Psychiatry & Psychotherapy Podcast - Disengagement Precedes Enactment: Mastering Countertransference with Dr. Karen Maroda

Episode Date: June 12, 2026

In this episode of the podcast, Dr. David Puder sits down with Dr. Karen Maroda, a renowned psychoanalyst, assistant professor of psychiatry at the Medical College of Wisconsin, and author of influential books including The Power of Countertransference and The Analyst's Vulnerability. Together they explore a powerful clinical insight: disengagement precedes enactment. Learn how therapists' unprocessed countertransference (irritation, boredom, guilt, anger, or helplessness) often leads to emotional withdrawal before erupting into destructive enactments that can rupture the therapeutic relationship. Dr. Maroda shares candid examples from her own practice, including a personal enactment she later processed with her patient, and demonstrates practical strategies for catching disengagement early, using constructive self-disclosure, and maintaining emotional presence. The conversation features a live role-play, deep discussion of parentification in therapists' histories, setting healthy boundaries, managing guilt and shame, and turning potential pitfalls into opportunities for deeper connection.   By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog Link to YouTube video

All right, welcome back. I am joined today with Karin Marota. Dr. Karin Marota. She is a refreshingly candid, unflinching, and clinically courageous psychoanalyst. She is assistant professor of psychiatry at the Medical College of Wisconsin, maintains an active private practice treating and supervising clinicians to a large degree, and is the author of four books, including the power of countertransference and newly released second edition of psychodynamic techniques. and the analyst vulnerability. Welcome to the show. All right.

Thank you, Dr. Pooter. It's a pleasure to be with. Yeah. So today, I was thinking about just jumping into a quote of yours. And then we'll kind of like unpack it. And I think the reason I always like to start with like what we're going to be talking about today. We're going to be talking about countertransference. We're going to be talking about enactments, how to stop enactments from happening.

and effective disclosure, we're going to have a role play. And so here's the quote. Disengagement typically precedes enactment. It is defensive seeking to avoid threatening stimuli from the patient and internal conflicts over guilt and shame. Enactment may well be the unconscious effort by one or both parties to reengage after withdrawal.

It succeeds in. stimulating deep feelings, essentially forcing renewed emotional engagement. Okay, so I think we need to start by defining enactment, and then maybe we'll go backwards and talk about how you think we can prevent enactments from happening. Well, that's not as easy of a question to answer as you would think. Okay. It's evolved. The concepts evolved over time, which is why people are understandably confused about it.

Originally, it was defined as a very discrete event that involved both people being emotionally triggered and acting out. But over time, people have preferred this whole idea that it really reflects this ongoing total communication conscious and unconscious between the therapist and the patient. I do not subscribe to that very broadened definition. And even some of the people like Wu Aaron, who did, said we do risk. we have the danger of using a term or expanding a term that then becomes meaningless, often in the way that empathy was used, you know, after a cohort.

So I prefer the discrete event. I think it's more helpful clinically. And an enactment is when people, and no one denies that the discrete event is enactment. The idea is that many people want to broaden it beyond this definition. So I want to stay with enactment as a discrete event, which is kind of this mutual triggering of therapist and patient. They both get triggered and it's based on a

transference, countertransference collision is the word that Richards used. There's a colliding. It's unexpected. It's uncontrolled. It's often discombobulating. The therapist is going like, why did I do that or why did I say that?

And it's very mysterious and it usually involves a strong emotional reaction. And the proponents of an and say it's a very positive thing, are saying having this emotional, you know, conflict is positive and it gives both people the opportunity to work through feelings that are actually going on subterraneously in the treatment. So it brings things up, you know, brings it out to air out and to discuss and to work through. That's the argument for enactment.

