Psychiatry & Psychotherapy Podcast - Beginning the Treatment with Jonathan Shedler, PhD

Episode Date: February 16, 2024

Dr. Jonathan Shedler is well known for his work on the efficacy of psychodynamic therapy. He has highlighted the importance of the initial phase of therapy in establishing a foundation for successful treatment. Dr. Shedler strongly believes the consultation phase is crucial to developing a working alliance between client and therapist and building a treatment frame and structure. Without this foundation, there is no mutual understanding about the goal or the purpose of treatment, and psychotherapy should not move forward. Join us in this episode as Dr. Shelder discusses how to create a firm starting foundation in clinical practice. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Jonathan Shedler, who has been on the podcast before. We did an episode on OCPD, and we did an episode on narcissistic personality disorder. And today we'll be talking about his approach to beginning the treatment. Welcome to the podcast. Hi. Good to be here. Good to see you again.

Good to see you again. Yeah, we were jovily talking before we started about. how I should open up a dating service for you, or like dating application. The most eligible Bachelor psychoanalysts in the world, Jonathan Shetler. Okay, now you're going to get some DMs in your Twitter. You'll make me blush, man.

Okay, here we go. So, in your... Talk about, like, how you... This is a great interview strategy. Get your, you know, get your guest to be as flustered. as possible before you get into the content of the podcast. Do patients ever do that to you? Do they like start off right at the beginning of treatment to trying to like...

Patients do everything you could possibly think of. Okay. Put you on the spot. Ask you personally embarrassing questions. If you could think it somewhere, sometime a patient has done it. Okay. Let's talk about the start. The start of treating.

So a patient calls you, they leave a message, you call back, tell me about that conversation. Do you handle that or do you have an admin person? No, I handle all of that myself. Lately these days, it's likely to be an email rather than a phone call. Okay. And so we'll start from the beginning. Different therapists have different ways of doing it. some people will offer a, you know, like brief, you know, free 15-minute consultation or something like that.

I personally think it's a terrible idea. I think when you accept a patient into treatment, you're both making a commitment. It's a commitment for both parties, the doctor or the therapist and the patient also. And you can't in good conscience. agree to treat somebody before you have a, you know, reasonably solid understanding of what's wrong, what kind of help they're looking for, whether it's something that psychotherapy, you know, could realistically help with, whether psychotherapy with you, the therapy that we provide, is likely to help.

Whether it's a good enough fit between the two people, whether the patient is able to participate, take on the responsibilities that come with being a patient, you really need to know all of those things before you jump into treatment. And that's why I don't like this idea of a phone intake, or a free 15-minute session, that first session, to me, is the most important.

That's the starting point and the foundation for everything you do. It is the most important thing that happens at the beginning of treatment. And you really want to take your time to do it thoroughly and carefully and do it well. So when I get that first phone call or email, I just want to get the most general idea of, you know, is this even, you know, is this even a reasonable, you know, for an outpatient setting, for a private practice setting? And I don't want to get too much into details. You know, I want to know that they can pay my fee or, you know, they have insurance that, you know, that I work with. I want to know that what they're coming for is, you know, generally in the ballpark of something suitable for psychotherapy.

I mean, if they tell me they're schizophrenic, you know, or, you know, or it's just coming out of an inpatient hospitalization, and that's their diagnosis. They're probably not going to be, they're not going to be a suitable patient for my practice, at least not on an outpatient basis. So I just want that it's just the roughest idea. Does this sound suitable for? therapy, you know, can they afford to be in my practice? And so this is really important.

The first session is never the start of therapy. And you should never frame it to a prospective patient so that they think that the first session is the start of therapy. The first session is a consultation. And actually, it may take more than one session. And the, the, but purpose, and this is what I, this is to answer your specific question, what do I tell the patient on the phone or by email, the purpose of this first consultation is for me to find out what kind of help they're looking for, to get to know enough about them to make a realistic assessment of whether I think I can help. And for them to get to know enough about me, you know, to make at least, you know, an to get an initial sense of whether it feels like a fit and whether I'm someone they want to work with. So it needs to be a mutual decision of both people. Both people need to, you know, both people need to say, you know, I want to proceed with this. And that should be an informed decision that comes after spending some time together, you know, working and working toward understanding, you know, what's wrong.

if we're going to proceed with therapy, what would that look like? Okay. And so in that first session, are you making an assessment of diagnosis? Are you making an assessment of like a case, a mini case formulation? Are you making? Yeah, all of the above. And I want to emphasize, you know, if the patient is relatively healthy functioning, you know, what we call in the psychoanalytic world,

you know, the healthy neurotic level of functioning, then you're likely going to be able to do it in a session. As you move into, you know, character pathology range, it's very unlikely that you're going to be able to do it in a single session. It's going to take longer to know the things that you need to know and see if you can get on the same page with the patient about what the purpose of this work is. So, you know, I can't, it's so easy to say. I can't emphasize this. because so few people do it. The first session is not the start of therapy. The first session is for me to get to know them well enough to make an informed, you know, offer an informed professional opinion, you know, recommendation about whether I can help and for them to get

me to know me well enough to decide if they even want to work with me, right, assuming that I think that psychotherapy with me could help. So we tell the, we tell the prospective patient, You know, our first meetings, you know, maybe one meeting, maybe several, can't know in advance, is going to be a consultation to determine whether it makes sense to proceed with therapy. And at the end of the consultation, I'll make a recommendation about what I think would be best for them. They'll be in a position to, you know, decide if the recommendation is going to continue, they'll be in a position to decide whether it's a fit for them and whether they want to work with me. and we'll take it from there.

So you don't want to start down this path with false expectations on either side. And I do a lot of consultation and supervision, and not just to, you know, beginners. You know, some are early career therapists. Some are mid-career and more senior therapists. What I see over and over again is that people jump into therapy very quickly without really knowing what they're getting into. And they get into hot water. And then they start, you know, hating life.

Okay, so when you think about like knowing what you're getting into, what comes to your mind like as a common mistake that maybe a professional makes and not knowing what they're getting into. Like how does one know what they're getting into and what is getting into? I mean, you know within certain parameters. I mean, I know I can treat psychotic patients. I need to work with a psychiatrist closely coordinated around medication issues. I can treat bipolar patients, you know, same deal. I don't want to do it in my private practice. I don't have a team. I don't have a support to do that.

