Working with Transference: Timing, Technique, and the Here-and-Now with Jonathan Shedler

In this practical Q&A episode with Dr. Jonathan Shedler, the psychodynamic psychotherapy cohort explores working with transference in real time, focusing on timing, technique, and the here-and-now. Shedler addresses how to recognize meaningful transference patterns, decide when an interpretation will open growth versus overwhelm the patient, and adapt the work across levels of personality organization (neurotic versus borderline). The discussion covers handling negative and erotic transference, protecting the therapeutic frame, triangulation, idealization and splitting, devaluation, projection, and projective identification. Clinicians will also learn to use their own countertransference as essential clinical data, the ongoing value of consultation and supervision, and how to respond to chronic reassurance-seeking without colluding. Link to blog https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-275-working-with-transference-timing-technique-and-the-here-and-now-with-jonathan-shedler Link to YouTube video https://youtu.be/jwOYbY72WqM

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

• 0:14David Puder?

  Welcome back to the podcast. I am joined with Jonathan Scheller today. This topic is called Working with Transference, Timing, Technique, and the Here and Now. This was a part of one of my psychodynamic cohort special sessions. So you will hear a bunch of different people ask Jonathan Scheller questions. We'll be talking about the practical realities of recognizing and working with transference as it unfolds moment by moment in the session. Rather than staying at the level of theory, we will focus on clinical decisions therapists face in real time. How do you know when a patient's feeling towards you reflect a meaningful transference pattern? When does an interpretation open space for growth?

• 0:58David Puder?

  And when does it risk overwhelming the patient or derailing the process? We discuss how the work changes across levels of personality organization, the handling of negative and erotic transference, the importance of the therapeutic frame, triangulation, idealization, and splitting, devaluation, projection, projective and enphurication. We also explore the indispensable role of the therapist's own countertransference as clinical data and the necessity of ongoing consultation and supervision, and how to respond to patients who chronically seek reassurance. This is only part of our conversation. Unfortunately, we had to cut out about half of it due to, you know, actual clinical cases being discussed.

• 1:43David Puder?

  So I hope that this is enough to whet your appetite, to enjoy, to get something of value out of. As always, you're welcome to send me an email at psychiatrypodcast.com with any thoughts, reflections, people, other people I should have on the podcast. I will leave it there for today and enjoy the episode.

• 2:07Speaker 01

  Helping the patient define words to describe their experience, you know, which is often metaphorical, or listening to the patient's stories and understanding them metaphorically. So for example, you know, a patient might talk about going to see their physician or, and, you know, they thought it was a minor issue and the physician, this is this like actually literally happened. And, you know, the physician actually like got some very troubling test results and it turned out they had something fairly serious. I hear that metaphorically, well, they're telling me about their doctor's visit, but they're telling it to me now, you know, during our therapy session.

• 2:49Speaker 01

  So I also like hear it as, you know, a metaphorical commentary, perhaps on the experience they're having here and now. So no, I don't bring a stockpile of stories to tell patients. I get curious with them and try to, you know, expand the space for the patient to notice and intend to more of their experience.

• 3:14David Puder?

  That's good. Yeah. Okay. What are indicators that it is appropriate time to address the transference? So like when?

• 3:24Speaker 01

  How often do you address it?

• 3:27David Puder?

  And then how early? Yeah.

• 3:30Speaker 01

  Ooh, yeah, that's a tough question. So first of all, we're always addressing the transference. Like the transference is never not there, right? And the countertransference is never not there. If there's two people in a room interacting and they're alive, there's transference and countertransference. So I would rephrase the questions like, how do we make constructive use of the transference? Well, that's such a potentially big question.

• 4:00Speaker 02

  Can I, can I break it down? Sorry.

• 4:02Speaker 01

  Yes, please.

• 4:03Speaker 02

  Can I break it down a little more just based on my cohort and thinking about like, what was driving, you know, this question in large part? Because as we said, we have people from all different types of practice and different developmental points in their professional lives. But this idea of like, and you'll probably speak to this at many points today, but how much of the time are you really focusing in on the transference versus like the content of what's coming up? You know, like early on, are you allowing for more time for the story and the content?

• 4:44Speaker 02

  Or are you initially, right from the beginning, bringing in issues of the transference and countertransference more overtly?

• 4:57Speaker 01

  We try to create a relationship where the patient can talk as freely as possible. Maybe we like, really the instructions to the patient are, you know, whatever you notice here, whatever you become aware of here, whatever comes to mind for our purposes, it's important, try to say it. So we're not overly structuring it and what the patient has to talk about. And then I'm going to divide your question into two sub-questions.

• 5:23Speaker 02

  Right.

• 5:23Speaker 01

  As a practical matter, we have to be very, very attentive to negative transference. You can let positive transference ride. We'll, we'll deal with it later, but very early in treatment. I mean, really from the first meeting, you know, the negative transference, if it's not made explicit, if it's not conscious and talked about and acknowledged, can blow up a treatment before it even starts. So one version of a transference interpretation is, you know, you make some observation or comment, whatever, and the patient, you know, starts defending themselves. And right, right.

• 6:07Speaker 01

  So there's a negative transference there. You said what you said for whatever reason, whatever clinical reason you had, but the patient heard it as a criticism. So we have to make that negative transference explicit or it could sink the treatment. You know, so in this case, it was really as simple as saying, you heard that as criticism. You felt like I was criticizing you. Right? So I'm just taking something that's pretty close to the patient's conscious experience. And then putting it into words, I'm saying, you know, I can hear this, you know, there's room to talk about this. Let's talk about it directly. So that's one version of, you know, attending to the transference.

• 6:48Speaker 01

  I mean, any negative reaction that the patient has early on, we really want, we don't want to brush over it. Like we really want to recognize it, attend to it, put words to it, and invite the patient to discuss it. No, no, there's another kind of transference interpretation, which I think is really your question, which is, you know, when do we, right? These are sort of the big, you know, the big guns of therapy. When do we bring this in? So there's the content of what the patient is saying. There's the transference of what they're doing with us and showing us in the room. That's actually more important.

• 7:29Speaker 01

  But what we're really listening for is when we can hear parallels, see parallels between the content of what the patient is saying about things that happened in other times, other places, other relationships, and what's happening here and now in the room. Right? So that's the best kind of transference interpretation, the one that, that bridges the gap. So I have a patient who it's been an ongoing theme. She's had a couple of like previous failed therapy attempts. She'll sort of get a little dysregulated and, and then somewhere in there, she'll start to tell me about, right? Her thoughts will go to a previous therapy when the therapist actually said in one way

• 8:12Speaker 01

  or another, like, this is too much. I can't, I'm not like, I'm not up to handling this. Right? So, so I make the link, you know, and I might say, you know, that, that came up, your thoughts went to this previous therapist just on the heels of, you know, of telling me about this overwhelming experience. You know, it makes me wonder, you know, whether you're concerned that you're going to be too much for me right here, right now. So it's really very close to the patient's experience, but I'm making a link between something that happened in their past and then something happening in the room. So we want to listen for those links. And actually, there's three links.