The argument against waiting for an enactment is that often these enactments can be destructive. they're not just always pure emotional exchanges either. Examples of an enactment can be, you know, like the analyst saying something sarcastic and the patient taking offense, or the borderline personality disorder patient who naturally fears abandonment and is criticizing the therapist. And the therapist says, well, maybe you should find another therapist. That's an inhabit. But there are other more subtle enactments like falling asleep. fantasizing or going off into their own world,

disengaging emotionally and emotionally abandoning the patient during a difficult time, extending sessions, cutting sessions short, canceling a patient at the last minute where you've been having some type of internal conflict with. So we can't assume that because there's an enactment, and I've treated people where therapists, the enactment involved them, the therapist totally losing control and screaming at them. that they were impossible, that they were untreatable. And many people who write about enactment say that it can be, while it can be very helpful,

and it can bring things up that were heretofore hidden, it can also be very, very destructive, and it can ruin it. So what do I propose instead? I propose that the answer is to be more aware of our feelings. I always tell people that the feelings that come out in an enactment, whether it's falling asleep or yelling at the patient or criticizing them, those feelings were present and in awareness prior to the enactment. What may be true and often is true is there not in the forefront or fully an awareness at the time of the enactment. And that's why they get acted out.

So what I favor instead is being more fully self-aware, accepting those feelings, being curious about them, and maybe trying to find a way to address them with the patient, sometimes involving self-disclosure of your experience of the patient. And I can give you an example, if you like, of one of my own enactments that I was not terribly proud of. Yeah, can you give me, that would be great. Why don't you give me an example of something you're not proud of? Okay, all right. I was feeding them, you know, in my own defense, it was very difficult.

You know, some super intelligent patients, they litigate you there. I mean, they have incredible defensive systems that are engaged very quickly and easily. And this woman was like this. She really couldn't tolerate any negative feedback from me. And she was talking about her son, who was in his early 20s living at home, and she often brought him up because he had actually had a suicide attempt as he was graduating from college. and was briefly hospitalized. And he was living, he spent years living with them.

And I found myself getting increasingly irritated by this and even disgusted, impatient. I kept wanting to go, why are you doing this? You know, you're enabling him. He didn't work for long periods of time. And he was, you know, very intelligent, did very well in school, somewhat on the spectrum, but, you know, mildly so. and fully capable of working and doing other things.

He just had trouble with, you know, relationships, intense relationships. So he was lonely, but I'm not saying she, they shouldn't have let him live there, but not only did he live there, he didn't do a thing. He was weighted on hand and foot. He didn't clean up after himself in the kitchen. He didn't have to run the dishwasher. He didn't have to do his laundry. And the more I heard about this from her, and the more she said, well, you know,

he just needs all of this TLC. And because, you know, he's somewhat special needs and he needs all of this love. And so I knew for quite some time that I was getting very upset about this. And finally one day I just said to her, you know, what are you doing, you know? Why do you keep infanelizing him?

You know, you just treat him like a baby and you're playing to all of his weaknesses instead of his strengths. How is he ever going to be independent and whole? if you keep babying him, which of course she did not appreciate. She didn't appreciate that truth, that truth, ball. And I said it pretty much that way, and even with more irritation that I was feeling at the time. I was clearly inappropriately disapproving of her.

It built up. It built up. It built up. For weeks and weeks and weeks, and it all came out. Exactly. And that's what happens. It was an accident. And all of a sudden, like, you just feel compelled to do something. that's how you know it's an enactment. When you feel compelled to do something, I felt compelled to tell her how she was screwing up her son. She responded with, she got very annoyed, very hurt, very angry, and said, she said, well, since you don't have any children, I don't think you're in any position to be critiquing my parenting.

Okay. And I was very hurt and humiliated by that response. Yeah. Yeah. So she stroked back. Oh, yeah. She knew my vulnerability. So you can see how each of our vulnerabilities are colliding in this moment. And it was, and it was fairly, it was in the first year of the trip. So we had a fairly good relationship, but it was, it created a ruptured between us that we, it took us several sessions or even more to, to try and, work through. And what really helped was that I did dispose. She said, how did you feel when I said that to you? And I said, I was hurt. I was hurt. But I said, I understand you, you came at me because I hurt you. I hurt and humiliated you and made you feel, she's told me later, I made her feel like she was a bad mother. Hmm. Yeah. There's an enactment with a capital E. So an enactment, there's a role that you and the patient are both taking through the transference, countertransference, maybe through the therapist's own reaction.