I don't have an affiliation with a hospital in case the patient needs to be hospitalized. So I have some ideas in my head about, you know, like who can I work with comfortably and who not. And I think every therapist needs to, every therapist in an outpatient setting, it changes. If you're in a, you know, if you're in a clinic or an agency and there's an entire treatment team, then you can do a lot more. But if, you know, if this is individual therapy in a private practice setting, every therapist needs to have a pretty clear idea of, you know, what they're capable of working with in that setting and not just what they're capable, but what they're comfortable with and what they're good at.

So you're a psychiatrist, right? You might be comfortable seeing people in private practice, you know, a stable patient with a schizophrenic spectrum disorder, a stable, you know, a patient with a bipolar disorder who is stable or can become stabilized, right? So you may be comfortable with a different range of people than I am. But the point is every single clinician needs to understand what am I comfortable working with? And that's going to be different for every clinician. Some people thrive on working with multiple patients in their practice, with borderline personality organization,

where there's a lot of drama, intensity, chaos. Some people love that. Most clinicians don't. That's kind of a rule of thumb. One patient in that level of functioning is probably, you know, is probably all that most clinicians can reasonably do a good job with. But you need to know yourself as a clinician. That comes with experience.

So one thing that's implicit in what I'm saying is this is a two-way street. I see a lot of younger therapists feel very responsible. They're sort of caretakers and helpgivers, and they feel very responsible to try to take care of the patient. And what they end up doing is, you know, putting the patient's needs ahead of their own. And it's a recipe for trouble. A treatment relationship has to work for two people or it works for no one. So the therapist really needs to, you know, come into that consultation with a pretty clear sense of what their needs are to function effectively as a therapist so that they can be a good therapist to that patient.

And that means we need to know our own limits and boundaries, right? Not just our areas of competence and skill, right? Maybe we can do it, but who can we see that's not going to be an undue burden, right, that we can see comfortably. And I said it before, but I just want to say it again, right? This has to be a mutual decision by two people who both choose to work together, and the treatment relationship has to work for two. That's what a lot of younger therapists sort of lose track of, that it has to work for them

also. The therapist has legitimate needs. They have scheduling needs. They have needs around their fees. They have needs around, you know, where are they in their professional development and their trajectory? Who do they want to work with? to continue developing

developing their skills as a clinician. Not everyone. Yeah. So I have a couple thoughts. One is I get some difficult calls. You know, like there was one guy, this is you're going to love this frame or this sort of situation, but, you know, he wouldn't come in.

So I actually went out to his house. And I don't think I, I don't know if I would do that again, so don't call me if that's, what you want. Sometimes we have to learn by trial and error. He proceeded to jump out the window. Oh my God. Luckily, I saw enough to know that he was floridly psychotic and he was hospitalized.

But I think that having this conversation is good because I think as professionals we can think we need to solve every problem. But if we're talking about, I mean, psychiatrists and psychologists and other kinds of therapists, we do a lot of different things. You know, I mean, we have a lot of different activities and skill sets that fall under the general umbrella of the profession. If we're talking about outpatient therapy, psychotherapy, then there's certain basic requirements, right? The doctor or the therapist has certain responsibilities to the patient and to the treatment, right? We have our responsibilities. But the patient

has certain responsibilities. If they can't fulfill them, treatment, you know, treatment can't happen. One of those responsibilities is they need to be able to show up for the sessions, right? If the sessions are in our office, they need to be able to get to our office. If the sessions are online, they need the technology and, you know, to be able to do that. And they need to be able to come and keep their appointments. I mean, I use humor a lot. I mean, sometimes I'll say it to patients like, you know, the kind of therapy that I practice doesn't work very well on people who aren't present to receive it. I mean, as a bare, bare minimum, right, you need to be able to agree on a meeting schedule that works for two people and that has enough consistency that real therapy can happen. So you need a

meeting schedule, and the patient needs to be able to pay the fees. That's the bare minimum. And if we try to kid ourselves and say, well, we can work with it, you know, we can work with it anyway. I think it's a recipe for, you know, a recipe for trouble. What about like, okay, so one of my thoughts is some patients are more avoidant. They don't necessarily, like, it's not on day one that they're going to want to come every week, you know? So how do you, how do you, are you flexible with someone who has like a lot of natural avoidance? I would rather work with it in the treatment than, you know, yeah.

So we're talking about the treatment frame. And the treatment frame is basically what are all of the arrangements that we make with our patients that make it possible to do this work. And, you know, the treatment frame is things like, you know, a consistent, well, privacy and confidentiality, a consistent, you know, predictable meeting schedule, the agreed on fee, your policies regarding, you know, missed or canceled appointments, right? All of this isn't the work of the therapy itself, right? maybe part of the frame is we do therapy in therapy sessions and not outside of therapy sessions. All of these things are not the therapy itself, but they're the conditions that make it possible to do therapy.

So you're asking about, you know, as far as I'm concerned for the kind of therapy that I do, which is, you know, psychodynamic or psychoanalytic therapy aimed at self-understanding, aimed at psychological change, right, not just aimed at managing symptoms or supporting, you know, not trying to change something, just, you know, supporting someone through a chronic condition, right? I can do that, but that's not what I choose to do in my private practice. I'm in it to help the person to change something about themselves. That requires consistency of meetings. It requires, there's enough frequency of meetings that you can actually do the work. And the truth of the matter is it's really hard to do therapy once a week.

It takes more skill to do that than to do therapy twice a week or three times a week. And the reason is it's very hard to move beyond the catch-up of the events of the week and get to the, you know, the sort of enduring psychological issues, right? The issues, not the problems or the stress or the crisis du jour, but what's going on psychologically that leaves the person vulnerable to these kinds of problems and stresses and crises. So less than once a week, there isn't enough continuity. I will tell that to the person, you know, right? They don't necessarily know.

And I'll say it pretty much the way I said it to you. You know, it's less than once a week. it's very hard to get past, you know, the weekly catch-up. And I don't think, you know, I don't think you're going to get the help that you want from this. So, I mean, I'm pretty adamant that, you know, that's part of the frame. And you say, do we apply the frame, you know, are they rules to apply rigidly and, you know, inflexibly? No, of course not. We have to do things flexibly.