• 8:53Speaker 01

  It's the links between things that happened in past formative relationships, often parents or siblings or an important teacher, things that are happening in current important relationships, you know, with a partner, spouse, girlfriend, boyfriend, some, you know, important attachment figure, and the therapy relationship. So past relationships, important present relationships, the therapy relationship. And when you hear the same pattern and you connect, connect the dots and say, oh, here it is, here it is, here it is, in these three areas, here it is right between us. That's really the ideal kind of transference interpretation. It links it directly to things that are important in the patient's life. So, good answer?

• 9:38Speaker 01

  Good answer? Enough answer?

• 9:41Speaker 02

  Yes. Yeah. I imagine a piece of this is also informed by your conceptualization of their, their organization. Like, you know, someone who's, who's has more mature defenses, who's more on the inner neurotic range of functioning, it might be easier to have this discussion, more accessible to have this discussion earlier on potentially. Or is that not the case?

• 10:07Speaker 01

  No, that is the case. And, and as you go into the borderline range of functioning.

• 10:14Speaker 01

  Actually, that shifts things. You read the, so what I just described, we call psychoanalytically a genetic interpretation, not genetic in the sense of, you know, genes, genetics, but genetic in the sense of the person's developmental history. When you're dealing with somebody who's in the borderline range, they just,

• 10:34Speaker 01

  it takes it too far out of the here and now experience in the room. So generally, we don't want to make genetic interpretations. We want to focus, you know, certainly through the early stages of the treatment, on what's happening like right here, right now, you know? So my first example about, you know, you felt like, you felt like I was criticizing you. That was yesterday. It actually didn't go very well yesterday because the patient's response was, well, you were criticizing me.

• 11:03Speaker 01

  And, and, and then you get into what people who are writing about mentalization-based therapy, Foniki Bateman and their group, you know, really very good at this. I mean, really staying in the here and now. You know, something like, well, you know, I couldn't understand why it landed on you that way, or why you interpreted it that way. I wonder if you could imagine other reasons why I might have said that. It was like, because you're critical. I mean, well, yeah, okay, yeah. That, that's certainly one way to understand it. Just, you know, humor me. Like, what else could you imagine? You're trying to sort of expand their capacity for mentalization. That is their capacity to think in terms of, you know, the other person's motives and, you know, intentions.

• 11:47Speaker 01

  Right? And it stays very much in the here and now through, and for quite a long time in the treatment.

• 11:55Speaker 02

  Thank you. That, that really answers that.

• 11:59Speaker 03

  You mentioned the past formative transferences, sort of the sources of what's coming up. When you're dealing with patients who aren't ready to go there, don't have the capacity to go there, do you bring it back to the here and now? Like, for example, let's say you draw a connection to their father and you, you bring that up in the dialogue and they're, they're not in a position where they can receive that or process that. Do you then bring that back to the interpersonal dynamic between you and the patient?

• 12:25Speaker 01

  Yes. Yeah. Yeah, exactly. Right? So the, the problem that you have when you're dealing, you know, primarily at the borderline level of functioning is if you look at it through a mentalization lens, there's really a deficit in, in their ability to, you know, imagine somebody else's internal states, motives, intentions, as well as a deficit, you know, in their recognition of their own internal states. You're really working on that. If you look at it through like a transference-focused therapy lens, they're, they're really different sides of the same coin. What the patient is responding to is their projections, rather that, right?

• 13:08Speaker 01

  There's a certain rigidity to the projection where, where the projection isn't, you know, well, you know, this is how I'm interpreting it. The projection becomes, no, this is a fact. So, yeah, if, if I tried to make a, a, a transference interpretation that had the genetic component that linked it to something outside the room and the patient couldn't go there, I would say, oh, you know, that was a mistake on my part. Let's come back to the here and now. Right? And then, you know, then it becomes, you know, how are, how are you seeing me now? Like, like, what's your understanding of how I'm listening to you?

• 13:50Speaker 01

  And, you know, when I'm thinking and experiencing, when I respond to you, who are you right now? Right? What are you experiencing on your end of the relationship? So, yes, short answer, you, you have to come right back to the relationship. And there's a general principle in all psychodynamic therapy, which is the process takes precedent over the content. The process meaning what's going on interpersonally right here, right now, between the two of you. So, I mean, I, I really, really believe that, that the dividing line between a master clinician and not a master clinician is the ability to shift

• 14:35Speaker 01

  from being immersed in, in the content of what the patient is saying and shift attention to what's going on in the room right here and now between us and, and to address that. And, and like, if you guys take nothing else away from today, like, that's the issue. When, like, take this away. When you're feeling lost, you know, or bogged down, or, you know, you're, you and the patient are not tracking with each other, or you're not understanding something, let go of the content. And just think, what, what's happening here in the room between you and, you know, between us? And you can even say it that way to the patient. Right? Something just happened between us, like, like something just, just shifted now. You know, I'm, I'm, I'm not really, if it's true,

• 15:20Speaker 01

  I'm not really sure what, what happened, but something, something changed, you know? Did, do you notice it also? And, you know, help me understand your experience of, of what just happened. You know, who am I to you? Who, who are, you know, who do you think you are to me? Right? So we're inviting, right? We're, we're inviting reflection of the process. Sometimes you get a lot of pushback from the patient. That's not what I came here for. You know, why is that of interest? You think they're the most important thing in the world? Like, why do I want to talk about the relationship with you? You know, and, and we need to know the answer to that. We need to be able to respond. And, and, you know, the, the answer is some, you know, some version of,

• 16:04Speaker 01

  because by virtue of being human, this is how we're built. We tend to recreate and repeat relationship patterns throughout our lives. Right? And we repeat them wherever we go. And then, you know, in your case, it's caused problems for you. And I'd link it specifically to, you know, why they're here. And, you know, what happens between us here is a window into these relationship patterns. Right? If we could understand something about, you know, how they repeat here with us. Right? That, that understanding then spill over into your other relationships. So that you had some freedom, you know, so you don't have to spend the rest of your life

• 16:47Speaker 01

  repeating the same painful or self-defeating patterns. So, you know, when we make these transference interpretations or we shift the focus to the interaction in the room, we really need to know why we're doing it and we need to be able to explain it transparently to the patient.

• 17:04David Puder?

  Okay. Let's jump into some more difficult ones. Okay, we're gonna ratchet up.

• 17:09Speaker 01

  Those weren't the difficult ones.

• 17:13Speaker 01

  We started with some softballs for you.

• 17:18David Puder?

  How have you dealt with sexual transference? Erotic.

• 17:23Speaker 01

  The patients?

• 17:24David Puder?

