Countertransference and Transference with Frank Yeomans, MD

This is a conversation with Frank Yeomans, initially recorded as part of a special guest speaker series offered to our cohort groups. The groups consist of professionals who have enrolled in small group training opportunities to deepen psychodynamic formulation, reflective function, and facilitate the how of bringing complex cases into a place of thriving. The conversation is generally a question and answer format, and we encourage cohort members to develop questions for people like Frank Yeomans. We've also had Nancy McWilliams and Jonathan Shedler on and different things that may not be released. And we encourage the cohort members to ask questions and really deepen our understanding of things like transference and counter-transference in the process. So in this conversation, Frank discusses counter-transference quite extensively, a little bit on transference, projective identification and using detailed examples that bring concepts to life. A few details were edited out for privacy purposes, but I'm really excited to share this content with all of you. I was struck by Frank's way of inviting the disavowed projected emotion or transferences into the room without over-disclosing or intellectualizing. I hope you enjoy. One of the things I was thinking about with you specifically though is like the role of counter-transference how you use that therapeutically and how you supervise people and help people kind of overcome their or kind of work with their own counter-transference sure um in my own practice in thinking counter-transference is becoming more and more important. I think it's one of the things that psychodynamic therapy has to offer that's missing in the other models. Just a brief reference, years ago, when we did an RCT, where one of the treatment cells was DBT, which of course helps a lot of people, as we observed what was going on in the TFP cell and in the DBT cell, we thought the DBT people did a lot of good work, but they didn't have a concept of countertransference. They didn't know how to use their reactions. They had their reactions, but they didn't have this understanding of feeding it back into the work. And when I talk about feeding it back into the work, the way my colleagues and I handle countertransference is not to disclose, not to say, you go, this makes me angry, I'm feeling angrier, I'm upset, whatever. We talk about something as a feeling. There's a feeling here. I don't know if it would help to give a sort of elaborate example from the game. We would love a great example. A lot of people have watched your YouTubes. And so anything that's like that you haven't spoken about is probably the most interesting example. Yeah, I don't think I gave this example in a YouTube because I think it's too detailed. And it might be, well, it's a long time ago, so I don't think it'd be recognizable. But, oh, I also wanted to say in a couple of weeks, I have to give a talk in Amsterdam about psychotherapy and AI. Now, I didn't just have a loose association. I'm connecting that to countertransference because I think it's when we work with countertransference that we can do more than AI will ever do. I think AI is probably capable of a lot, and I could talk about that later. It surprised me. but and and frank just to let you know i just posted an episode on that today oh cool um where we talk about the suicides and the psychotic breaks that people have had in the midst of using ai right and specifically the sycophantic nature of ai to only affirm and then um like i'm going to send you the article. The article is like, I spent hours on this and my team spent hours. Probably it's like, it's, it's one of the best articles written on this. So I'm excited. That's perfect. Thank you. Anyway, let me talk about projective identification, which of course is a very intense experience of counter-transference. Um, if you know, um, Racker's article, what's his first name? Heiner cracker, way back from the 50s. It's, I think, the best thing written about countertransference. It's called like the understanding and uses of countertransference. And in that article, he distinguishes between concordant countertransference and complementary countertransference. Should I go into that or does everybody already have a grasp of that? No, I would go into that. You could go into it. Okay. Anyway, concordant, same as countertransference is the basis of simple empathy. So your patient comes in, they're bummed off, they just failed the test, they're disappointed, you feel disappointed, concordant. Complementary countertransference is when you're, it's what I call a form of deeper empathy because you are empathizing with what is in the patient's mind that they are not yet in touch with. It's too painful to be in touch with. So you're feeling what is split off from their awareness. So the simple example is the kid comes in, failed the test. He's bummed out. You feel bummed out. And the complementary countertransference would be he comes in, failed the test, and your reaction is, I knew it. He's a useless, lazy SOB. So, you know, you're not obviously going to say anything about that. You'll notice, gee, look how critical I'm being. I wonder if that's a split-off part of his mind. He's just feeling bummed out, but maybe he's attacking himself with the kind of things I'm feeling now. And that actually could explain why he's so chronically depressed if he's going through life with a part of himself that is doing to him what I'm experiencing right now. And how can I begin to get him aware of that? Now, what I'm talking about in terms of countertransference, I think obviously has a clear relation to object relations theory. So I'm talking about a model of the mind where the building blocks of mental experience, psychological experience, are internal representations of self and other that are linked by strong emotions and drives. So when I talk about using countertransference, I'm talking mostly about working with what we in the object relations world call the borderline level of organization, which is a broader concept than borderline personality disorder. It essentially is any personality disorder based on Melanie Klein's concept of the paranoid schizoid organization, an internal mental structure where there are dyads, experiences of self in relation to other that are like ideal and perfect and you're in heaven because you found the caretaker who's never going to fail you and so on and so forth. And on the other side of the split internal world, it's all hell. It's suffering and persecution and anger and so on and so forth, people who don't meet your needs. And the problem with the split internal organization is since you, even though it might not be fully conscious in your mind, you still believe in some kind of perfect possibility. Anything that's short of perfect gets totally negative in your mind. So anyway, I think when you're working with this patient population, and by the way, the reason it's called the paranoid schizoid organization, it's schizoid because it's split, but it's paranoid because individuals with this psychological organization generally aren't fully aware of the aggressive part of their internal world. they're not comfortable with that, they have a malaise about that, so they project it and see it in others. So they're paranoid about the world in general. They can't get close to people, so on and so forth, which by the way, going back to DBT, you might later on say I'm obsessed with DBT. A lot of patients who have had DBT that has helped them symptomologically come to us and say, you know, I don't cut anymore and I can control my affects better, but I can't manage to really find an intimate relationship. My understanding of that is because they haven't integrated the aggression that they project and when they begin to get close to somebody, it's like, oh, they're going to reject me, they're going to criticize me, they're going to hurt me in some way. So you can't be comfortable with somebody else. So let's go back to the elaborate example of countertransference where I finally understood years after I had been taught in my psychiatry residency about projective identification, I finally understood it. And projective identification, by the way, is what complementary countertransference is. It's when the patient somehow finds the way to activate in you emotions that they can't, They just, it's impossible for them to feel in themselves, although they can act them out, as you'll see in this example. But in any case, when I learned this as a resident psychiatrist, I said to myself, you know, that sounds almost mystical. My professor is telling me that my patient can make me feel something. It's not my feeling. It's the patient's feeling. I was very skeptical of that. It sounds a little hocus pocus to me. Anyway, here's what happened. I'm working in a hospital. This was back in the 90s, and although it barely exists, in fact, I don't think it exists at all anymore, we had very long-term units. I was the unit chief on what was called the long-term unit, which the average length of a stay, believe it or not, inpatient, was a year. The hospital also had acute units, which were like three to four weeks. Then it had intermediate units where the average length of the stray was three to six months. You need to know this because the patient was admitted to an intermediate length unit. 25-year-old guy made a vicious suicide attempt, cut himself really deeply, comes into hospital, and what's the problem? Smart guy, college student. He had missed some years of college, so he was a little behind the usual schedule because of his illness. But the problem is that when he shows up on this intermediate unit, he seals over and he's the ideal patient. He's like a good Boy Scout. That was my internal representation of him. I was not on that unit, but I heard about it. So, you know, he says smart things in the community meetings when the nursing staff is having trouble with one of the difficult patients. He's very helpful and tries to calm the patient down. So he's great, but nobody could get a handle on why does he try to kill himself periodically. It would just burst out of insulophrine. Anyway, so after a couple of months, the staff on that unit said, we don't know what to do with this guy. We're getting nowhere. Let's discharge him. Now, in those days, you would say to somebody, you know, we're starting your discharge phase, which meant two or three more weeks, which would be more than a whole hospitalization. Anyway, so you do discharge planning and you find a therapist and you get all the things in place. Anyway, when the guys heard we're starting