There are exceptions. Somebody is just, they're just not prepared to make that commitment of more than once a week. Okay, with this particular person in this particular situation, you know, let's flex a little. What does it take to make it possible for this person to, you know, sort of dip their toe into therapy relationship? But I want to make, I want to make a point here for you and for everyone. Because this happens all the time. These are exceptions to our sort of standard way of working, our kind of a standard frame that we, you know,

because we adjust and we do things flexibly and, you know, we do things flexibly so that we can meet the patient where they are. But the key is they're exceptions. I mean, when you say, okay, I'm going to agree to meet with you every other week, at least for a start, right? It's an exception. When the exception becomes the rule, then we've got a problem, right? Then we don't have a frame that we can work in. And we have to be clear that it's an exception.

It needs to be thought through. We need to understand why we're making the, right? It's part of a case formulation. Why are we making this exception for this particular person at this particular time? What are we trying to accomplish? What are we hoping that we can accomplish? Where is this going to lead? It has to be part of a larger plan.

And what I see, especially among younger therapists, is there's only exceptions that they don't have a sense of this is this structure that's necessary to do this work and do it well. Yeah, one thing I hear from you is you don't want to go into a scenario where you know you're not going to be able to get an outcome, which is the outcome you want. You don't want to set yourself up and you don't want to set your patient up for failure. You want to set yourself up for success. So you said, what do you say to the patients? You know, like, you know, this is too much. This is too intense. I'm not sure. I want to come every other week. what I would prefer to do first with that patient. This is just one very, the resistance or the defense against engaging in the treatment accompanies the treatment at every step of the way. There's no such thing as psychotherapy without resistance, without defense.

Change is really complicated. It's really hard. The fact that the person has come to treatment, something in them, wants change. It wants to grow, wants to be different, wants to get well. But there's also something in us that is, you know, we're wired to try to maintain the status quo. Change is really scary, right? Frightening. So we're always, when a patient comes to us, we're always working, there are two minds or many minds about being in treatment. We are always working with ambivalence. We have to understand part of the patient wants to be there and wants to

to engage in treatment. Part of the patient wants to protect themselves from, you know, confronting things that are unpleasant, that are frightening, you know, that are painful. And that part of the patient has a different agenda, and we're always working with, you know, multiple parts. So the person who comes in and says, you know, I think every other week, first I just give them the information. It's really not enough continuity to get what you want out of it, you know, but I hear you. You know, there's something about, you know, jumping in that doesn't sit right with you, that feels wrong to you. Help me understand that. Tell me about that.

So what I want to do is what we try to do in what we try to do in psychotherapy, the patient is not just patients, humans, all of us. We are all of many minds about, you know, everything important. And what we try and, but some of those, right, some of those parts of self get all the airtime, you know, they get to speak and some of those parts of self get silenced or, you know, disregarded or disavowed. But out of sight isn't out of mind. Right? If we don't hear from those parts in words, they start running the show from behind, you

you know, from behind the scenes. So part of what we want to do in therapy is make, is create a space where it becomes possible to hear from all of the different facets of the person, including and especially the parts we don't usually get to hear from in words. So, you know, think about a patient who agrees to come weekly and then starts missing sessions. You know, what does it mean? Well, we hear from one part of the person in words.

I want to come weekly. I want to do this work. We're hearing from another part of them, another part of them is communicating loud and clear, except it's not in thoughts and words. It's in actions, the action of missing sessions. What we want to do is work to put words

to what's being communicated, you know, not in words. And, you know, so we might say to that patient, you know, I understand that part of you wants to be here, agreed to come weekly. but I think, you know, another part of you is communicating something else, but not in words. I wonder if we can start to attach some words to it, you know, that there's a part of you that would prefer not to come here or this would prefer not to come here that often.

I wonder if we could hear from that part. Let's roleplay that, so I'll be that person, okay? All right. Let's go. Someone asked on Twitter for the roleplay. Okay. Oh, no, no, no. I was just, I just got really busy and, you know, I know I missed three sessions, but that's like, you know, I was busy and I was doing things. I honestly just lost track of time and I just, you know, I forgot. Well, you know, I believe you. I believe that things came up and that you lost track of time. But, you know, one of the things that we know, one of the things we learn as therapists is, you know, people have sort of many layers to our experience. You know, that things have lots of meanings, you know, not just one. And, you know, if you had missed a session and, you know, your car broke down or something. You know, three times in a row suggests that there's something more going on that deserves our attention.

And yeah, I understand this came up, you know, on that date, that came up on the other date, this other thing came up. I understand, there's always, you know, there's always an external thing that can get in the way. But I just think there's more to this than meets the eye. And I wonder if, you know, instead of sort of, you know, batting away my, you know, my curiosity. Well, you know, I'm, you know, I paid you for the three sessions and I, you know, I apologize. I don't, I don't know. Nothing's coming to my mind. Let me just, hold.

Let me just interrupt right here. I'm not looking for an apology. Yeah, I understand that you paid. It's not about that. it's about there's, I think, you know, I could be mistaken. I'm open to, you know, understanding it differently. I think there's a part of you operating here that's communicating not in words, but in actions. And I wonder, you know, because I notice you kind of batted my comment away very quickly.

You know, when I said, maybe there's more here than meets the eye. And you're like, no, no, no, just this. And I watched a talk of time. You know, what I can't help but notice is you responded so quickly, right? That you couldn't really have had time to take in my question and, you know, and let it sink in and actually give yourself some, space to think about it and see what occurs to you, see what comes to mind, see where your thoughts go.

Your answer, no, no, no, it's not that. Happened so quickly, there really wasn't space to notice other thoughts, feelings, images, memories, whatever that might have come up. That's what I'm suggesting, that perhaps there's something to understand here. And there would be some value in you and I making some time and space. to see if we could understand. Well, one thing that comes to my mind is when you shut the door at the end of our last session, you shut it louder than usual.

And I thought that you were really glad to have a door between us, especially after what I shared last session, which I feel embarrassed. about sharing? Say more about that. I know it's hard to role play, but I want, see, this is really important. The patient has just made a shift from, you know, it's nothing. I just, you know, I lost track of the time to this has something to do with two things in the last session.