  The erotic's patients, transference towards you, sexual feelings. How have you dealt with that in the past? What's your approach?

• 17:35Speaker 01

  It's just another transference to explore, right? So, I mean, everything gets really, really simple once you have an understanding of the concept of the therapy frame. Right? The therapy, like, people, trainees especially, often misunderstand. You know, they think the frame is a series of rules to follow. And it's not, it's not rules. It, it's,

• 18:03Speaker 01

  the frame is, is like sort of the rules of engagement for the therapy relationship. You know, what we do here and how we do it. So, part of the frame is, you know, what we do in therapy is we talk about things, right? Anything that you think, feel, anything is, is, is fair game for therapy discussion. In fact, it's something, you know, invited in that we want to hear about, right? Within the rules of engagement, which are, we, it will stay in the realm of thoughts and feelings and fantasies and not be acted on.

• 18:45Speaker 01

  Once you understand that as the therapist and you're like, you know, rock solid, this is what we do. Right? Well, then it's thoughts and feelings and words like anything else. And we treat it like any other transference. But I think behind your question is, right, when you, as you start getting into the like borderline range of functioning, right? You start to get patients that don't really,

• 19:12Speaker 01

  that really don't separate thoughts and feelings from actions, right? Now we're dealing with those projections. You know, no, you really do want to sleep with me, or, you know, whatever form it takes.

• 19:26Speaker 02

  I'm curious in, you know, regarding this question, people in the more neurotic range where they might have, you know, more of a sense of like, oh, this is, this is inappropriate to, to this setting. And so, so disavow, you know, sort of have that, that part of them, either it's, you know, too shameful or disavowed. And so it's, it's there, but it's unsaid.

• 19:48Speaker 01

  Yes.

• 19:49Speaker 02

  And how, if you're attuning to that, that that might be something coming up, but how would you approach that?

• 19:56Speaker 01

  Well, yeah, that's a really good question. So I mean, this is, when you think diagnostically, I don't mean DSM diagnostically, I mean psychoanalytically, case formulation diagnostically. Like, this is a real dividing line between neurotic and borderline level functioning. Like, the neurotic level functioning, I mean, the person typically feels guilty and ashamed and hesitant. And, you know, they're, they're not going to come out with it directly. Especially these, these sort of, you know, cross-sex therapy pairs, where, you know, it's like the patient thinks it's inappropriate, but now you're dealing with, you know, old fashioned garden variety conflict and defense. You know, I feel certain things, I have certain,

• 20:41Speaker 01

  you know, desires, wants, and something inside of me says, but no, it's not okay. You know, you shouldn't feel it, you shouldn't talk about it. The borderline patient is more likely to act it out, right? Right? Not, right? It's not, it's not, it's not buried and under the surface, right? I mean, they're being openly seductive, right? Or openly, you know, openly salacious. So the, the neurotic level is, you know, I mean, it's harder for the therapist to deal with because often the therapist also feels uncomfortable with the topic. But the way we deal with that kind of neurotic conflict for, you know, for anything is, you know, we listen to the derivatives, which is to say that, you know, the metaphor,

• 21:24Speaker 01

  we, we pick up on it. And, you know, we really want to signal to the patient, you know, first of all, we hear it. Second of all, unlike the patient, you know, hopefully, we're not passing judgment on it. And third, like everything else, it's something to be curious about that we can think about, right? Like, it might hold some meanings. You know, so sometimes I use humor, like I was treating a pretty high functioning person. And it was the situation you described, but, and she, but she was pretty, you know, she was pretty straightforward

• 22:04Speaker 01

  about it. She's like, like, you know, oh, you know, yeah, I mean, I, I could never tell you about, you know, I could never tell you about, oh, I remember. She's like, I, you know, well, you know, I have some thoughts, but, and, and feelings, but, you know, it wouldn't be, it wouldn't be appropriate for me to say, because, you know, you know, rules and, and boundaries and, and frame. She had the idea of frame, but was misusing it here. She was, you know, it's like, it's not appropriate for therapy. And I just like used a little humor. And I'm like, I think you misunderstand, but the rules are for me, not for you. I'm the one who has to follow the rules. You get to say, you know, you

• 22:45Speaker 01

  get to say whatever you think or feel. I mean, so we just sort of broached the topic that way. And it, it took quite a while. But, you know, you really want to continually invite it into the room and communicate to the patient, yeah, this is just one more pretty normal, common human response, and so much more grist for the mill.

• 23:12David Puder?

  I, I think, um, maybe there was a, there was an example in one of my groups where it was like an overtly, it wasn't like a psychodynamic case. I don't know, does anyone, does anyone feel like they have an example of this that they feel doesn't fit this kind of approach? And maybe they just want to share it? Okay, no one.

• 23:34Speaker 01

  Be brave. I mean, it, it comes up all the time. Like, you know, look, you guys are, just from my take of your little postage stamp windows on the screen. I mean, like, you guys are young and good looking. It's going to come up. It is coming up. You, you may or may not be attending to it, but it is going on between you and patients.

• 23:55Speaker 02

  Do we, or do you want to give, and do you want to stay with this, given more of an example, David? Or do you want to, do you want to pivot to like, to the countertransference regarding sexual transference here? Countertransfer?

• 24:10David Puder?

  Um, I, I think, okay, so I think it could be a little bit different if it's like someone who's coming off of meth and you're in the inpatient as a psychiatrist, you know, and it's obviously just inappropriate. It's like, okay.

• 24:24Speaker 01

  But you're not doing psychotherapy under those conditions. You're doing, you're, you're managing, right? You're, I mean, this is psychiatric management. If you're doing psychotherapy, meaning you have an ongoing relationship, right? You're, you are both expecting and planning, you know, to meet on a regular, ongoing basis. And the purpose of the therapy is deeper self, self-understanding, self-awareness, right? And not for its own sake. I mean, deeper self-understanding, it, so the person can be, can free themselves

• 25:05Speaker 01

  from having to, you know, from being sort of destined to live out the same unhappy patterns over, over again. And so the person can be, you know, more whole, just say, you know, more, right? If the, if the person is, if there's like splitting or dissociation, you know, more whole and integrated, if the person is in, right? That's borderline range. In the neurotic range, the person is, you know, conflicted, right? Certain parts of their experience are, you know, welcome and, you know, get to be seen and heard, heard from, others not, right? We want to hear from all of the sides of the conflict, right? When you say more whole, right? The person's sense of themselves encompasses more of their

• 25:49Speaker 01

  experience. Um, let me say that. So if it's, if it's that kind of therapy, then sexualized transference is just one more kind of transference. Right? What do we look for in the transference? Right? The person is repeating difficulties in their life. It's not a one-time thing. I mean, it's a pattern that, that we, we can see recur, and ideally they can see recur. We're listening for that theme, but we're also looking for the convergence of that pattern with a pattern that's happening in therapy. So this really depends on their capacity for insight and, you know, reflection. But that's a pretty fertile ground for interpretation.