to plan your discharge, he said, you better think twice about that. So they said, why is that? Because, you know, I'm not ready for discharge. In fact, you know, if you guys are going to discharge me, I could get suicidal again. So they put him on what's called 15-minute checks, which most of you probably know what it is. But in case you haven't worked on an inpatient unit, the man is confined to his room and a nursing staff member goes by every 15 minutes to make sure he's okay because of the threatening things he'd said. Now, you might say, why did he so much not want to be discharged? Here's my hypothesis. He had a very narcissistic personality. He had to be the king of the hill. And in an inpatient psychiatry unit, he could fairly easily feel superior to people, population of people who had clear impairments. In the outside world, his king of the hill status was very threatened by other high-functioning people. Anyway, so here's what happens. Now, I'm going to tell you this. I was going to apologize, but I won't apologize because you have to be willing to work with very strong affects if you're going to treat these kind of patients. he's in his room and nursing staff comes by and says how are you doing? Fine, fine, fine in between the 15 minute checks he took a little nail clipper and very methodically and I'm telling you this because everybody thinks acting out with personality disorders is always impulsive, it can be methodical, so nursing staff, how are you doing? he says fine, then he rolls up his sleeve, and he starts clipping away at what we call the anticubital fossa, the internal part of the elbow. And, you know, he did it. I'm just laughing as a defense, but anyway. And, you know, the nursing staff would come the next time, he'd cover up the cut he was making. And then, you know, when the nursing staff left, he took a while to isolate this big vein that exists right here in your inner elbow. And then when he had isolated the big vein, he clipped it. And so the next time the nursing staff came by, there's blood all over the bed. So they decided not to discharge him, but to transfer him to me. Thank you very much. So anyway, I became his therapist. And here's what happened. I'm meeting with him three times a week. I had three times a week individual therapy in the hospital. And I was getting nowhere. He's sealed over. He's the boy's guide. Everything's fine. No indication of any problem and so on and so forth. So after a couple of months on my unit, we decided the same thing that we would have to discharge him. We can't keep somebody indefinitely if we don't feel we have any kind of handle on them. So he was told that he was going to enter discharge phase and he comes into my office for the therapy session. She says, Dr. Yeomans, you know, I'm so lucky to have had you as my hospital therapist. You know, in my lifetime, I've had 10 therapists already. None of them knew anything. You're the only one who ever helped me at all. You know, all this idealization, which of course... Which was justified in this case. Well, no, I wish. But in any case, you know, that's the ideal side of the split internal world. So he says, I just want to know if you'll be my therapist when I'm an outpatient. Can I go to outpatient therapy with you? So this was the end of the session, and I just invoked reality. So I said, you know, we have to look into that. We have to consider a number of things. We have to consider, you know, if our schedules are compatible, we have to look into payment issues. But remember what I said about the split internal world. if the other person isn't giving you perfect caretaking, which would have been, yes, we'll do it, then it's no go to hell. So he comes into the next session. He sits down and he says, this is going to be our last psychotherapy session, even though he was going to be in the unit a couple more weeks and he could have come three times a week. I said, oh, why's that? He said, well, it's a waste of my time coming to see you. So I felt very comfortable. We're in familiar territory. We've got the two sides of the split internal world. I'm idealized one day. I'm devalued the next day. I just proceeded like, okay, I know how to deal with this. And you proceed with curiosity. Like, I don't understand because last time you said I was the best therapist you'd had. And now I'm used to it. And usually the patient says, oh, yeah, how can I understand that? I felt both things and they don't add up. But he didn't go into that reflective process. He said, I'll tell you what happened. I had an epiphany after the last session. And you know what? I never thought you were a good therapist. My epiphany was to come to this awareness about me. He said, I am such a good person that I realized I'm willing to sacrifice my own interest for the sake of pathetic individuals like you, that I only asked you to be my therapist because I knew how devastated you'd be if I didn't do that. And then it just dawned on me. Don't go into therapy with an idiot just to save his feelings. You're a very good person. Of course, he's disowned. But don't sacrifice. I mean, you can be a good person without being a martyr to this jerk who thinks he's so smart and special. Anyway, so here's where we start getting to the countertransmits. I'm trying to work with that, you know, contradiction and trying to sort of see if maybe my usual approach, yeah, but maybe there was something to the idealization and we could think about the two ways you have feeling about me together. No, I never felt you were any good. I realized it was my own goodness that was going to sacrifice my interest for your pathetic, puny little ego. So anyway, this just went on and on and on. I'm only giving you a small dose of it. And about halfway through the session, I'm sitting there getting these smuggy insults. It was really impressive how he was portraying himself as the best person on earth because he would go so far as to sacrifice interest for those awful, dumb people like me. So I'm listening to this thing, what the hell do I do now? And I've tried everything I have in my toolkit here. And in the back of my mind, and I remember to this day, oh, this was 30 years ago, first there was like a fog in the back of my mind or like a mist. and then as the mist started to dissipate, I had a visual image before a conscious thought. I had a visual image of strangling him to death. Yeah, so I noticed it and I said, Oh, that's interesting. You're thinking about, you want to strangle this man. so you know I'm listening to him you have to sort of listen to yourself and listen to the patient at the same time I'm thinking as I'm continuing to sort of engage in some sort of interaction I said you know you don't usually think about strangling your patients in fact I said I think this is probably the first time I've ever thought about strangling a patient because there's a rule of thumb it's a little simplistic, but we call transference, we say the operational definition of transference is anything that comes out of the patient that's kind of more than a standard deviation from what might be considered a normal reaction to something. So transference is something the patient does that's out of the ordinary. Countertransference, if it's provoked by the patient, because we have to remember that countertransference could be our own issues, but countertransference evoked by the patient is something that's not normally part of our internal repertoire. So I said, you know, I've never thought out strangling a patient before. This must be what they tried to teach me 10 years ago in my residency. This must be that projective identification. He's getting me to feel something that's very important in his mind, in his internal world, but he can't access it. It's too distasteful for him. And yet, I started to think, that's what comes out whenever he makes one of these really vicious suicide attempts. He's attacking that hateful part. Then I said to myself, it's all about hate. So then I said, what do I do with that countertransference? Now, some people say you disclose your countertransference. Think of how, I'm just going to say crazy that would have been. If I'd said to the patient, you know, I just want to let you know, at this point I'm hating you. He'd say, proof, proof, you're a bad therapist. Therapist shouldn't hate their patients. Disclosure would have been awful. So I was fumbling around in my mind, and I was thinking, what can I say? And I just said the following. I said, you know, you can decide not to come back to therapy with me again, and this could be our last session. And, you know, whatever you do from here on in therapy with me, with somebody else, I just have a feeling that it would be important to consider and think about and just have some kind of thinking about hatred. That's the best I could do. So I didn't say I was feeling hatred. I just said there's hatred here to be thought about, to be contended with. And that kind of caught him in his tracks. It's not what he expected. It surprised him. He toned down. He did come to the other sessions before he was discharged with me. He did go into outpatient therapy with somebody else. But from what I heard from her, the outpatient therapist, he wound up doing quite well. So that's an example of projective identification, a.k.a. complementary countertransference. Now, I'm going to say, because often we in the world of TFP get criticized, say, oh, you don't give empathy to the patient, you're harsh, you're critical, you're confrontative. Well, we say we give more empathy than you do because we just don't give simple empathy based on concordant, you know, countertransference. You're sad, I'm sad. We give complementary countertransference, which helps the patient get in touch with what they literally have not been able to get access to up until then. And that's the wonder of countertransference. I think no one in this group, by the way, Frank, I don't know if you're projecting on us that we were critical of you, but we're not. you know i was thinking like back when you went through training you learned about projective identification um people aren't learning about this anymore i mean in this group i think we're we're talking about these kind of things but i think what i've heard over and over from people in training is that they're not learning about that and then my second thought is i think when patient, when, when providers feel that countertransference, that hate, maybe, um, it, it almost becomes a moral injury on the provider. Okay. This is kind of what I'm seeing where it, because the provider is so not regulated or not. Yeah. They're not regulated to feel that and to know how to feel that. And