One is the patient's sense, I don't really want to, I don't want to do this with him. I'm glad to be rid of him. There's the patient's feeling, you know, sort of rejected or that I don't want to be here with him. And that's really important. The second thing the patient is saying is I think it's going to go to their sense of shame about what they shared last session, which we're making up as we go. it, right? Their sense of shame, right? And that that's tied to the feeling of rejection. They told me something that they feel ashamed of. And the concern, the underlying concern in the background is, you know, I'm, I think ill of them for it. I'm judging them for it. I'm criticizing them for it.

But I don't want to rush in the interpretation yet because it's too soon, right? The patient has just put the idea on the table for the first time. It's kind of of a new, they've just put words to it themselves for the first time. It hasn't fully registered, sunk in, become palpable. So you think about what do we do in psychodynamic therapy? The three major, you know, major areas of technique are clarification, confrontation, interpretation. Interpretation comes last. Clarification is, I want them to elaborate. I want them to hear say more about it. I want them to feel it. I want it to become palpable in the room. that they felt, right, I want them to elaborate on.

They felt that I was happy to shut the door on them. They felt ashamed of what I said and are filled with worries, concerns, fantasies, fears about what do I think of them? I want them to feel that. And then I could say something like, I'll jump back into the roleplay. So we just kind of condensed a whole discussion. Once the patient has elaborated. on this and it's really out in the light of day. So we both feel it.

You know, then I could say something like, you know, so no wonder you weren't thrilled about coming back for your appointment. You know, if you felt that I was happy to be rid of you and couldn't wait to shut the door in your face, why would you want to come back? It makes sense. Yeah. Yeah.

It just, it's really, it's like weird because I was thinking about it all week. And I even had a dream about it. It's weird to obsess about how loud you shut the door all week. I feel silly for even imagining that that was, I don't know, that I cared so much or thought about it so much. That feels silly to me. It feels silly that you want help, that you're here for help. Yeah, I mean, you know how.

That it feels silly, that it's important to you, that it matters. Yeah, it feels important. I guess I didn't want to, you know, I talk about this because I felt like the more I talked about it today, the more likely you would fire me or something. I couldn't help us see like a frustration expression on your face there. Were you thinking about firing me? No, not at all. Frustration, you meant like just right here right now?

Yeah. Oh, yeah, that wasn't frustration. I was trying to formulate my words because I want to say this carefully, right? Because first of all, you know, you're right. This is important. You didn't come here for support. You came here because you need help. It is important.

And you know, you told me some things that, well, I hear you judging yourself very harshly for the things that you told me. And, you know, I'm getting the impression that it's really hard to believe that I wouldn't be judging you as harshly as you've been judging yourself. Let me make an aside here for the listeners. What did I just do there? I interpreted a projection.

What's going? I want to let everyone in my thought process. The patient feels ashamed. They are judging and criticizing and condemning themselves. they feel bad, right? That's their internal experience, right? Something inside of them is judging something else inside of them. But they're attributing that judgment, that condemnation, that shaming to me.

And so what I really did when I said, you know, it's hard to believe that I wouldn't be judging you as critically as you're judging yourself. You know, first of all, I'm putting that phenomenon into words. I'm naming that it's a projection. and I'm also planting, you know, the seed of an interpretation that the judgment is coming from inside, right? Not necessarily from me. So let's pick up the roleplay from there. It's hard to believe that I wouldn't be judging you as harshly as you're judging yourself. You know, I hear that from you. And I think that myself, well, of course, that's the right thing for you to say, you know, that you don't judge me.

I notice we get into a bind, though, you know, damned if we do and damn it if I don't, right? See, if I do judge you, that just confirms your worst fears. And if I say, no, that's not what's going on. That's not what's going through my mind. Well, that's not my thoughts and feelings. Then you quickly explain it away so that you can, so that you can, so that you're, you know, your mind. I'm still judging you. I'm just, I'm just saying otherwise. So, you know, I notice, you know, it puts you in a bind. But how could you not judge me, though, for missing three appointments? Like, I would judge myself. Like, if I had a client who did that, I might,

I might fire them. So I don't know, like, I guess I'm trying to, uh, by the way, I'm still in the role of the, uh, the client here. I got it. Business executive maybe or something, right? I would fire him right away. No, I think, but I, so I have a hard time. Because, because I understand that, you, and for that matter, everyone who comes to treatment

is really of two minds about this, right? That, you know, you've come because you're looking for help. There's another part of you in the mix, It's just like, you know, this is awful. No one would want to deal with me. My therapist wouldn't want to deal with me. There's reasons. You know, there's reasons why people miss sessions

and do all sorts of other things, right, to try to protect yourself from things that are really pretty uncomfortable. And again, I feel like maybe I'm repeating myself again, but it's hard, I think it's hard for you to believe that when I bring up the missed sessions, and actually bringing it up out of curiosity because I do believe that there's something here to understand.

And that's part of the work of the therapy, getting to hear from that part of you. Okay, I think that's again. I think we can move on topics because I'm a little bit uncomfortable with this. I'm joking. I'm like, it's hard to know if I'm still in the patient role or if I'm not anymore. Come out of the patient role.

Just you observing yourself in the patient role. I'm interested in how did it feel on your end? What did it bring up for you when I said, it's hard to believe that I wouldn't be judging you as harshly as you're judging yourself. What was your in the role of patient? What did I think? What was your reaction to that?

What did it bring up? I thought to myself at this point, point in treatment, you have a lot more context for understanding why I would be so judgmental of myself. And so I thought to myself, you know, maybe you are being honest that you have compassion. And it's not just an intellectual, the correct thing to say, you know. Well, I mean, it's true. I'm not saying it because it's correct. I'm saying it because that's, in fact, what I'm thinking.

But what you said is what I hoped, what I mean, what I'm going for, which is always, I would like to open space where it's possible to think and feel and experience and express in words, communicate more than before. So, you know, we work in the therapy to open that space. It's variously been called in the literature. You know, it's been called reflective space. It's been called mentalization. It's been called analytic space. Anyway, space to think and feel and reflect beyond, you know, what the patient has been able to do previously. So I'm trying to open space.

Sometimes patients are working to collapse the space. when you said at the beginning, well, no, no, no, no, it just, you know, I lost track of time. It means nothing, right? That's collapsing space. I'm working to open the space to think and feel more beyond that. And, right, you know, this is just a moment in time,

but it had the desired effect, right? Something inside you said, oh, maybe I could think about this differently. Like, maybe there's something more here than I realized. Hmm. Yeah. So. No, I appreciate it. To circle back, right?