• 26:33Speaker 01

  And, and, you know, the interpretation, you know, you think of, think of it in terms of scaffolding up to the interpretation. And the scaffolding is clarification, confrontation, interpretation in, in psychoanalytic work. You know, clarification is, you know, this is happening. Let's bring it into focus. Let's, let's, you know, let's recognize this. So, I mean, there might be, you know, they might be telling you about one of these difficult triangular relationships with, you know, that they get into. And you say, you might,

• 27:13Speaker 01

  the clarification might be, you know, that, that sounds like another one of these triangular relationships that always involves some, you know, sticky situation with a third person. The clarification doesn't ask the patient to do anything. It, it, it, right? It, it is just, it's just sort of bringing something that we think is important into focus. Or if it is asking the patient, it's asking to elaborate and say more. And are you getting that right? Are you getting that wrong? Right? Right? Can, can they clarify the experience? The confrontation is, what about that? Let's think about that. I mean, we want the patient, confrontation is not confrontation between therapist and patient. It's asking the patient

• 27:57Speaker 01

  to confront themselves with more of their experience, right? Basically to pay attention to it. Let's, let's pay attention. And let's really think about it. Interpretation is making a link that, that's not already apparent. And in the example you gave, it says, you know, I might say something like, see, once it's established, here's the triangular relationship that, you know, that you're describing. Here's the kind of, it's the kind of thing that gets you in trouble for, you know, this or that reason. You know, here it is, it seems to be happening again in this certain situation you're describing. Right? Once, that's the scaffolding. Once that's established, then you're in a position to say, you know, it,

• 28:39Speaker 01

  it seems to me that there's a way that that same thing is happening here between us. You know, what do you mean? Say, well, you're tell, I'm just making this up. But you know, you're telling me about how, you know, this person is in the position, you know, of having to see or hear about what's going on between you and this other person. And this, this third person is in, you know, this, this, this, this third person is seeing things that, you know, either trying to draw them into something or trying to let them know they're not included in something or whatever's going on. You know, there's

• 29:18Speaker 01

  something in the way you and I are talking about it. And it's just like, it seems like I'm in that same person's situation. Do you see how there's something similar happening in what you're telling me about? And what, what happens between the two of us right here as you tell me? Now I'm, you know, I'm the witness to something. And, and then it becomes a question of how much curiosity, right? Because what we're really after is curiosity. I mean, we're always sort of testing the limits of the person's capacity to get curious about themselves. Do you see how this is happening here and there? Oh, I never

• 30:02Speaker 01

  thought about it that way. I mean, I guess, I guess I am putting you in that position. It's like, what about that? Let's think about that together. You know, help, help me understand what that means for you, just right here, right now. So that's a way of working with it. And I will add, I know there's other questions that the thing that gets in the way for therapists, especially younger therapists, you know, is we're like, we're uncomfortable with our own sexual feelings toward the patient. I'm not supposed to have it. I'm only supposed to have like benign physicianly or therapist-y feelings toward the patient. No, we're supposed to have the full range of all of the normal feelings that we have in all of human life,

• 30:46Speaker 01

  right? Within the frame of anything I think and feel is fine, but there's a frame about, you know, what we do and don't act on. Like, so then I'm like, huh, you know, feeling attracted to this patient, or feeling put off by, repulsed by this, whatever it is, more than I normally would. Right? My internal process as a therapist is, I should have noticed that. Say, okay, well, how much of this is about me? You know, my life situation, the kinds of things I'm attracted to or put off by, turned off by, how much of it is it about something going on in the relationship with the patient? Right? And so doing that internal work. And that's, you know, that internal work is what prepares us, right?

• 31:31Speaker 01

  To say something that's helpful to the patient. If we back away from it, oh, I'm not supposed to think that. I'm a, hey, I'm not supposed to be attracted to my patient. Bad thought. I shouldn't think that. Right? Then we close off a channel of information. Because our feelings are in part, you know, created in response to something happening in the relationship. I saw somebody wave a hand. Daniel.

• 31:54Speaker 04

  Yeah, thank you. I'm, this all makes a great deal of sense. I find myself sort of wondering about the issue of the behavior itself, like how much of that comes into the interpretation? Because I could, I could sense myself, like putting myself in carly shoes, feeling really uncomfortable about that content part of it.

• 32:14Speaker 01

  Yeah. And that's the work we have to do, right? The question becomes, why is the patient doing that? And then, you know, how do we work with them so that they can start to get a sense of why? Right? So you just put a hypothesis on the table. The hypothesis is either true or not true. We don't know in advance. We have to explore it. So one hypothesis is, this is, there's something performative. It's a defense against talking about, you know, it's a defense if, you know, we say, if they weren't doing this, what else might they be talking about? Right? So if, if, if there's something that starts

• 32:56Speaker 01

  to feel, you know, sort of repetitive or scripted, right? In how the person presents, then we think, oh, okay, you know, that's not free. We're, we're looking for free association, which is, you know, just really say whatever comes to mind, be open to attending, right? To whatever we notice. But the person isn't doing that. So we could think of it as a defense or resistance. Right? Another hypothesis, right? Another hypothesis is, they want to enact something with you. They're trying to titillate you. They're trying to get a response. I don't know, so that you should feel left out, not them. Right? Or there's

• 33:34Speaker 01

  a whole lot of hypotheses. So, you know, one option, you know, might be just in a very wide open way. I say, but you know, this, there's a way that you're, you know, you've, you've told me about this situation, this situation, that situation, you know, now, again, you know, there's a way, it seems like it's, you're telling it, you know, in a way that seems like, you know, I don't know if you should say it directly, in a way that, you know, seems like you want to tell, in a way that's titillating for me.

• 34:13Speaker 01

  You know, I'm, I'm curious about that. Help, help me understand that. And, and of course, when we say, help me understand that, what we really mean is, you know, let's hear more so that we both have a chance to understand it, right? We, you know, we, we ask the patient, help me understand it. But part of what we mean is, let's, let's look at it and think about it so that we can both understand it. So, you know, help me understand that. He said, well, I didn't, the patient says, suppose, well, I didn't really think about it that way. Yeah, I, I know. But now that, you know, I've put it on the table and, right? It's out in the open as something that we can think about. I wonder what your thoughts

• 34:57Speaker 01

  are about this. And so that's part of the scaffolding. That's, that's clarification. This is what, you know, here's something I want to bring into focus. Confrontation, which really, confrontation is, is just clarification plus an expectation that the patient should pay attention. That, that's, that's really all it is. And then we see where their associations go and what comes up. Right? We tune our ears to, is this taking the place of something else that they might be talking about? Is this repeating something else? Right? If it starts to sound like it's taking the place of, you say, you know, I noticed there's, you know, there's a kind of pattern, you know, they're almost, you

• 35:40Speaker 01

  know, to, to make one random example, like, almost like you feel like your role is to entertain me or to, you know, perform something for me or to keep me titillated. Right? I want, I wonder what, what that's about. And, and then we listen to what they say and maybe we get to be able to say something like, you know, maybe it's easier to do that than to pay attention to, you know, whatever else might be coming up. Huh. I wonder about that. So we're just continually inviting the patient to take things that they do

• 36:22Speaker 01

  pretty reflexively and automatically, and slow down enough to pay attention to them and to recreate some space to notice more, just, just a bit more than they noticed previously, and to think about the bit more, and to put that into words, right? And, and that's the process that that's transformative. Right? We're, we're trying to create spaces, you know, pauses between things that otherwise happen very, you know, very quickly and automatically, pauses to notice and reflect. And out of those pauses, right, comes the understanding and, right, the freedom and flexibility to maybe be able to do something else.