then they feel bad about feeling that. So that's a training issue and a personal issue. I mean, there might be some individuals, I wouldn't be one of them, who could be a really good psychodynamic psychotherapist without having had their own, in my case, analysis or psychodynamic therapy. By the way, I want people to know, because everybody thinks I'm a psychoanalyst, but I'm not a fully trained psychoanalyst. And I say that because I think you could do really good psychodynamic, psychoanalytic work without being a full-blown analyst. In any case, but what you're saying, David, is really important. I know somebody, a colleague of mine, specialist in personality disorders, well-respected, published, and in a conversation with the person not that long ago, she said, oh, who believes in projective identification anymore Anyway And I think there a simplification a reductionism going on in our field where people just deal with symptoms They don't deal with the underlying subjective experience. And if we're only dealing with symptoms, we're never going to help our patients truly get better as a person. And let me just say, because you're touching on something. When you say the therapist doesn't like to feel hate, they kind of would probably feel uncomfortable, maybe not know what to do with that. I just gave a talk a month ago. What keeps psychodynamic therapists from doing what they know they should do? It's fear. when you need to try to help the persons see something about them that they're not seeing. They're not seeing it because it's painful to see. So I swear, now that I've started thinking about it more consciously, in half of the supervisions I do, the patients, the therapists will start to reason the case, and they say, well, I was going to say this, but I was afraid I would hurt the patient. Or occasionally, I'm afraid the patient would hurt me, usually not physically, but by getting devaluing or insulting or something like that. Or I'm afraid that if I say what I think I should say, the patient's going to drop out of therapy. So we have to work on our ability, first of all, to contain the negative affect. Because the patient can't tolerate it. Now, this guy, you could say he was full of negative affect. Look at what he could do to himself, his suicide attempts. But that was negative affect expressed in action, in behavior. He never felt it. He did it to not feel it. It's like what I said in that interview with you last year. The lady who threw the TV at her husband said, well, he was aggressive because he forgot our anniversary. She didn't see any aggression in her behavior. She was just discharging something she couldn't allow herself to feel. So we've got to accept being the bad object for a while. And so you say for a while. I'm going to jump in here real quick. And how do you know? How do you assess when it might be appropriate? So like this case example, he was leaving. And so it was sort of this, you know, times where like, I doubt it was impulsively, but it was like, speak now he's leaving, you know, maybe you want to talk about anger. But if this was someone that you were working with that, like, how do you assess how long to contain something, whether it's negative affect, like if their ego, if they wouldn't be able to hear it at all, like, you know, denied or when that might start, there might start to be some space for integration. Yeah, that's a good question. When I say contain it, I don't mean not name it. So even if this had not been possibly the last session with that patient, once I was aware of it, I probably would have said, you know, since let's take your hypothetical case, if this were the middle of an ongoing therapy, I might say, you know, it doesn't have to be right now, but sooner or later, it just seems like we might benefit from thinking about hate. Now, the patient might be surprised. Why do you say that? I don't know. It just seems around somewhere. We talk about something being in the room. Mm-hmm. Yeah. Okay. so i like i like that so i'm feeling there's some hate in the room is that it or you said um this hate there is hate to be contended with yeah yeah and uh i mean it's clearly opening up what could be a can of worms because the patient this patient was curious about it but the patient can say, well, I don't know what you're talking about. Where is that from? I'm not feeling any hate. Then I would say, you know, maybe I'm wrong somehow. I'm trying to think of what I might say. Maybe I'm wrong. But let me just give you another example in a minute, but I'm trying to think of, or I'd say if the patient were saying, Where is that coming from? I say, you know, I could be totally off base, but something, just some hunch that it might be relevant. That might be as much as I'd say. But then I might say, and now that I think of it, the way you've treated yourself at times could be seen as hateful, you know, the cutting and suicide. I don't know. you know kind of you take that attitude like the detective colombo like you know i really don't know let's think about it yeah um okay what about um what about like more so okay so i guess to continue with this like the anger uh kernberg in his interview that i did he said the one thing therapists need the most is to get in touch with their own aggression yeah are we talking about the same thing here? Is there, I think about when I think about aggression, keeping the frame, you know, not, but like, what are the things that you're thinking of in terms of like, like as you've supervised people, like, what does it mean for a therapist to be in touch with their own aggression? Well, can I use an example I used recently in that lecture that I got Otto's okay to use? Because I said to him, you know, years ago, Otto, I remember you're using this example and teaching, and I just want to make sure I got it right. And this example is one of those instances where people either love Kernberg or Hayden. So he, I mean, it's very similar to my example, but it's his version of it. He's teaching about what you've just brought up, David, or need to be in touch with their own aggression. Because the way I understand the human being is that everybody has aggression in them. It's just genetically a part of us. We would not have survived as a species without it. And I really like Freud's work, Civilization and Its Discontents, about the fact that civilized societies have advanced more quickly and changed and evolved more quickly than neurobiology. So a lot of psychopathology comes from, we have drives that we can't just act out in civilized society, aggression being one of the main ones of them. So this is what I think Otto means by being comfortable with his aggression. Because if you don't allow yourself to feel your aggression and to somehow channel it through a fantasy, it gets blocked in you and then you get stiff and your work isn't so good and you probably collude with the patient to find some outside bad guy. And, you know, so having freed himself of a very intense, oh, I've got a great example of countertransference I want to give you in a minute. But, you know, if you can sort of be comfortable with it in you, then you can work with it. And I think this is what we're seeing with a lot of like, well, every ex that you've ever had is a narcissist kind of language. like pop psychology, pop. It's like everything bad that's happening to you is because of everyone else. And there's no, you are like, you are this just loving oracle of glowing love and compassion. Misreaded and misunderstood. Which AI is saying the same thing to people, interestingly. It's parodying this sycophancy. Yeah, it's like an echo chamber. You know, you just hear what you think, and it's kind of the opposite of therapy. It might give the person support in the moment, but it doesn't help them function better in the world or feel better in the world. I mean, they feel better as long as they're being overtly validated, but they don't feel better when their life is going downhill and their relations are all shot to hell. But can I give you an example where I shifted from a concordant countertransference to a complementary one all in the same session? Okay. That's good, yeah. 35-year-old woman comes to therapy, this is relevant, after one year of CBT by a very good CBT colleague of mine. But at the end of that one year, the colleague said, you know, I'm not sure we're getting anywhere. Maybe you'd be better off with somebody like Yeomans who does a different kind of therapy. So the patient comes to me. What's the problem? First of all, when you present a case, always, what's the problem? 35 years old, chronically depressed, periodically some suicidal ideation, no attempts, very, very, very upset because she can't find a man to marry and have a family with. she's desperately eager to get married and have a family, but it's not happening. She can't get anywhere with dating. So, you know, I do my evaluation, I make a diagnosis, and she seemed to be what I'm sure you're familiar with when we talk about a covert narcissist. She was not arrogant or grandiose on the surface, but she thought she was the most morally correct and well-behaved person on the planet. And she had this devaluing kind of condescending way of interacting with others. And you could see how, you know, you wouldn't want to go on a second date with her. So she was relatively successful in her profession, but other people, and some of them now younger, now that she's 35, get promoted instead of her, that she would say, that doesn't matter to me. They get promoted because they're willing to make compromises. I would never make a compromise. I'd rather live by my values than compromise. Anyway, maybe that's good, but it was a little rigid. And so anyway, we start the therapy, and this is what I mean by containing the aggression for a while. Even though she acted or behaved in therapy like a very proper patient comes in, associations, stories, and all the kind of material one would want, I noticed that pretty much whenever I made an intervention, she would either roll her eyes or wrinkle her nose. Now, you clearly a sign of a devaluing part of her. With somebody less rigidly and fragily, it's funny, it's a combination of rigidity and fragility, narcissistic, I might have not waited so long to say, oh, you know, it's kind of interesting. I think it might be worth reflecting on the way you react to a lot of what I say with growing your eyes or wrinkling your nose. but I thought she can't hear about a flaw in herself. It's not part of her self-representation. So I'm three or four months into the therapy. I'm just sitting there getting the eye roll and the wrinkled nose. I'm sitting there thinking, okay, it's