Because you asked, what about the patient who wants to come, you know, every other week? Before I jumped into making a decision like that, I would want to do the process of, you know, we're working with defense and resistance. This is how you work with resistance. I would want to go through the process of, you know, there's reasons why you might want to come every week. The patient needs to know that I understand that, right? Ideally, I'd like the patient to understand, you know, that discomfort, that thing that you're trying to avoid. That's what we do here. That's what we talk about, think about, understand.

So it doesn't have to continue to be frightening, right? I want to do this work and see if the patient and I can get on the same page. But, you know, what makes them not want to come weekly, why it would be a value, what we could do together in here? Like, what happens if they come weekly? I don't want to tell them this is the work I'm going to do. I want to do the work with them. And the patient says, oh, so this is the experience of being in therapy. Oh, it's a little different from what I thought.

Like, this does feel useful to me. I mean, that's where I'm trying to go. So none of these things are rules. We say, this is the way we do it, you know, my way or the highway. These are the conditions that give us the best chance of working in a way that would be helpful to you. but I understand you have good reasons why, you know, yeah, like, there's good reasons why some of that doesn't sit well with you. Let's talk about it. All this is part of the consultation, which I love that.

Be longer than one session. I love that. I like it because it's like, it's not jumping prematurely to tell me what's going on. Okay, let's go back into the, let's go back into the roleplay. Yeah, so I was afraid, I was afraid, Dr. Shudler, that you were going to, you were going to fire me. And one thought that came to my mind right now was I had a previous therapist that never really got off the ground. And the therapist said something like I wasn't idealizing her enough. Or she didn't use those words. She didn't use those words. It was like, she said most of my.

clients who come to see me, they know who I am. They've, and they know what they're getting into, and they don't have any hesitation. And this person said that they felt like I had too much hesitation. Doesn't sound very good at all. Yeah, it was very, it felt a little bit like, it felt rejecting. And not allowing me to explore my, my hesitancy.

Well, I think you're right. It didn't leave a whole lot of room for you. And I'm just imagining, trying to imagine myself in your situation. It must have felt like shit to be spoken to that way, treated that way. I, I, it felt like it was a little bit, yeah, it's almost like I'm speech. right now thinking back at that because it was so painful. I can imagine. So, I mean, that sheds some more light on things. I mean, you know, no wonder you're of two minds about coming to your sessions here. You don't want a repeat of that experience. Yeah, absolutely.

I think, so, yeah, it's like, I would hope that there's some part, like we just did earlier, that we could explore if I was hesitant, that's helpful to me. I would like to do that also. What I would like to do, and it sounds like you absolutely did not experience the previous therapy this way. What I would like to do is be able to do things together. in a way that makes it possible to talk about anything here. That's good. Okay.

Shall we move on from the role play? Sure. We'll have to get a voting from Twitter if people want us to continue more role plays in the future. I do want to, let me. Yeah, if you want to reflect. Bring some focus, yeah. So let me tell you where I'm coming from

in terms of my thoughts about starting the treatment. So, as you know, I got a lot of attention for a paper I wrote in 2010 called the efficacy of psychodynamic psychotherapy. But it led to a lot, you know, a lot of invitations to, you know, speak, lecture, to workshops all over the world. And when I do a workshop, I always have a clinical case consultation component. So I'll do a didactic presentation. and then I'll have one or sometimes several, you know, real clinicians in the community who want to volunteer for, you know, to present a case for live supervision or consultation. And I always say, you know, I don't want the case where everything is going swimmingly. I want the one you're struggling with.

I want the one, you know, that's a challenge that feels like it's at an impasse where you feel stuck in some way or overwhelmed or directionless in. lost, I want the case that you really need help with. And the reason for that is for purposes of teaching, there's much, much more to be learned from that. And every clinician has a case or several that they're struggling with, that they feel lost with with their impasse. If they say otherwise, they're lying. We all have that case. We'd never outgrow at any point in our career. We never outgrow the need for consultation. So, um, so, I've been doing these kinds of public case consultations for just about 15 years. And over time, I've noticed some patterns.

And what I've noticed is that when the treatment gets stuck in this way, and the clinician is struggling, the problem almost always traces back to the very beginning of the therapy, to those first sessions, those consultations. And I don't think it would be exaggerating to say like 95% of the time. That's the problem. And the problem is that the therapist jumped into doing therapy, in air quotes, before the therapist and the patient were on the same page about what they were trying to do together. So we think what has to happen at the very beginning of therapy?

If we're going to set up therapy so that it can be successful and it doesn't hit an impasse or become directionless, we need to develop a working alliance, but the term working alliance does not mean what most therapists think it means. It actually has a very specific meaning. And a working alliance has three components. One of them is there's attachment, right, that both people are invested enough in this relationship. They want to continue meeting. Now, when somebody presents a case to me that's, you know, stock me, they've usually been doing it for a while, usually almost always, that part's intact, right? There's enough mutual attachment that they're meeting together.

People think, clinicians think, a working alliance means we like each. other, we feel good about each other, you know, we like hit it off. That's not what it means. That's one of where there's three pillars of a working alliance. Attachment is one of them. The second pillar, and this is where huge numbers of people stumble, is there needs to be a mutual understanding and agreement about the purpose of the work. The patient has not come here for sport, right? They've come here. We're going to roll up our sleeves and get to work, but we need to both understand and be on the same page about what is that work, what is the purpose of that work. So mutual agreement about the purpose of the

treatment. And the third pillar is mutual agreement about the methods that we're going to use to try to achieve that purpose. So recap three things. A working alliance is number one attachment, number two, mutual agreement about the purpose of the work. Number three, mutual agreement about the methods of how we're going to do that. Everybody falters on number two, mutual agreement about the purpose of the work. So let me give you an example. The purpose is not a diagnosis. The purpose is not a symptom.

