, OCD & Narcissism Page updated October 29, 2026 · transcript and summary are machine-generated