• 37:09Speaker 03

  A lot of great information. You, you've alluded to some countertransference. And so I, I think the group is curious, you know, how you've dealt with countertransference, particularly idealization? And if there has ever been any sort of idealization dynamic with a patient that you can recall, if you'd like to share about that?

• 37:30Speaker 01

  Yeah, well, for me, idealization is like waving a flag, red flag, because I know what comes on the heels of idealization, right? So there's, I mean, there's sort of milder, like neurotic level idealization, which we could say is, you know, positive transference, the patient wants to feel cared for, feel like they're in good hands, feel like they're, you know, somebody who knows what's, what's what, knows how to help them. But then there's idealization in the sense of, you know, borderline level defense, which is half of devaluation, you know, which is the defense of, of splitting. Right? So when we're, is that, is that what you're referring to?

• 38:07Speaker 03

  Yeah.

• 38:08Speaker 01

  Yeah. So there's something very seductive about the, right? It, it comes up especially with narcissistically organized patients. There's something very seductive about the idealization. Because if we have, you know, our own narcissistic vulnerabilities, and we all do, it, it becomes very tempting, you know, to kind of join the patient in this mutual admiration society, you know, we're like, oh yeah, we're, we're both, you know, we're both so special together.

• 38:41Speaker 01

  But you have to remember, you're on one side of a split. You're now the good, idealized object. And where they're splitting, you could very easily, you will, if the treatment goes well, you will end up on the other side of the split and you will become the, you know, the bad, devalued object. So, you know, again, you know, how do we work with, with splitting? Actually, David had a wonderful podcast with Frank Yeomans. And I thought Frank Yeomans did a masterful job of illustrating, working with a certain kind of splitting. So, so, something that often goes along with either idealization or do,

• 39:26Speaker 01

  let's stick with idealization, is a kind of omnipotent control. It, it's not just that you're seen as idealized. You're expected to, you know, behave in a way that's consistent with the idealization. And, and you find, you know, there's a way the patient is managing you into being that idealized person. And what, what Frank did in the podcast that I, I mean, illustrated so masterfully, is, you know, he noticed, right? This is the countertransference, the, right? If, if you can, if you can notice the seduction to feel like, yeah, I am, I am a better and smarter therapist than the last five people this person saw because

• 40:10Speaker 01

  I'm really that good. I, right, I, I get pulled into that, hopefully just momentarily. And then like, oh yeah, I know that feeling. But hopefully you notice that. Then the next thing is, you know, it, it seems that, that like, then I noticed that I'm, I'm, I'm feeling managed. I'm supposed to talk about certain things and I'm not supposed to talk about other things. I'm supposed to talk about things in a certain way. I mean, so we could, we can make that, right? Right, because there's something very limiting about this. You have to be the idealized object, right? In a way, you don't get to be a full human being.

• 40:52Speaker 01

  You don't get to make mistakes, which we all have to make mistakes because we're human. If you do make mistakes, they can't be acknowledged and recognized, right? They have to be sort of like reshaped into something that the patient can idealize. So, you know, what, what Frank does is bring that, you know, more into focus. You know, like, it wouldn't be okay for me to fall short in this way. And, you know, like, you know, I forget the specifics, but the way that you're feeling managed. And basically what he does is say, but you know, there, there's more to it than this.

• 41:35Speaker 01

  You know, you see me as, you know, wise or the one with the answers or whatever it is, whatever form the patient's idealization takes. Just, but, but you know, there, there's more to, there's another side to this. Because, you know, I mean, in seeing me that way and in sort of shaping on conversations so I could be, you know, so that I am that to you. You know, it, it, it suggests that, you know, it suggests that there might be another way of experiencing me in the background that's, you know, dangerous or, you know,

• 42:20Speaker 01

  or, you know, that you need to protect yourself from. No, no, no, you're the greatest doctor. Well, well, yeah, but that, that's not the whole truth, right? That you're, you know, the fact that you're managing our interactions in the way that you do, right? Tells us that there's a part of you that's worried about another side of me. What about this side of me that screws up? What about this side of me that misunderstands? What about this side of me that, you know, gets it wrong?

• 43:01Speaker 01

  I mean, it, it seems like there's a way that we're doing something here to, to, to protect yourself and, and me from encountering all of that. And so he's, so basically what he's saying is, there's, there's two parts to the split. You know, for you, it's, I'm this or I'm that. You know, but for me, and maybe with some work for both of us, maybe we could see that it's, you know, some of this and some of that, right? So he's always inviting the patient to bring together the split experiences that the patient is really working to keep apart.

• 43:38David Puder?

  Okay, so let me, let me jump back to your prior example. Patient says, all my previous therapists, I was too much for them. She's telling you the story of her awful trauma. She's saying, you know, I'm remembering back as I'm telling you the story, how this previous therapist said, like, this was too much for me. Is that a subtle idealization of you? Or is she fearful of you abandoning her?

• 44:03Speaker 01

  No, she was terrified.

• 44:06David Puder?

  Well, okay. Is she, is she?

• 44:09Speaker 01

  Yeah, it like, she was, yeah, it wasn't, it didn't have a narcissistic flavor, but like, a patient, but a patient who met, you know, like, I've also had patients, like, you know, I've seen five therapists in the past and they didn't understand me and they weren't good enough, you know, but you, you know, now I know I'm in good hands, right? That's, that's, that's the idealization.

• 44:29David Puder?

  What, what is the, so is, was it more the abandonment fear, do you think?

• 44:33Speaker 01

  From my patient?

• 44:34David Puder?

  From your patient? That you would abandon her like these previous therapists abandoned her in the midst of it?

• 44:39Speaker 01

  Yeah, I think it was two things. One was the abandonment fear, right? It wasn't a fantasy, like, it had really actually happened. And the other was her own fear of, you know, overwhelming pain, rage, you know, I mean, just overwhelming feelings, right? So I heard it as, I'm afraid I'll be too much for you if we get into, you know, certain things. I'm afraid it's too much for me, right? I'm, I'm too much for you, I'm too much for myself. And, and real, I mean, it's much, much complicated than that, but really, in a very basic sense, the solution to that is the therapy frame. Well, you know, everything, I never said this to her, but it was always my, everything

• 45:24Speaker 01

  that we say and do here is thoughts and words, like, you know, really, within our, you know, 45 minute session, I mean, really, what's the worst thing that could happen?