The purpose comes out of a case formulation. So we're working reliance in a case formulation. go hand in hand, you can't separate them. In order to articulate a purpose of the work, we as the clinician have to develop an initial case formulation. What is going on psychologically that is giving rise to this person's difficulties? What would need to change psychologically for them to feel better in the ways that they're hoping? So the patient comes in and says, I'm anxious or I'm depressed or I was a

abused as a child. Do we have a shared understanding and agreement about the purpose of the work? No, we do not. So the case where, suppose the patient says, you know, they're depressed, assuming it's something psychological that, you know, that's amenable to psychological treatment, our case formulation is, what is going on? What is it about the person? What is it about their psychology that's making them vulnerable to being depressed. So the purpose of the work isn't, you should be less depressed. We could say that's a desired outcome, but it's not a treatment purpose or a treatment focus. The treatment purpose or focus is what is it about this person's psychology? What is it about themselves that would need to change? So,

they don't continue being vulnerable to depression. That takes some serious work and skill on the part of the therapist. I need at least a first draft of a formulation. What's going on psychologically? In the case of depression, you know, some prime candidates are, you know, are they hypercritical? Have they internalized, you know, a critical, judgmental fault-finding interject? So there's something inside the patient that is continually attacking, something else in the patient. Well, that's one recipe for depression. Another one is issues

around abandonment and loss. Some people sort of collapse when they don't feel like, you know, there's somebody else that they can lean on and sort of prop them up to support them. So they're very vulnerable to separations, abandonments, or any kind of friction in a relationship. Those are two, you know, possibilities, I think literally among infinite possibilities. This is where our skill in listening, you know, listening not just to what is said, but listening to the metaphor, to the underlying meanings, to the underlying, you know, underlying conflicts, defenses, object representations. We need to say we need to listen in a very sophisticated way. But when we're done, we need to be able to say to the patient, not in theoretical language, In very experienced near language, you know, one thing, one example, one thing I notice is inside your mind.

You can't catch a break in there. That I'm noticing you are very, very hard on yourself. You're punishing yourself. You're depriving yourself. I think this has everything to do with your depression. If you treat someone like dirt, you know, if you abuse them, if you castigate them, if you, you know, if you punish them, you know, it hurts. The same is true if we do that to ourselves. And so the patient has never thought this before.

I'm putting a new idea out there. When I say, we have to reach a mutual agreement about the purpose of the work, this is work for too much. minds. The patient can't tell me what the purpose is and I can't tell them. I don't know. We have to put our heads together and think together. That's the purpose of this consultation phase, right, for me to learn enough about them. And I say to the patient, you know, you're very hard on yourself. I think this has something to do with why you feel so depressed and down. What do you mean? At this point, I have specific concrete examples. You know, well, you know, you told me that you told me this happened at work and, you know, what I can see is, as an outside observer, is, you know,

these are circumstances beyond your control. But I couldn't help but notice how you were just berating yourself and abusing yourself. You know, you were a spectacular failure because you couldn't solve something that you had no control over to start with. Oh, yeah, I see that. give them another example in the situation with your wife, in the situation with your friend. I want to connect the dots. I'm listening for the patterns and the themes. I'm not interested in what happened in this particular instance. I'm listening for themes across lots of different instances of things in their life.

So that we have kind of a shared database when I say, you are blaming yourself continually. I never thought about it that way before. but now that it's on the table and we're talking about it. Yeah, yeah, I see. Why do I do that? I don't want to do that. Why do I do that? We'd like to get there with the patient.

I don't know. We don't know yet why you do that. It's a really important question. I think if we could understand why you do that, I think that might open some doors for you to do not have to keep doing it the same way, right, in this painful way. I think it might give you some options to not have to keep doing this to yourself. And if we can do that, you know, I think there's a pretty good chance that you'd feel better. Does that sound to you like it would be helpful?

is that what you'd like to do in therapy? So I've just put an idea out there that the patient didn't come in with that derives directly from my case formulation. And I don't say it to the patient in jargon or theoretical terms. I could say it to you in theoretical terms, but I say it to patient

in very experienced neuro language using their actual life experience that they've shared with me. I share it with the patient. I say basically as a hypothesis, It's not as a conclusion. This may be what's happening. It looks like.

This may be what's happening. Perhaps this is what's happening. What I'm doing is I'm offering it as a hypothesis, and I want them to jump in with me, right, to engage with that and think about it together with me. And I want them to do one of two things. I want them to either say, yeah, that's right. I see that. I hadn't thought about that before. But, and then start elaborating on it, filling it.

It'll bring a hundred other things to mind. and start filling in the blanks and putting more flesh on that skeleton. Or I want them to say, no, no, that's not it. Dr. Shedler, do you have your head up your ass? That's not what I said. And I want them to revise and correct. Either way is fine, because whether they agree or disagree, if they're engaged and thinking and reflecting on what I said,

they're taking it in, right? We can either home in on a shared understanding, or if they say, no, that's not it. that doesn't fit. We keep circling through it. I invite them to correct me. I got it wrong. Tell me how you understand it differently. I want them to supervise me. And we keep iterating through this process until we can home in on something that we both agree, right? Two things have to be true. It has to fit my case formulation. As the clinician, I have to think, you know, this is where the action is. I think if we did work around this, this would make a difference.

This fits my psychological understanding of what I can do in therapy, what we can do in therapy. And the patient has to say, yeah, like, I do see this in myself, and it bothers me. And I would like to be able to do things differently. So when you say, you know, a mutual agreement about the purpose of the treatment, I'm talking about a meeting of the mind, not about a diagnosis or the symptom, but about what, at least our initial first pass understanding, draft 1.0 of what's going on psychologically that's fueling their difficulties that we could realistically work with in psychotherapy that could make a difference from them. So that's the working alliance, right?

There's enough of a connection that we want to continue meeting. We develop a shared understanding of what is the purpose of our work. Only then can we talk about the methods. How are we going to work together? How are we going to structure this so that we can best accomplish that? And what I see, after 15 years of doing these consultations with people with cases that are stuck or directionless or at an impasse, we can trace it all the way back to the beginning of treatment. That process, that kind of working alliance was never established from the get-go.

So what does that mean in treatment? It's never too late to go back and revisit that. and restart that process. That's what I was going to say. I was going to say, I'm imagining a lot of people out there are listening to this at this point, and they're like, I have that one patient.

And I have, like, no clue what the, I've confused maybe treatment purpose with treatment outcome, right? Yes. Remove depression. Treatment purpose being, what is it that we're working on? What psychologically are we working on?