time to mention this. She can't be oblivious to this. It's just so, or maybe I just couldn't contain it anymore. So I said as tactfully as I could, I said, you know, and by the way, when you're doing this kind of work, you have to, at some points, not follow that so-called golden rule of psychoanalytic work, which is pure free association. You have to say, I'm interested in what you're saying, but there's something else that might be worth thinking about. You shift gears. Otherwise, you could just collude with their defensive posture forever. So I said, you know, it's interesting what you're saying, but I just thought we might benefit from reflecting on something that I've noticed. What's that? Well, I tried to be very tight. I said, you know, not infrequently when I say something, you know, this reaction kind of rolling your eyes, a wrinkle in your nose, trying to not sound critical. And I said, you know, that kind of suggests something where we might not be having a positive reaction to what I'm saying, but maybe you're too polite to say something negative and maybe nonverbal communication is expressing something a little disapproving. And I escalated, I intentionally escalated my vocabulary. Maybe you're communicating something a little disapproving or a little devaluing or maybe even a little condescending. She said, what? Me condescending? said, you're the most condescending person I've ever met in my life. I haven't mentioned it so far because this is my therapy. It's not your therapy. That's your problem. If you're in therapy, and I hope you are, I hope you're discussing your condescension. So when I was young and naive, I would have stuck to my guns and said, well, look, I'm not the one rolling my eyes and wrinkling my nose, so maybe we should look at that. You can't force something that's being projected back into the patient prematurely. You do what we call therapist-centered work or working within the projection. Work with how they're seeing you without yet bringing it back to the patient. So I said, oh, I wasn't aware of how condescending I am. Can we talk more about that? Now, first of all, that disarms the narcissistic patient because they expect you to fight back. And they expect you to say, I'm not the problem, you're the problem. The basic dyad in the narcissist is somebody superior and somebody inferior. And they expect everybody to want to impose their superiority. And when you don't take the bait, then they're kind of curious. what's this experience? What's this, who is this being in front of me? He's not defending himself. He's not reacting. He's not fighting back. And you become an object of curiosity. But anyway, that's not where the countertransference came in. I mean, it did. But a year into the therapy, this very well-behaved patient comes in and sits down and starts laying into me in a way she never had before. Not unlike the guy I talked about. You're going to think this is just what all my patients do. So she comes and she sits down and this previously well-behaved patient says, you know what? I've been coming here a year and I haven't got one ounce better. In fact, I've gotten worse. Under your watch, I've gotten worse. And then she had this plea, like she's horrible, you know, just terribly suffering victim, which she was in a way. She said, I came to you. I confided in you. I put my life in your hands. I put my future in yours. You were supposed to help me. You just sat there and watched me deteriorate. I've gotten worse and worse. A year has gone by. I'm no closer to getting married. I'm no closer to having a family. So I could have defended myself because in fact, I could have pointed to some signs of progress. The last time you dated a guy, it lasted longer than usual. But when somebody's that into enacting a dad, don't take the bait and fight back. Just contain it. So I'm sitting there. In fact, I can remember this session. I was like holding the arms of my chair like I was on a roller coaster and just trying to make sure I could stay, you know, without getting bounced out of the chair. And, you know, she's going at me. You shouldn't, you shouldn't have the right to call yourself a therapist. You know, you should give up your license. You should be a cab driver, an Uber driver. Yeah, that's a new thing now. Uber driver, this is years ago. So, you know, she's really laid it into me. So here's my first countertransference, a concordant countertransference. She's enraged at me. I'm enraged at her. So you have to let yourself go through it. So she'd say, I haven't learned anything from a year here. And, you know, you're useless and you're worse than useless. So my fantasy, you have to let yourself have your fantasies, would say, well, you know, the door's right there. And, you know, you can use it and you don't have to come back. But my fantasy got more sadistic because I thought if I said that, I pictured saying that and she looked like really surprised, like I'm just saying she could leave. So my fantasy was when she looked surprised, I said, what's the matter, honey? You don't know how to use a door? Well, you know, maybe you've been coming here a year and you haven't got anything else out of it, but before you leave, I'll teach you how to use a door. That little bronze thing is what we call the doorknob. So, you know, I'm spitting this out in my mind, just letting myself feel this rage. But halfway through the session, I started having a complementary countertransference. I started feeling, maybe she's right. Maybe I am no good. I was really feeling that. Maybe I should be an Uber driver. I felt like, you know, maybe I don't help anybody. I'm really feeling this. I remember having this little image. I thought, maybe I'm not at all significant. Maybe I'm just like a little grain of sand on the beach and have no. So, you know, I went from being enraged to feeling totally worthless. And then I said to myself, oh, that's what she's been defending against all this time. That's what her narcissistic, perfectly correct, goody-two-shoes image is defending against. In the core of this woman, she feels nothing. She feels she is nothing. She feels she amounts to nothing. I've gotten beyond her defenses. But here's the thing. psychoanalytic psychotherapy is great for having ideas but defenses are so strong you can't just offer an interpretation that directly I mean, if this were some sort of very simplistic textbook of therapy I might have said, oh, you know what here's something maybe we should think about you tend to go through life with this very correct, proper self-image and, you know, that's fine. But now that I think of it, again, I wouldn't refer to my countertransference. I might say maybe at a deep level you don't feel like you amount to anything. And so to not feel like you don't amount to anything, you have to be perfect. I think that would be an accurate interpretation. But it's not the moment to give it. She's too worked up in her rage at me. The rage, which, by the way, is at the root of her feeling like nothing. Because the root of narcissists' empty core feeling is they're always attacking themselves aggressively and saying they're no good. Anyway, so what happened? I got this understanding that she's defending against the feeling of worthless, but I didn't think she would accept it. I thought it was too intellectual. So she's going on, and we're like 30 minutes into the 45-minute session, and at one point she said, I went to that CBT therapist for a year, and that was useless. I've been coming to you for a year, and it's exactly the same experience. And then I thought, hmm, maybe I understand better now why my CBT colleague referred this patient out. Maybe it was getting too intense to contain. So the first time in the session, I had what I thought might be a useful intervention, and I said, you know, maybe you're right. Maybe it's exactly the same as what happened with the CBT therapist. But if you think about it appealing to some observing ego in her or reflective functioning, if you want to call it that, if you think about it, maybe there's one little difference. And she thought for me and she said, yeah, you're not telling me to go somewhere else right now. And I think that somehow helped her become aware that I was able to contain something in her that she couldn't consciously feel in herself, and she certainly felt nobody else would allow her to express to them. So this poor woman was suffering with the idea. She had to go, and she had, obviously giving sort of abbreviated vignettes about this, she had a pretty traumatic history, so she had a right to feel rage and anger, but she didn't think the world gave her that right. And she was convinced that without the proper presentation, anybody on earth would turn their back and walk away from her. So just to say, when she said, yeah, you're not telling me to go somewhere else, showed we both understood maybe this part of you that's just burst out now, unseen before, is something we can experience and think about and try to sort of put in its place. So that's another example. Other questions or comments on that? Yeah, let's maybe like, I think that's such a good case example. I imagine people have some questions. Let's kind of stay on that. Jeremiah, you had something? Daniel had a question, but I was going to say by doing that, Frank, in essence, you're maybe meeting an unmet need for her for the first time in her life. Yeah. Right? Yeah. I agree. How would that influence your work? I mean, would you say something about that? Well, I think by identifying that you're the first person to stay with her in that experience, I think you're a unique presence in her life. And I think it opens up an opportunity to go to places where she's never gone, certainly professionally, but maybe interpersonally before in her life. But Jeremiah, I think Frank is actually turning the question on you. Okay. What would you say? Yeah. To what exactly? To her. I mean, how would you use that insight? It's a very good insight. I would say I'm curious if maybe this is the first time that someone has stayed with you through this feeling or through this experience. Yeah. Or remained present with you through this experience. or what does it feel like for me to potentially consider sticking around with you through this? Yeah, yeah, yeah. I think those would be both good. I tend to be very parsimonious because I worry a little bit about feeding the patient an idea. So I like your idea, but I think my intervention would be more like, is this new for you? And then see where she went with it. Yeah, but I think we're both on the same page. By the way, I asked you what you would say because one of the things about