• 45:40David Puder?

  Are there any examples of devaluation that have occurred in your practice and how did you deal with them?

• 45:48Speaker 01

  If it's, if it's really sort of borderline or narcissistic devaluation, and, and this really applies to any kind of like, projection or projective identification, right? The, the difference, the difference being projection, the patient sees you as somebody that you're not, right? And it's pretty insistent that it's true. Projective identification is, they do that and they also somehow manage to get you feeling, maybe acting like the person that you're not, right? So it, it's a defense for two, right? It pulls the therapist into it. In one way or another, the patient pulls, pushes, you know, manages you into the role that they're projecting.

• 46:31Speaker 01

  There's, there's really only two things that you can do that are wrong. If it's a devaluation, it's usually, you know, pretty offensive, right? Like, nobody likes to feel devalued. Like, you know, we get angry or, or, you know, or we start to feel, you know, inadequate. Well, what if the patient is right? Like, oh my, like, what if I'm totally missed the mark? What if I'm, I'm, I shouldn't, I'm not good at doing this work, but maybe I shouldn't be a therapist at all, right? You know, so, so there's, there's two things that therapists are pulled to do that we want to not do. And, you know, one is to take on the projection.

• 47:15Speaker 01

  And, and we start feeling really, you know, in doubt about ourselves or helpless or hopeless in, in our ability to do the work. And we have to let ourselves feel that. That's, that's part of it. I feel that. Hopefully, we then, you know, bring an observing ego online and say, well, wait a minute, I don't feel this way with all of my patients. There's something going on with this specific patient. What is it that's going on between us? What's happening? Why am I feeling this way with this person right now? Right, so then I shift from, I'm a crappy therapist to, maybe this is information about the patient and about what's happening in the relationship. So, so, sorry, I'm getting, I'm getting a little, um, let me stay focused.

• 48:00David Puder?

  Can you get?

• 48:01Speaker 02

  No, this, this is good. Oh, go ahead, David, sorry.

• 48:04David Puder?

  Oh, I, I want to get some like, like, was there examples that really stung or like, like?

• 48:10Speaker 01

  Oh, yeah. Let me, let me come back to that. We just, there's a principle here at the night. Let me, so there's just the two things we don't want to do. One is, we don't want to

• 48:23Speaker 01

  You know, we don't want to be taken over by the projection and, you know, and basically say to the patient, you know, yeah, you know, you're right. I am these bad things and continue to feel and act that way. Right. So we don't want to be overtaken, you know, if we're swallowed up by the projection. That's one thing that happens. The other thing that happens is the therapist gets very offended and, you know, angry and, you know, and Glenn Gabbard has this wonderful phrase. He says, you know, the therapist wants to take the projection and cram it back down the patient's throat. Say, I'm not the one being, you know, angry and, and, you know, oppositional and impossible. You are, and here's why you did this and you said that.

• 49:07Speaker 01

  Right. But that's not helpful either. So to answer your question, how do you work with it? We say, we talk about containing the projection. Containing the projection, right, is not agreeing with it, you know, and basically conveying to the patient, yeah, you're right, I am this awful person. And it's not cramming it back down the throat, their throat and, you know, sort of counter attacking and turning the tables on them. Right. Containing is, right, I'm not in a hurry to disabuse you of your idea. This is how you're experiencing me. Right. That would feel like really crappy if this came, this literally came up yesterday.

• 49:48Speaker 01

  If you have a, if you had a therapist, you know, who you think is in this, you know, to just to have the upper hand, you know, to handle you and manage you. Right. That would feel, that would feel really shitty.

• 50:06Speaker 01

  So notice, I'm not saying that it's true that, you know, I'm in fact doing this. And what I'm really doing is jockeying for the upper hand. You know, I'm also, right, but I'm also not saying it's false and trying to, you know, convince the patient otherwise and say, let me tell you why it's not true. What I want to do is allow them to have their perception of me. This comes back to the therapy frame, right? There has to be a mutual agreement, right? Things, shit's gonna happen, things are gonna go wrong in the session. A mutual agreement, whatever happens, we'll continue to meet. We'll make our best effort to talk about it with each other. That's what we do here.

• 50:50Speaker 01

  That's different from all the rest of life, all the rest of life. You, you know, have your projections and act on them and play them out. And then the same pattern repeats over and over again. Here we're going to do something different. You're still going to have your projections and play them out and repeat them over and over again. It's still going to happen. But we're going to talk about it. We're going to explicitly make it part of the, you know, our treatment contract and part of our frame. That one of the things we do here is talk about what happens in our relationship. Right. So containing the projection is allowing the person to have their experience, neither agreeing nor disagreeing, you know, empathically recognizing their experience. What I tried to do when I said, like, that would feel really shitty.

• 51:33Speaker 01

  If you think that I'm in attack at the upper hand, I mean, what a horrible position that would be in. Right. And I'm not being, I'm like playing coy and like sincere. Like, I would genuinely feel like shit.

• 51:47Speaker 01

  But I'm also leaving it as an open question. Right. That's her experience. It's a fact that it's her experience.

• 51:55Speaker 01

  But it's an open question. What's happening between us that's, you know, that's leading her to have that experience of me? Right. And whether there could be the potential to have other experiences of me. So that's what containing the projection is. So don't, don't do two things. Don't let the patient sort of bowl over you and get you feeling like, oh, God, I'm, I am no good. But don't be in such a hurry to disabuse the patient of their, you know, mistake either. Treat it as something like, let's let them have their experience and let it become a topic for exploration.

• 52:33Speaker 01

  Like, so to answer Mike David's question, you know, suppose the patient responds by saying, you know, ha, see, I knew it, you know, you are trying to get the upper hand. So, well, I, I didn't, I didn't actually say that. I mean, I'm, I'm hearing you and I'm getting that that's your experience of me. And, you know, and why it feels like shit for you. I mean, and getting that's your experience. I, I, I didn't say that that's what I'm thinking or doing. I'm focusing on your thought. I didn't say that was my experience. I'm focusing on the experience you're having.

• 53:15Speaker 01

  And then if you have a particularly difficult patient, like the one I had yesterday, it's like, well, that's another way of getting the upper hand.

• 53:23Speaker 01

  Well, what, but most patients aren't that difficult, thank God.

• 53:28David Puder?

  What advice would you give to the, the therapist who's like more, who has a very sort of, um, maybe a some depressive personality style stuff that's very internally critical?

• 53:39Speaker 01

  Yes.

• 53:40David Puder?