That treatment, can directly affect, treat up treatment outcome. We could say that's a life outcome. You know, somebody comes in, they've never been able to have, you know, they've never been able to, you know, develop a lasting relationship. They want a life partner. I'm in therapy because I can't, I can't do that. I want to be able to have a relationship and keep a relationship, right? That's a life outcome. We can't directly affect that through psychotherapy. What we can do is we can say, what is going on psychologically? What is going on in the way this person relates to themselves

and relates to others that's been getting in the way of that? That's what the case formulation needs to be about and the shared purpose needs to be about, you know, can we look at, can we understand, can we find, you know, a way, can we find our way through these patterns that you've been living out so you don't have to keep doing it that way? Right, that's, right? So there's the treatment purpose or the treatment focus

and then there's life outcomes that we hope the psychological work will, you know, will lead to or make more likely than they've been in the past, but those aren't the treatment focus. Okay, so if I was your dating coach, what would be the treatment purpose? We know what the outcome would be. The treatment purpose is, if the person is coming to therapy for, you know, and this is front and center, right, this is something painful. This is something, if they're coming to a therapist, there's an implicit acknowledgement, this is something about me.

I don't necessarily know what it is, right? I have no idea what's going wrong, but I'm coming to a therapist, right? I'm the common denominator here. There must be something about me. And if we can get to that, that's for, you know, we, we, the, the, the, the, the, the, the, the, the Even our case formulation and the treatment purpose is dynamic. It's not static. It's going to evolve as we both understand more.

But we need a, you know, first, we need a draft 1.0 of a formulation and a purpose. I don't know what it is, right? If we can just get to, there must be something I'm doing that's causing difficulties. Yeah. Perhaps what we can do in psychotherapy. as we understand more, as we hear more, know more, is, you know, we can begin to understand what you're doing that's getting in the way

of the relationships that you want. Right, right now, neither of us know. I don't know. You don't know. All we know is this keeps happening to you, and there must be something, right? Some way that you're, you know, tripping over your own feet here,

is that what you'd like to do here? Would you like to work to understand what's been going on in your relationships and what's been going wrong? So there's the possibility of not having to keep doing it. Is that what you'd like to do here? Yes. Now we've got a meeting of the minds. That'll get more refined and nuanced and specific, but that's a pretty good starting point. Here's an example.

this comes up all the time. I supervise these always ask. The patient comes in, they're miserable. They have no idea why, right? You can't get a purpose. You can't get a treatment focus. The patient's like, I just, I just feel empty. Something's not right. I don't know. I don't feel comfortable. You know, what's your understanding? I don't understand it. I just, something feels wrong. They have no words for it. They're given us no help at all. But in fact, the patient is actually giving us a lot of help, a lot of words, right? That puts us in a pretty nice position to be able to say, right, here's our first pass at a formulation and a treatment purpose. You know, what I'm understanding is that something feels very wrong and you don't have words for it. You don't have

words to describe what's wrong. And, you know, usually at that point the patient is like nodding or, Yeah, yeah, yeah. I think it might be helpful to you if we could work together to find words for what's wrong. If we can find the words for it, we'll be able to see it more clearly. If we can see it more clearly, we may be able to see a way out of this. I think there would be value for you in finding words for why you're feeling this way. Does that sound like it would be helpful for you? Is that what you would like to do here?

And I either want a yes with elaboration, you know, where the person fills in and elaborates and tells me more. You know, or I want the person to say, no, no, that's not it. But let me tell you how I'm understanding things now. right as we want to continue elaborating and iterating back over this until we get on the same page okay so that's a perfectly valid reason to proceed with treatment something's wrong and the patient doesn't know what it is and doesn't have words for it our job is to find words so so i've had a couple patients who come in usually male their wife rope them into going and they don't want to be there they don't think they need to be there but they're going there to appease you know

know and let's say they're a little bit more like narcissistically oriented you know so we've done a prior episode on that so okay how do you go about with that person you know so that's a really good question i'm glad you asked that and i know that patient i think we all do so you know recap working alliances attachment a mutual agreement about the purpose of the work a mutual agreement about the methods where they're going to use. This brings us to, the purpose can't be just anything. I had a supervise very recently. They had exactly that situation.

The patient came in and, you know, their problem is, their problem is, you know, their husband is narcissistic and, you know, an awful guy. And the patient is devoting all of their session time to, you know, trying to build a case to convince the therapist. Right. Can you diagnose by husband? The husband's right. So we don't have an alliance, a working alliance.

So the purpose of the treatment can't be anything. It has to be something about oneself that we want to change. Something about themselves, not something about someone else. And this, right, we don't have that much time. This is a very tricky, you know, it takes them. finesse to deal with us, this kind of situation, but it does happen all the time. And where we need to go with this, you know, is, you know, I understand your wife wants you to be here.

But, you know, that's what she wants. I'm interested in what you want for yourself, right? whether there's something in psychotherapy, something in working together that we might do, that would be a benefit from you, to you. And we have to move the conversation from what's wrong with somebody else to, you know, what is it that I would like help with?

What is it about me that's making my life harder than it needs to be or, you know, causing unnecessary suffering? or getting in my own way. Like, what is about me? Now, if the person is really narcissistically defended, that's a pretty, it seems easy to say, hard to get there. We might need an intermediary step. You know, it's like, you know, okay, I understand

you haven't really come here of your own accord. And I haven't heard from you something about yourself that we were hoping that therapy, could help with or I could help with. You know, I'm curious, what's your understanding of what your wife is seeing that's making her concerned and leading her to think that,

you know, think that therapy is right for you. So what I'm doing is, you know, I'm inviting the patient to take perspective. We could talk about this in terms of mentalization. I mean, the patient, their perspective is, I'm fine, what's wrong with you? And you say, okay, well, there's at least one other person in the world who seems to think that there's something about you that's of a concern, even if you don't agree with it. What's your understanding of what's causing them concern?

That might be our way into it. But this is really important. This is going to take weeks of work, maybe longer than weeks. we've got to get to a place where the person is able to say, yeah, like, I guess I'm playing a role in this, or I'm making things worse, or I keep getting into the situation. Oh, now we've got something to talk about. If you can't get a working alliance around a shared understanding of why we're here, you do not have a foundation on which to do psychotherapy, and psychotherapy should not be. proceed because you would be proceeding under a false pretext. You don't have an alliance. You have a pseudo-alliance. It cannot work. Now, the goal isn't to, you know, like, the goal isn't to make an ultimatum and say, you know, well, this is how we have to work and take it

or leave it. The goal is to help the patient, right, to do the work of therapy and help the patient to recognize what they didn't recognize when they first came in, the patient helped them to recognize, like, oh, yeah, there's like a way that they're getting in their own way. There's a way that they're contributing to these difficulties, right? There's something, there's a pattern here. There's something repetitive about it, right? They have some role in this. I can't stress this enough.