psychotherapy is we all have ideas, but an idea doesn't help the patient. You have to figure out what words can you use with the patient to use that idea. And I think your words were good and my words were a little less precise, but you tried to open up her mind do it a little bit more. I think, and I'll call on the people that are raising their hands in a second My idea is that to feel you not reject her and not leave her like everyone she dating like the other therapist so there a theme is kind of the counter to this grain of sand type of feeling, like all I am is a grain of sand. Yeah. And so I would say, and I'd be curious what you would, your reflection on this would be something like, um you know i think that there's something about um let me i would so that was the idea so now i'm going to try to think what i would say okay i think i would say something like you know i think that what i've heard from you is that there's part of you that really thinks that what's gone on here and what's gone on in the last therapy has not been helpful and you haven't achieved your goals. And I agree, you aren't in a long-term relationship. And I think like, um, you're, you, the significance of the hard work that you're doing, showing up, trying to do this type of work to try to accomplish your goal could, and the futility of that would feel like a grain of sand, like experience. and yet the comment that you just made is really curious to me that I haven't left you like the previous therapist and I'm wondering if that somehow relates to what's going on here between us like if that changes the dynamic at all okay I hear you that's more complex I like to give just a little bite-sized intervention because I think you have to start with the affect and then get deeper. So, you know, although it's interesting, you're validating her experience that the therapy is worth it so she's turned the therapy into the grain of sand. I think that's an interesting idea. But again, I would just want her to spend a fair amount of time reflecting on the experience that somebody doesn't turn away from them because she expresses rage and anger. And so I think I would limit it in the moment to saying, and this is a little bit, I can't remember exactly what I said before, but I might say something like, well, before I said, is this new for you? And my second comment, are you surprised I still want to work with you? and I'd stick with just the rageful affect and show that we can contain that. Because my concern about your intervention, David, is it's very smart, but it's almost a little abstract compared to the raw experience of emotion that I'm trying to help us both be more comfortable with. I do it later. You would want that immediate intervention to be framed to like you know to have immediate reflection inward what is coming up for me right now like emotion wise you know because typically until this point this has been an unconscious interpersonal pattern where she either immediately acted out to try and get rid of the emotion or control the situation i control what the other person's doing um but in that moment of recognition of you not leaving in this being new like you know what are you feeling right now um yeah um yeah that's it just let's let's just sort of have this experience together. Yeah. It seems like it's having an impact on you that, you know, you could kind of, you know, chew me out for a half hour and it's like we're still here. You haven't destroyed this or either I haven't, you know, walked out or you haven't destroyed it. So, again, I would just try to help her think about the, to immerse her in the affect of the moment. Yeah. Alibab, if I'm saying it right? Yes, you are. Thanks so much for even coming here. Huge fan. One comment, kind of question I had just thinking about this case was that it seemed to me that this new experience that she was having with you not leaving or, you know, kind of like engaging with those negative thoughts that she had because it's a new experience. I was thinking like, okay, she's probably having this conflict in her mind of previous men or previous relationships that he's been able to kind of build her reality around. And so the fact that this situation that she then is like conflicting with her previous experience, it's creating almost like this challenge to her. And then that's inciting this anger that she's having and that anger is again coming from the fact that she may have to lose this defense that she's built up lose these walls that she's being challenged to you know think about and then it's like thinking and like in my mind i'm thinking okay if that's like what the emotions she's probably dealing with and going through i would then probably ask her you know as she's like talking about it's like you know pause and think like do you trust what's going on here? Do you trust me? And I think that kind of will then have her think about, wait, why am I not doing that? And why am I then projecting that I don't? Yeah, the last sentence kind of confused me a little bit. I think that, let me just type all the trust issue with patients who have pretty much gone through life in the paranoid schizoid psychological organization. I always use this phrase, it sounds a little bit like a wise guy. They don't trust trust, they only trust mistrust. But I think that's what you're saying. If you're being mean and rejecting to them, they can think, oh, this is real, you know. So she did have a way of getting attracted to not-so-nice guys or going out with a nice guy and being very devaluing of him. So when this session is over and she goes home, her defenses are going to start emerging again. I think that's what you're talking about. was that for real? Was he acting? Was he just pretending that he wasn't wanting to tell me to go to hell? So then you're not going to, like all in one linear process, get her to begin to see that she can trust people. She's going to go back and forth and say, you know, and you as the therapist have to figure out how to pick up on this. sometimes people say that wasn't real last session. You were just acting. You know, I know you want to get rid of me. But sometimes you have to sense it and then you help them. Sometimes I say, you know, it's hard for you to experience something positive. You don't trust it. If this were negative, you'd trust it. That's what we have to work with. And that can work. Now, before we get to the other questions, I wanted to say something that I get to at the end of my... teaching about narcissistic personality disorder. Because my whole take, I mean, my simplistic take on narcissistic personality disorder is the patient's going to devalue you, patient's going to try to provoke you, patient's going to try to show their superior to you. You have to contain that for a very long time, often months and months, and not react because we have research about unfortunate countertransference enactments. but if you oh and here's the little secret when the patient when the narcissistic patient is devaluing you and sometimes very cleverly you have to say you know this is painful this is annoying but I know it's because they're suffering deep down inside so if you can maintain an empathy with their deep suffering you can contain the devaluing so my message is whatever happens with the narcissistic patient, stay committed, stay curious, stay involved and devoted to working with them. And eventually, that begins to sink in as an alternative relationship dyad in contrast to the superior or inferior. And when I say that to people, they say, okay, yeomans, you just, you know, finally admitted what you provide is a corrective emotional experience. It's as simple as that. But I say it's not as simple as that because if you do not interpret the paranoid transference, you can be as nice as a person can possibly be and it's not going to be experienced as such. So it's a combination, and I can give you an example later, but I want to see the next questions. you can be as nice as you want forever, but if the person is strongly into a paranoid projection, they're not going to see you as nice. But why don't we go to Daniel and then Serena? I had a question about the therapist's reaction. I mean, you tell the story and it's an emotional experience for you. You start to feel like maybe I should be an Uber driver. And this signals to you the emptiness, the worthlessness that she must feel. And yet I imagine that intellectually, that interpretation was already pretty clear to you in the previous months, that the way she was living her life was suggestive of an inner worthlessness. And so I'm trying to understand the sort of difference, I suppose, between the intellectual and the emotional understanding within the therapist. Yeah. It makes a very good point because, I mean, certainly with my understanding of narcissistic pathology, I'd always assumed there was that devalued, empty core sense of self. But I'm trying to think. Oh, I know what I was going to say. she had a way up until that session I just summarized of kind of seducing me into a certain admiration of her. She was very smart. She could discuss things in a very interesting way. So I don't think I had experienced on a gut level that emptiness. And I mean, this is another thing I teach my students. I said I went into therapy, into becoming a therapist, with the idea that it's all about having smart ideas that are going to change how the person is. But the ideas are far less important than the affects. So just to get back to your question, Daniel, I had that formulation in mind, but I didn't really feel it in my gut until that moment. And that's when I thought I could work with it more meaningfully, eventually. I didn't bring it up in that session. that makes a lot of sense thank you okay thank you serena you're muted sorry okay unmuting unmuting uh thank you um so this may or may not be a rabbit hole and if so um feel free to treat it as such but one of the my experience so far trying to take care of people with narcissistic and borderline tendencies is that they do evoke um very strong counter transference and aggression on staff members And a lot of staff members in group practices or in patient settings insist that the only proper way to treat these patients is to challenge their delusions immediately and their distorted thinking. Do you have any experience with how to address this disavowed countertransference on the part of mental health professionals? I haven't had that exact experience because when I was doing inpatient work with a team we were very much into the therapeutic community model and the idea of group process so we'd be having these very frequent staff meetings everybody to process their