  Evaluation feels very, it's, it's hard for them to even hold that. They ruminate on it outside of sessions. What would you say to that person?

• 53:49Speaker 01

  That's a great question because it's the most common configuration. So most therapists, you know, like most, like pretty solid, good therapists to differentiate, tend to have, you know, some version of a depressive personality style. Like, you know, hopefully a neurotic level depressive personality style. I mean, when a patient project, a projective identification is like a really interesting thing. The patient doesn't project into a vacuum. The reason it becomes a projective identification and the therapist feels something is because the, the projection hooks something that's already inside of us.

• 54:29Speaker 01

  That's, you know, already there and, and like sort of waiting to be activated. Right. So, right, the patient finds a way to tap into something that's already inside of us. And now it becomes a, you know, potentially it could become a very difficult enactment because the therapist is very likely to feel that way. Especially like, I was gonna say early in your career, but this actually continues for much of your career. I mean, this is really tough, challenging work. We are always faced with something new and different that we haven't seen before.

• 55:09Speaker 01

  It, it's an occupational hazard for therapists to be questioning and doubting themselves. And, and we also get in a like a certain like, you know, special way of beating ourselves up, like some common variants are. Like if the treatment goes well and the patient seems to like getting better, it's like, you know, we, we credit the therapy and the method, but, but if it's not going well and the patient does not have a good reaction, we blame ourselves, right? That's a pretty common trap that we fall into. So if we really know that about ourselves, you know, hopefully we can take some, some distance. Right. And say, oh yeah, you know, I, I recognize that again.

• 55:51Speaker 01

  Sometimes though, that's, that's really where either your personal therapist or a supervisor comes in. You know, sometimes you really need a clinical supervisor to help you take distance from that. You know, to step back from it rather than being lost in, oh my God, you know, I, I, I suck and I really don't know what I'm doing. Right. Sometimes you need a third party involved or a second party or a guy to, to say, but, you know, well, but wait a minute, you know, you don't always feel this way. You didn't feel this way with, about the patient you told me about two weeks ago. Something is going on here with this one. And then you start to step back from it, right?

• 56:32Speaker 01

  So it's shifting from a position of a, in classical analytic language, an experiencing ego. You're, you're lost in the experience to an observing ego, where you're going to sort of step back from the experience and observe it and think about it and try to understand something. But, right, it really does take, it really does take another, you know, another mind involved some of the time. So I would say we never really outgrow the need for clinical consultation. You know, I would say, like, for, I don't know, the first five years of your career, like post licensure, it would probably be a good idea to have a supervisor or a clinical consultant, you know, for regular meetings.

• 57:17Speaker 01

  And, you know, if you're like senior in your career, like me, like I, I don't, I don't have regular weekly meetings with someone. But there's always somebody that I can contact when I feel like, you know, this is like a struggle. I need another, I need another mind here. And so you, you really never outgrow the need for clinical consultation. And if you're working with borderline level of patients and that includes, you know, the more severe end of narcissistic pathology, then you really need that supervisor. Because the, the projections, the projective identification are just so powerful. You just, you get just sucked into it and you need someone else.

• 57:55Speaker 01

  And, and the interesting thing about every evidence-based treatment for borderline personality, the thing they have in common is they all have like extensive consultation or supervision for the therapist. That's true if it's psychoanalytic, like TFP, it's true for Marshall and hence DBT. Right. Like that's the common thread.

• 58:21David Puder?

  Jeanette here says, how do you respond to a patient who is very sensitive to judgment and asking for reassurance about how you view them? Do you provide reassurance?

• 58:31Speaker 01

  No. If you provide reassurance, it's tempting. You know, most of us go into this field, you know, we're like pretty tender hearted people and we want to help other people. And, you know, you see somebody in pain and looking for reassurance and really, you know, kind of tugs at your heartstrings and you want, you know, you want to give them that reassurance. And they'll feel better in the moment, but you know, what we have to keep in mind is we're just participating in a pattern, right? The, you know, the, you know, the cure, giving, giving them the reassurance is in fact the disease.

• 59:16Speaker 01

  It leaves untouched and unexplored. What's going on in the patient that, that they're so continually in need of reassurance? And, you know, we can think of this as a projection also, but more often than like healthier neurotic level of projection. The patient is, the patient is very worried that you're thinking ill of them or judging them harshly. But we, as the therapist, have to remember, the call is, is coming from inside the house, right? The judgment is coming from the patient. They hear it, right?

• 59:58Speaker 01

  As if it's coming from us, or at least they, you know, worry that it's coming from us. But it's coming from inside of them. And, you know, so with a, like a healthier level patient, I mean, you know, one way of working with it is we want to help them to become aware of that, right? If, if, if the call is coming from outside, there's never a solution. You know, every new person is like someone who's potentially judging them that they need to, you know, be reassured by and it never ends. Um, you know, so something I say fairly frequently when this comes up, like the patient, it often takes the form that the patient's hesitant to tell me something, they think I'm going to think less of them, I'm going to, you know, judge them for it.

• 1:00:42Speaker 01

  And, you know, one very gentle way of interpreting that kind of projection, right? That's, that's the transference, that the projection is the transference, is I might just say something like it, it's hard for you to believe that I wouldn't be judging you as harshly for this as, as you're judging yourself, right? In other words, a very gentle way of saying, maybe this doesn't belong to me, maybe this is something that belongs to you. And, and what I'm trying to do is open the door to be able to hear about the person's internal harsh judgment and, and the whole, you know, interconnected network of things

• 1:01:26Speaker 01

  that that relates to, right? Their associations, their memories, their fantasies, right? Somewhere along the line, they've internalized a relationship with some, you know, important detachment that's, you know, critical or judging, right? But now that judging and criticizing is theirs, is them judging the filth, right? When we can start making these links, you know, you're feeling this way, we would like the patient to say, oh, you know, that reminds me, I don't know why this comes to mind right now, that reminds me of this time, you know, you know, I spilled the milk and my, you know, mother like punished me and I couldn't watch TV for a week or what, right?

• 1:02:08Speaker 01

  And then you get to make the links, it's like, but, you know, I would sort of be appreciative that they came with that association. And I say, you know, it's like, it's like that part of you that spilled the milk and got that harsh response. It's like that, that, that part of you is, is here in our relationship, right? There's a way you're expecting the same treatment from me. And the patient starts to differentiate what's past, what's present, what's another relationship, what's this relationship? And that's really the work. And, right?

• 1:02:49Speaker 01

  And that leads to psychological change that the patient takes outside of the consulting room, right? Something is, right? Something is shifts and is different about them, right? That changes how they relate to other people in, in real life. And so the goal of the work isn't, we're not doing this so they have a better relationship with us, although that's the vehicle. You know, we're doing it so they can have a better relationship with us because that understanding and knowledge of where things go wrong and how and why, right? Then transfers over into real life and the patient is different. And then you start really enjoying their company because they're like, become really cool and interesting and you like seeing them. And around that time, the patient decides that their relationships are really going

• 1:03:32Speaker 01

  well and they're better and they don't need therapy so much. And that's like the tragedy built into being a therapist, you know, like just, and I guess being a parent also, I like, you know, like, just around the time that you're really getting something out of this relationship too, because they're so engaging and open and present and, you know, around then is when the patient starts thinking and should be thinking, yeah, I think I got what I needed here.