If you can't get there, you should not proceed with treatment. And that's not a treatment failure. That is an honest and authentic recognition, right, that you're not on the same page about what you can do in therapy together. And for a lot of people, you know, saying, just saying that honestly and authentically, you know, we aren't seeing this the same way. Like, I'm really not, you know, I'm not sure what we can do together. You know, it doesn't, you know, it doesn't make sense.

I mean, we, you know, it doesn't make sense to do therapy if we don't know what we're here to do. Right. That, for many patients, that's actually an intervention. It's the most honest and authentic thing you can say. You see it this way. I see it that way. we don't seem to be able to get on the same page. You know, nothing for us to do here.

The intervention is, you know, maybe months later or years later, the same issues will come up in the person's life again. You know, maybe down the road, they'll think, oh, you know, that therapist said, you know, said this and that about, you know, why they didn't want to proceed with therapy. I wonder if this is what they were taught. about. Huh. They were trying to, they were telling me something and I didn't hear it then. That's an intervention. There's a wonderful, it's a wonderful video of Otto Kernberg doing an

interview. It's like a two and a half long interview. And the reason it's realistic is because when it's a real patient and you bring a camera into the room, everything changes and it's now an artificial situation and it's not realistic anymore. The reason it's realistic is because he has an actor playing the role of the patient. And paradoxically, but the actor really studied the role, you know, got in the mind the patient, right? So you can create some realism. I mean, paradoxically, you need an actor to create a therapy video that actually, you know,

like actually captures what's going on. Anyway, the patient had come because his wife or his ex-wife or partner, you know, had insisted he should come to therapy. And it was exactly the situation you described. You know, my wife is horrible. My wife is a bitch. My wife is this, my wife, that, my wife. The universe goes on.

And Kernberg is, you know, curious, inviting, questioning, creating space, for the patient to elaborate, to say more. Well, then it comes out. Actually, it's not just the wife. It's court-ordered, and she has a restraining order. And then it comes out that, his previous relationship. It also had a restraining order. And every single thing the patient says is, you know, women are horrible, you know, they're out to take advantage. They're gold diggers.

This is what they do as soon as I wasn't, you know, useful to her. She, you know, she got a restraining order against me. It's all about what's wrong with the women. I've heard that. It's a wonderful video. Checked out. This goes out. No, no, I've heard that from patients. And this is where he winds up the two-and-a-half-hour interview. He says, I want you to go home and think about this, really think about this, because anything we do or don't do after this really hinges on what you end up deciding. You know, you've told me about one relationship after another that's just blown up in your face in, you know, awful, painful, ways. If you think the problem is, this is what women are, this is how women are, this is what they do,

if you think that's the problem, I'm terribly sympathetic to how much pain this has caused you over the years, but there's nothing as a psychiatrist I can do to help you. On the other hand, And if you think that there's some way that you're contributing, you know, to these awful experiences, the women you're choosing, who you're drawn to, you know, what patterns, what you're doing when you get in the relationships, you know, how you're treating them, how you're responding to them, if you think that there's a way that you may have a role in. the way these relationships will keep blowing up in your face, then there's potentially a great deal we could talk about that might be helpful to you. And we never get to find, you know, hear the answer.

He sends the patient home and with that decision point. Presumably the patient comes back next week and there's, you know, a follow-up. But he's demonstrating, you know, he's demonstrating something that there has to be a working alliance in order to have any basis. is for proceeding with psychotherapy. Beautiful, yeah. It's really good. I think that the patient has to be ready

to be a patient, right? If they have no desire to fix anything in themselves. I would say it differently because no one's ready or relatively few people are ready. It's our job. This is the skill. This is the expertise. It is where people come at varying levels of readiness.

it's our job to help them to become ready if that's possible. We have to help them get there. People don't come in on day one and they're ready to jump into it. They don't even know what the work is, let alone being ready to jump into it. It's our job. Our case formulation needs to be so specific and speak directly to the patient in a way that when the patient hears it, they say,

oh yeah like I didn't think about it before whoa I do see that I do want to be able to be able to do things differently and not keep repeating that we we need we need to help them to get there sure and if the patient comes in at a healthy neurotic level functioning we can get there in a session if the patient comes in at a more disturbed borderline level of functioning it may take months to get there. And possibly after months, we may end up coming to a shared decision that we can't get there. Yeah. I think, I like how you rephrase that. It's like we're kind of working with them and hoping them discover it, co-discovering together. What is the purpose? Yeah. I've said it at the beginning, but maybe it means something different now. It's not an ultimatum. It's not we say to the patient,

you know, well, you know, this is what you have to sign on for if we're going to work together. We have to help the patient understand something about themselves differently in a way that they didn't understand when they first came in that gives them, it's not didactic, it's not psychoeducation, in a way that gives them a taste of what this work is about and how it could be. helpful to them, right? We don't tell them about how we do therapy. We give them the experience of what it's like to be in therapy with us, what it's like to do this work so that they can, you know, feel, you know, it's not intellectual, they can feel in a way that, you know, sinks in, it takes to heart, oh, this isn't quite what I expected, but I'm understanding things differently.

I can see how this could really help me, right? We want them to have an experiential understanding of what therapy can do for them. In the absence of that, they don't really have an informed basis to make a decision to proceed or not proceed. So that's all part of the consultation phase. Good, good.

Well, I think we'll wrap it up here. We've got about an hour and a half. And I imagine people want a part two or have questions. You can go ahead and tweet those at us after we post this episode and see what other people have commented. And when we get the written version for CE, CMEs, we can include a little bit more that we didn't get to in the discussion. Yeah, we did that, by the way, for the narcissism episode.

We added extra to the article. and we've been enjoying doing a little writing together on these episodes to kind of like flesh out some of the things we didn't get to. So if this was helpful, go over to Psychiatrypodcast.com, check that out. It's free. Enjoy it. And yeah, look forward to having you back on in the future. I guess. Thank you, David.