stuff so what's the alternative model? You're saying that somebody should say to the patient, that's off base, that's not an accurate perception, that's not necessarily happening. Yeah, I haven't, well, I mean, I guess they need a lot of education, but seriously, the education could pay off because patients who are convinced of what they're projecting aren't going to give it up by being told that's not real. Let me just go back to that example I was tempted to give a little bit ago about how you have to work with the paranoid transference before the patient can feel your commitment to them. An early patient in my practice was a mid-30s guy, borderline and narcissistic, and very angry all the time, very critical of me, very developing of me. So I used to kind of brace myself for the sessions and wait to be told once again how stupid I was and to contain that, that's okay. But in one session, two or three months into therapy, he said something that was very touching. I think I used this example in our interview, David. It was very sad. Something happened when he was a kid and it was just a very sad thing to imagine happening to a little five-year-old. So it brought tears to my eyes, which, of course, I didn't mean or want, but, you know, it's happened. So he looked at me and he said, you have tears in your eyes. He said it with a kind of a not-so-positive tone. I didn't know what else to say, so I said yes. And he looked at me really hard, like scrutinizing me. He says, you're mocking me. So that's an example of a projection that really distorted external reality. So, if I followed what I think you're asking about, Serena, I would say, no, trust me, I wasn't mocking you, I really feel sympathy for you. That wouldn't go anywhere because he would just say to himself or to me, oh, you're just trying to make up for your mockery, I saw your true colors, you pretend you're a caring therapist, you would just mock your patient. So, you know, the training of the staff has to be to understand a little bit more about projection and working with it. In fact, we have a little branch of transference-focused therapy called Applied TFP, and it is meant to help mental health workers in any setting, acute inpatient units, emergency room, doing psychopharmacology, on the consult liaison service in the hospital. Just think in object relations terms. Think about how is the patient perceiving me and factor that into your interaction with them. It must be hard to adhere to this medication I'm prescribing if you think that really I don't care about you or even have it in for you in some way. And so you're empathizing with their projection instead of saying your projection is wrong and just take this way I prescribe it and trust me, I'm here for you, which they won't believe at all. Does that touch on the question? I think it did. Yes, it did. Get in a position to educate other staff members and look into applied transference-focused psychotherapy. Yeah, I can send you an article. I can send it to David. He could send it to everybody. i think it gives a good summary of what i'm trying to i think as well like um how is it gone like you know like if i i think if i had a person that was professing this is the way that we should do this like um how is that going when you do that like how do you feel like that's working for you um is it successful does it make the patient more agitated like does the patient if you Oh, yeah. Go ahead. Sorry. Oh, the confrontation usually leads to the staff deciding that the patient would not be helped by the modality of treatment that they're offering and sending them elsewhere. yeah so you know interestingly when um motivational interviewing came out they were the contrasting view was a very shame oriented like approach and they found that the shame oriented approach actually drove alcoholics further into their addiction yeah and so if you can google that or see if you can find that early research because i think that that's that's what i would argue with them and i have very little like i i would use the same level assertiveness that they're telling you to um have for the borderline i would use with them and i would say i would if you have a shame oriented approach you will drive them further into a worse place and so like is that what you're arguing for a kind of a shame oriented psychotherapy i wonder yeah i like oh no dr peter we're not saying we should do that okay thank you sir that's a good that's a helpful thought yeah ali good sort of along these lines you know as far as this could be relevant to explaining things or or presenting things to to staff who have varying degrees of like psychological knowledge um can you demonstrate for us how you have this conversation with patients um who like after an assessment like explaining personality pathology um in layman's terms and also using this approach, like using, even if not everyone here is using TFP, but like the mechanisms of change, you know, what your approach is in layman's terms. I know that that's sort of a crucial aspect of what you do. Yeah. That's a great question. I'm glad you asked it. And a very important one, because as much as I'm a supporter of a psychoanalytic approach, analysts used to be their own worst enemy. And, you know, because I'm dating myself, but way back in, like, I wasn't in the field yet in the 60s, but I was beginning to get into it in the 70s. And at that time, analysts, how we can treat everything, and our method is useful no matter what, and it's sort of self-evident. Well, it's not self-evident at all. So let's go back, Ali, to the first party question. How do you discuss the diagnosis with the patient? And all the clinicians I know who specialize in severe personality disorders, along with some research, say we really should discuss the diagnosis, especially in a world where psychiatry, I'm very critical of my own field these days, is all symptom-focused. The patient comes and says, I'm depressed, and the psychiatrist says, diagnosis, depression. Well, what about other things that could lead to depression, like a personality disorder? Most treatment-resistant depression, in my experience, is a hidden narcissistic personality disorder. So anyway, let's try to move beyond symptoms. Let's acknowledge that somebody can come and their problem might be symptom, and then you have a simpler treatment for it. But, you know, you've got this chronically depressed person and you've assessed a personality disorder, or you've got this person who can't keep a job or can't maintain a relationship and they complain of everybody else, the way they treat them, or they say, I'm just anxious. but you see a personality disorder. So after our relatively lengthy evaluation in which you don't just ask about the patient's symptoms and their history, their personal history, their developmental history, and their functioning in life, you try to get a sense of what's the level of their identity. Do they have a complex and solid identity or is it superficial and two-dimension? What's the quality of their interpersonal relationships? Are they rich and deep or is it superficial and not that meaningful? What's the quality of their, is there much of a role of aggression in their life? So we try to get at what we consider the psychological factors. And then we would say to the patient, look, I'm going to press the button on an old tape recorder because it's so common. And I say, you know, you've been treated for 10 years, sometimes for bipolar and sometimes for, you know, depression that doesn't respond to treatments. And it's really dramatic. I mean, I've had patients, they've been hospitalized multiple times. They've had transcranial magnetic stimulation. They've had electroconvulsive therapy. They've had now, of course, ketamine. They've spent zillions of dollars, years of their lives, getting treatments for depression when one should focus on the personality disorder. So in any case, we say to the patient, I think the best way to understand your difficulties in life is through the lens of what we call a personality disorder. Does that mean anything to you? Now, sometimes people have their own ideas about it. They've read about it. They're often misunderstandings. Sometimes it's a new idea. But most commonly people don't like it. Because they say, oh, that sounds like, you know, that suggests there's something wrong with me. Now, when I hear that, I say, well, yeah, but when I go to the doctor, it's because there's something wrong with me. So I kind of accept that. But I guess what they mean is there's something wrong with me as a person. I don't like that. They say, well, you know, let's look at what it is. First of all, let's think of the concept of personality because that's the term everybody uses, but often it's not clear what we mean by it. And sometimes people used to talk just about personality traits, somebody's inhibited or extroverted or what have you. But the more modern conceptualization of personality, it's the way we process our experience in life, the way we process the ongoing stream of information we get, how we experience what happens, how we take it in, how we experience ourselves and how we experience others. So what I see in you is a sort of an automatic, innate way of experiencing yourself, and in particular yourself in relation to others, that hasn't worked out very well. I think there are things in your mind, and here's where it gets to the explanation of the model beyond just free association. You say, I'm going to propose a psychotherapy. We call it a psychodynamic therapy or an exploratory psychotherapy. It's based on the idea that there are things in your mind you're not aware of. And these things you're not aware of have a big impact on how you feel, what you think, and what you do. And the reason you're not aware of them is not simply out of ignorance. It's not that you just haven't figured it out yet. The reason you're not aware of them is that the awareness is painful. Sometimes there are things within us we don't like to think about, we don't like to acknowledge. So if you are interested in the therapy I'm proposing, which I'm proposing because I think it will help you in the deepest and most thorough way, then we're going to try to explore your mind and find things that you haven't been as aware of before as you might be. And we're going to do that together. But it's going to be uncomfortable at times. It's going to be painful at times. I want to know if you're interested in signing on for it. Does that answer your question to some degree, Allie? Absolutely. Yeah. It looks like maybe a few others. Oh go ahead David Sorry I was thinking let see I was thinking that it might be helpful