• 1:03:59David Puder?

  I think Dr. Latal had a, had a question, maybe you could delineate it a little bit, Dr. Latal. She said, is this consistent with children?

• 1:04:10Speaker 01

  Oh, yeah, I don't, I don't know. I don't work with children, so I can't really speak with any expertise. I mean, we're, I mean, with children, we're, I mean, we're, we're kind of often trying to develop a, a, maybe sort of a precocious capacity for self-understanding, right? In the service of overcoming a particular symptom or, or difficulty. I mean, so we are working toward understanding, but it's, it's really a whole different way of working, as I'm saying.

• 1:04:43David Puder?

  Okay.

• 1:04:44Speaker 01

  Not, yeah, I'm not the ideal person to ask.

• 1:04:47Speaker 02

  We don't have to get too far into, into that, but, you know, going off of what you were just talking about, what if, you know, there's a transference there in like the reassurance seeking, but like, you know, the, the patient's like, I'm, you know, I'm boring you, right? Like, I'm just, I'm worried that I'm boring you, you don't want to see me all these things.

• 1:05:06Speaker 01

  If we provide the reassurance, we are entering into an enactment, right?

• 1:05:13Speaker 02

  Right.

• 1:05:14Speaker 01

  We're, we're, we're living the transference and the counter-transference versus understanding.

• 1:05:19Speaker 02

  So, so you're not providing the reassurance and I, and, and I understand, you know, the, the reasoning behind that. But what if, like, what if you are feeling all of their fears, right? Like, what if, in the moments when you're feeling incredibly bored and they're worried you're bored, or you're feeling sleepy or whatever, or you're feeling like they are too much, or you just want them to go away, and that's their big fear, right? Like, you're not going to say that, obviously, but, but how do you approach those?

• 1:05:50Speaker 01

  Well, you, you might say it, actually.

• 1:05:53Speaker 02

  Okay.

• 1:05:54Speaker 01

  So, we don't want to, um, unless the patient is, you know, functioning at a psychotic level, and even then, there's some truth to it. I mean, you know, however distorted the patient's perception of us might be, you know, it's also based on, you know, some reality that they're picking up. And, you know, the, the truth is, we're not always at our best. Sometimes we're tired, sometimes we're preoccupied with something in our life, sometimes we actually get bored, right? And it's about the patient. I mean, we never want to, you know, sort of damage their reality testing.

• 1:06:37Speaker 01

  We never want to gaslight them by, you know, denying the data of their own senses.

• 1:06:44Speaker 02

  Yeah.

• 1:06:45Speaker 01

  So sometimes it's actually very appropriate to say, you know, yeah, you're, you're right, my attention wandered, or, you know, yeah, I'm, I'm not at my best today, you know, I am tired. I mean, sometimes we want to acknowledge that. I mean, if, if the patient is saying something that's true, we, we don't, you know, we don't want to contradict the data of their senses. But, but then it gets into a much more complicated transference, counter-transference issue, which is, you know, so I have to think about, as non-defensively as I can muster in the moment, like, did my attention wander? Am I bored?

• 1:07:29Speaker 01

  Am I feeling overwhelmed? And then I want to start to try to disentangle, is this something that I'm bringing with me, or is this something specifically in response to what the patient is, is doing? And it gets into the question of self-disclosure in therapy.

• 1:07:53Speaker 01

  I would say if there's a principle involved, what can be helpful to disclose in the therapy is our reaction to the patient in the here and now of the session, which generally not helpful to disclose to the patient is information about us and our lives. So suppose I'm feeling bored and it's not because I'm preoccupied or worried about my taxes or like there's something about what's happening in the room. So you're picking up on something.

• 1:08:33Speaker 01

  I mean, I was feeling all tuned out and my attention was wandering. And you have to be so careful. Patients are so, many patients are so primed to hear something like this as shaming or judging them and we're 100% not after that. We're after curiosity. So we have to be very alert to the patient's readiness to feel shamed. You know, my thoughts were wandering in a way they don't usually. And you know, some of that is me and some of that is us.

• 1:09:18Speaker 01

  I wonder if we could think together about what might be going on here that resulted in this? What experience I'm having, what experience you're having of yourself, of me? Can we expand the field of what we're going to talk about from am I or am I not bored because they're boring? Can we expand that to, well, okay, you are being boring just here, just now. But that's the beginning of a conversation, not the end of the conversation. So something I often say to the patient, a patient is that, you know,

• 1:10:01Speaker 01

  we all have our little lines and phrases that we, you know, that come up. It's like, you know, that's the opening sentence of a whole chapter or maybe a book. And often the patient wants to treat it as, you know, the final sentence in the final period. Well, I'm boring. And I might say that, it's like, you know, you're treating it like it's the final concluding sentence. I think we might look at it as the, you know, opening topic sentence. There's like a whole book to be read here.

• 1:10:34Speaker 02

  That's so good.

• 1:10:36Speaker 01

  There's something going on between you and me here that we're both experiencing in the ways that we do. But you know, just right now, I don't think either of us understands that something. Here's something we can talk about and think about. And I'm also thinking, I'm not saying it because this would really start to sound shaming at this juncture. I bet I'm not the only person that this patient bores, right?

• 1:11:04Speaker 02

  Right, right, yeah.

• 1:11:06David Puder?

  Great. Well, this has been just been wonderful. I think we got to wrap it up so you can get to your next thing. Yeah, thank you so much for coming on, Dr. Shedler. I know we have some super fans here. Some people are very excited to be with us. And I won't embarrass them by calling them out by name.

• 1:11:28Speaker 01

  Oh, I'm looking at all the icons or what do you call them? The emojis? That's, that's, thank you, that's lovely. And I will just say for my, you guys have been, I mean, just a lovely group. This is, this is like really fun for me and everybody who asked questions was asking really good, thoughtful questions. And I can tell that this group is really thinking clinically and psychologically about the issues, which is really nice to see. Like it doesn't go without saying in training these days, like there's something special here.

• 1:12:00David Puder?

  Awesome. Well, okay, we'll leave it there for today, guys. Thank you. Good to see all your faces. Thank you, Dr. Shedler. Thank you, guys.

• 1:12:08Speaker 05

  Thank you so much. Thank you so much, Dr. Shedler.

• 1:12:12Speaker 02

  Yes, thank you so much. It was wonderful.

• 1:12:15Speaker 01

  Thank you all. Yes, I agree. It was good for me, too.