to talk about some of the more positive transferences as well Idealization, sexual transference. I'm curious what your thoughts on what your approach is, or counter-transference in that regard too. Like if you start to idealize or have positive. Oh, sure. If we have time before the end, I did want to get back to Ali's thing before because if people are interested, I could talk about how we describe borderline personality disorder as a specific one and narcissistic. But I don't know if you want that because I think the positive thing is good too. Ali, I'm sorry. Did you ask another question? I'm just like... Well, I think it was implied in the first question. No, no. I mean, you answered it wonderfully. I think that there were others. I'm just looking at the chat and seeing others in the group who made a little additional question, but take it wherever I'm interested in hearing all of it. All right. Let me just do this because it's out of my mind. If somebody has BPD, after the more general description of personality disorders, you know, something not working so well in the experience of self and others, we say the more specific personality disorder that I see in use, what we call borderline personality disorder, Often people are aware there's a stigma about it. You can say, yeah, unfortunately there is a bad stigma about it. But it's a valid medical condition. It's an illness like any other, and there are treatments that can help with it and sometimes cure it. But here's the way I see it. I don't go into the DSM and the five out of none. The way I see it is you have difficulties in four areas. One is emotions. You tend to experience emotions very intensely. most often negative, sometimes very positive, very high, very little middle ground. Your life is like an emotional rollercoaster. I would go on a little bit more with the patient. I'm shortening for considerations of time. The second area of difficulty is relationships. Relationships tend not to be very harmonious or satisfying, stormy, conflictual, crises, da-da-da-da-da-da-da. The third area of difficulty, which I say the patient gets the most attention and therefore is considered by many people to be the disorder itself, is behaviors. Self-harming behaviors could be cutting, overdosing, substance abuse, eating disorder, unsafe sex. So these behaviors garner a lot of attention. And in fact, you've been treated for some of that before. But the fourth area of difficulty, which I consider the center of the whole problem, and of which the other three areas are just a manifestation, is an unclear sense of who you are in life. You haven't got a clear idea of yourself. You haven't got a solid identity. It makes life very difficult. It's like you're a ship at sea without a rudder, and you're just buffeted around by all the waves that come your way. So I'd like to focus on all these things, but with it at the perhaps back of our mind, that the identity issues and the sense of self are the more core issues. Okay, so now we can go on. That's good. I appreciate that. And guys, we're going to have a transcription of this for some of these things. So if you want, you can come back and listen or read that later. And Frank, we take out any patient identifiers so that it kind of protects the story. But yeah, If, if there's, um, I'm curious, the approach to, um, one of, one of the group members last week asked in the group, what do you do regarding countertransference, like of sexual attraction? Do you ever disclose that to a patient? Um, my perspective was you never disclose it. You, you did probably good to disclose it with the supervisor. Yeah. I kind of disagree with, uh. Yalom, who talked about how he would once tell a patient something like, if we had met and we weren't doing therapy, then I would be open to dating you or I would want to date you, something like that. That felt too, like, you know, propositional to me. So I'm curious what your perspective is and what you've taught people over the years. Well, it's a great topic. and I think we have to start by distinguishing between an erotic transference and an eroticized transference. An erotic transference is what it says. It has to do with libidinal feelings, including both sexual feelings, but love and attachment and stuff like that. And it's positive. But the eroticized, as the name implies, has an appearance of eroticism. of erotic, but it's actually a perversion of the erotic into something that's manipulative. I'll give you examples of both. So, first of all, when we start, let me start right at the beginning. Our basic idea is that in everybody, you've got, and it kind of goes back to civilization and its discontents. You've got libidinal feelings and drives and aggressive feelings and drives, and every mind has a kind of a tug-of-war between which predominate or, hopefully, how you integrate them, because, of course, our whole goal is integrating them. But if somebody has any level of serious personality pathology, they have not integrated of them. And in most cases, what predominates at first are the negative feelings, because as somebody was saying, was it, Al-Bab, you don't trust the positive. And so, you know, you're more comfortable in your suspiciousness, because if you allowed yourself to let your guard down and feel close to somebody, you're afraid they'd hurt you. So nine times out of ten, we get these negative transference is your tears are mocking me and so on and so forth, or you want to get rid of me or you're secretly thinking I'm an idiot or what have you. So what we try to do is look for the subtle, usually subtle emergence of a positive transference when the tone of some of the sessions gets less tense, when it gets more relaxed, when you feel like you're working together, we feel that that might be the first introduction of the positive part of the split internal world, the part that could imagine a closeness, an attachment, a healthy dependency. And eventually we might name that if it hasn't been discussed and say, you know, you still come in saying you can't trust me, and I understand that, but I seem to notice a change in the atmosphere here. Sometimes we kind of seem a little bit less tense, more relaxed. Sometimes we kind of even laugh together. What do you think of that? So that's an example of the subtle introduction of the libidinal part of the split internal world and how one might address it. Let me go from that to an erotic transference. A patient of mine who was quite ill at the beginning, suicide attempts and hospitalizations, she was doing quite well, stopped the acting out, beginning to make a life for herself. And I think it was about two and a half years into therapy, maybe two, maybe two and a half. she comes into a session and says, I can't come here anymore. I said, why is that? Because I love you and I know it's impossible. You couldn't love me. And it's just too painful to come to a place where I'm feeling love and I know I'll never get love in return. And I'd rather just leave and experienced that pain. So in a situation like that, you have to think about, well, who is she in love with? She doesn't know you that well. She has a sense of you, but if you're the kind of therapist I hope we are with psychoanalytic or psychodynamic work, you don't really reveal that much about yourself. I'm not naive. patients can pick up a lot about who we are, but, you know, sometimes the distortions are kind of amazing. Like, uh, this woman, well, I'll tell you more later. Um, so first of all, I get a little nervous that she loves me and it's painful for her. It's kind of a burden and kind of uncomfortable to ever give this declaration of love, but you have to say, okay, she's actually in love. Just like you tell yourself when the patient's saying you're horrible and I hate you, you say, well, she's really hating a transference object, an object she's projecting on me. When she's saying she loves you, you say, well, to yourself, she's really in love with some image she's projecting on me. I mean, it's nice to think we're so special, it's really us, but they're in love with the projection. So with this lady, I said a couple of things. I said, first of all, you know, it's really important you brought that up because anything can be discussed here. That's the special thing about therapy. We can discuss anything, help with it, learn from it, without anything happening. We have the total safety of the boundaries here. So I didn't say if I loved her or didn't love her, but I just said we can talk about anything. Then I went into the, let's talk about this guy you're in love with. You know, and I said a little bit of what I just said to you. You know me some, but there's a lot you don't know about me. Describe to me this man you're in love with. And she started describing somebody so ideal, she started chuckling halfway into it and saying, well, I guess that maybe couldn't be totally possible. So I said, well, that's worth thinking about because, you know, the love is very strong. And by the way, this is a woman who needed to explore and better understand her internal ideal part. Because everybody thinks, oh, in the split internal world, the aggressive part is a problem, but the ideal representations are fine. But I always emphasize the ideal representations are just as pathological because they don't exist in reality and they mess up people looking for something that doesn't exist. So the idealization of you is pretty dangerous. So she began to realize she was in love with an ideal thing, image, and maybe she should think about it. And this was very important because by that time she was married but getting very critical of her husband. I was thinking about leaving her husband. And she was thinking about leaving her husband because she still thought she could find some ideal guy and it would be me. Now, then it gets a little trickier when you talk about your feelings towards the patient. So she said, you know, it's just pathetic, my loving you. You could have no interest in me if we met at a cocktail party. you wouldn't stay two minutes, you just turn and talk to somebody else. So I said, well, let's talk about that idea as well. First of all, I found her a quite likable and interesting person. She's very bright and clever and so on and so forth. So I said, you know, where does that idea come from that I would just turn away from you and have no interest in you? So we explored that negative projection, and I think she came out of that with a better understanding of the danger of banking on or believing in ideal internal representations. But let me tell you about an eroticized transference than an erotic countertransference that I had. So another patient, not unlike the first one, but unfortunately more antisocial and more aggressive than the first one, also a lot of self-harm, suicide attempts, and hospitalizations. So anyway, again, interestingly, about two years into therapy, he jumps out of her seat in the session, sits on my lap, and starts to undo my necktie as though she wanted to unbutton my shirt and take it off. Yeah, I never had that happen before. I didn't hear anything except what? So this actually physically happened? This physically took place very quickly? Yeah. I never had it happen before or since. But she literally was on my lap trying to take my shirt off. So I just instinctively held my arm against her sternum in a way that was as unsexual as I could do. and say, you know, you got to go back and sit down or we have to end this session. And then listen to her discuss. She said, no. It's interesting. It goes back to the trust, mistrust issue. She said, we've spent two years working on this issue about if I can trust you or not. And now I want proof that I can trust you. I'm offering myself to you. And if you don't have sex with me, it'll be proof once and for all that I can't trust you and I can't trust anybody so you have to have sex with me to prove that I can trust somebody so I said you know what I think it's the exact opposite you're trying to get proof of mistrusting me you know as well as I do was she still on your lap when you're having this conversation and you're like yeah yeah i said you know as well as i do that um the worst violation that can happen in therapy is for a therapist to have sex with his patient so you're not trying to see if you can trust me you're trying to get evidence that I'm corrupt and that you can't trust me. So I think that's what we have to look at. So that's the eroticized transference. It looked like it was about sex and maybe love, but she was trying to show I was corrupt. It was perverse. It was a libidinal facade covering over an antisocial core. And then she sat down and we could talk about it. There might be questions about that. How quickly did that come up? It was two years? That was two years into therapy, yeah. Now, okay. So nothing sexual before two years from her? No, not that I can think of. I mean, one might argue she dressed somewhat sexy, but nothing. How often in your career have you dealt with people you were supervising? that have struggled or have come to you with these kind of things? What's the pattern that you've seen? About sexual transferences and countertransferences? It's funny, I don't see it that often. I like to teach about it, but I'm trying to think. They don't usually come up as literally as I've been talking about. They can come up more in fantasy material, which I can talk about. But you go ahead, David. I think because of the podcast and because people reach out to me when they have these dire situations, I had this conversation with this woman about five years ago where she was falling in love with a patient. And she had already gotten supervision and decided that she was going to divorce her husband. And she was anonymous to me. She was a therapist. I didn't even know her name. but I was like hey I'm gonna have a conversation with you like I don't need to know your name it'd be a one-time thing so but she was like very she was very naive to kind of like the the pull of any dynamic she wasn't trained psychodynamically you know and I said you know if you do this I think you should also decide that you're not going to be a therapist anymore good so that was one situation there was one other situation where I had a psychiatrist who had an affair with the patient, not trained psychodynamically. She was seeing the patient twice a week, which she was a psychiatrist. She wasn't trained to see patients twice a week. So I think she was naive to the pole of the transverses. Yeah. So yeah, anyways. But you know, I like what you said to that first therapist, but I would have gone a little further and say, you know, there is a literature about this, and it's kind of risky, because when therapists and patients begin to experience love, often it's based on, this is not a psychodynamic therapist, it's what's called a projection. He might be projecting a lot of stuff onto you that doesn't correspond to who you are. And historically, these relationships seem great initially, and then they can fall apart when reality comes in. So I'm a little further. I think I said, I think the person that he loves is a person who listens to him for 50 minutes. Oh, that's good. And who has full attention on him. and I think if you were to end up in a relationship, that fundamentally will change. And I think there's a reason why he's had three failed marriages and I'm afraid that you're not only going to blow. Oh, and then I also said, I think you need to decide if your current marriage is successful or not before you even start to think about this guy. You should think A or not A before you think A or B. I like that because you were really talking about projection in very sort of vernacular layman's language. So that's perfect. Yeah. Good. I just have a quick question for Al-Bob. Are you in London? No, I'm actually in Los Angeles. That's interesting. Because somebody I superize in London, it looks exactly the same. The window, the trees, the configuration. Anyway, so you're not in London. Okay, never mind. No, no, no. It's probably because we've just been going through like a week of rain. So we finally have green. Oh, good. So far, it's usually just dry all the time. All right. Just couldn't, I had to get that off my chest. Yeah, good. All right, other questions? We have five more minutes, guys. So any final, raise your hand if you have any final dying thoughts, maybe about this kind of topic of, any of the topics he's talked about so far, anything that still feels like it's still, you're still unsure about, you're still feeling anxious about. Oh, Daniel again, yeah. Let's see, I don't see. Sorry, unless someone, Does anyone else have since I already went? No, go ahead, Daniel. Go ahead. It goes back to the conversation about the 35-year-old and a question about the kind of analysis of the countertransference, the attentiveness to it, and whether it applies to sort of less intense reactions in the patient, whether you're consistently in less than sort of when there isn't a standard deviation, a single standard deviation from the mean, analyzing and paying attention to your own countertransference reactions? Well, that's a great question because we talk about acute and chronic countertransference. I'm glad that came up just before the end. The acute countertransference is often what gives the most payout because those are in moments of affective intensity, and they usually correspond more to the kind of stark internal representations at the bottom of the personality pathology. But if it's not that affective intensity, you can lull yourself into sort of what we call chronic countertransference dispositions of which you might be less aware because they're not as intense. and you kind of get used to them. And I could give an example, but I want to hear about Jordan's question at first, and then maybe I'll get to the example of the chronic one. Thank you. Yeah. I was just kind of curious, you know, on a week-to-week basis with the individuals you work with, how do you do case notes? How do you process the session from week to week? Do you include that in, do you include transference, counter-transference in how, yeah, you're documenting what you're doing? Oh, well, I include them in my personal notes, and it's been ages since I've gone over this, but from my understanding, there's the legal medical record and then there are your therapy notes. So I would put this in my therapy notes, but not in the whole medical record in which I put just a minimal amount of information because that's more subject to all kinds of bodies who might want to look at it. and you don't want to go too much into all these details and those. Yeah, Johan again. This was happening to myself and other therapists within our practice, which is regarding about like titles and names. Yeah. Introduce yourself as maybe, you know, let's say Dr. Ortizzo. And then over time, you'll notice like maybe there'll be a Dr. Johan or it'll be just a Johan. And I'm wondering how, you know, because you might be suspecting a subtle devaluation or maybe there's also like a generational difference because I do serve, you know, younger folks with older folks. How do you explore this without like prematurely confronting or short circuiting like the process? Yeah, that's a great question. And it's always a moving target because social amores are changing over time. so I would say it's probably more the norm than the exception for people that call their therapist first names I usually introduce myself as Dr. Owens and then I see where somebody goes from there and I try to be very neutral and just say something like like everything else that happens here it's interesting to think about, you know, how we sort of address each other. I noticed that you shifted from Dr. Gomez to Frank, or you started right away with Frank, which is fine, but I just thought that we might think about that, because there's always something there. Is it the narcissistic patient who can't tolerate a status difference, or are they wanting to feel closer to you with another type of narcissistic patient or they sort of trying to devalue you and take away from your expertise or so I just say you know it's like everything else everything's appropriate grist for the male and we can learn from thinking about it there's I say you know there's no right or wrong I'm not insisting people call me Dr. Yomason some do and some don't you know Any last questions? I mean, when it comes to the end of a meeting like this, there's always a certain discomfort, but I turn it into something positive because what I like about psychotherapy is it never ceases to be interesting. You can tell from a discussion like this, everybody has their own cases, their own experiences. There's always more to think about. There's always new twists and new variations. so never gets boring. I appreciate that. Yeah, this has been a great time with you and I appreciate you coming on. I think we'll be digesting it and we'll be thinking about it. And I think it also has kind of opened up people to read your book. Dr. Yeomans has a really good book on transfer-focused therapy and borderline personality disorder. Highly recommend that. And yeah, I'm excited to have you on the podcast again. so we'll talk we'll do that thanks for joining us thank you thank you so much Dr. Eumann thank you for coming bye bye now TheFxnR