It's a mutual triggering. It's a mutual triggering that leads to an event. I often see, or kind of help to help people figure out if they've had an enactment, have you ever behaved towards this particular patient in a way that you've never behaved towards anyone else? unless I guess you're having the same enactment with each person. It's just going to say, but we have enactments with other people in our lives as well. But I think the whole feeling that it was uncontrolled, there's a sense of regret, there's a sense of like what was I thinking, what was I doing there, that was not good. Right.

I think my point is that you're behaving in a way that you normally don't behave. Correct. And if you behaved the same way towards every patient, then maybe that's not an act. maybe that's your own stuff coming, you know. Maybe you're just a bad therapy. Yeah. Yeah. So, okay.

So you behaved in a way that was unique. It led to a rupture and somehow you were able to move it forward. You know, some people will just be like, that's it. That's done. Right? Like therapy's done. That's the end. There's no coming back.

And so you talk a lot about an alternative. to enactment is... Oh, you know what I should also point out that I reflected is that, you know, the idea is that she's triggering me. The question then is, why was I so triggered by her enabling her son? And the reason I was is that

my twin brother was very excessively pampered by my mother. And she played to his weakness and babied him because he had been a blue baby. He had the cord wrapped around his neck and he almost died in utero. And so, and he always had an anxiety problem as a result of that insecurity and anxiety. And she pampered him to make up, you know, because he was an anxious baby out of the womb.

And, you know, she just kept playing to that weakness. And he had tremendous strengths. You know, he was very intelligent. He was handsome. He was, you know. and she just kept playing to his weaknesses and babying him, and it just drove me crazy that I could not get her to stop doing it. And that's why I got, that's my past colliding with the patient.

So I couldn't, that's why I couldn't bear her babying her son. And I wanted her so badly to stop. So babying kind of like excessive empathy, like coddling, kind of entering into the never-ending childhood, treating the Peter Pan. Yes, not expecting him to accomplish anything or do anything. Yeah. Yeah.

I've had a couple of those. I mean, obviously we all have these types of diets that end up. And it's like how do you give that information? Looking back, okay, let's say you were to start to feel this tension again with a new patient. Right. How would you do that differently? Well, I think I would be more aware of how it was triggering me

and try to work through that internally, you know. And I would try to be more constructive and have her look at this with more curiosity. And to some extent, I think we all have to accept that people have attitudes or behaviors that they, at least at that moment, are not interested in changing. And we can't have the agenda of, you know, forcing that change on them. Yeah. increase your own internal reflectiveness regarding where this is coming from, why you're feeling a strong emotion. Also thinking about where is her disavowed assertion assertiveness. Why does she need to do

this? Right. I mean, she herself is very accomplished. So was her husband. Right. So maybe, yeah, what is the trauma, the early childhood? Like, was there something? that led her to start this sort of journey. I imagine you found that out in the years in the future. I did. I think I didn't fully appreciate it at the time, but her own mother had been very, not very nurturing. Both were parents.

They had very, they were high achievers, had very high expectations for achievement and accomplishment and little empathy for any weakness or neediness. So she had gone the polar opposite. She had swung the other direction too far? Overcorrecting. Over correcting. She was giving maybe something that she yearned for continually.

Yeah, I think so. Yeah. Another common enactment is, and I've done this, I think all of us have done this, the really dependent patient who's always seeking advice and is lost, and then when they keep doing things that are making poor decisions, and then I don't know what to do or whatever, and then you start giving them advice,

even though you know you shouldn't be doing it. And then that might go well briefly, you know, so it gets reinforced, but then eventually the patient gets angry, feels infantilized, and says, you know, why are you always telling me what to do? You're just like everybody else, because the dependent patient who feels helpless,

everybody else tries to tell them what to do. So we do not want to be repeating that, right? But it's very easy to fall into when they behave that way in sessions, especially over time. Yeah. Okay, so it's like you get pulled into this dyad of operating in a way that normally wouldn't operate, giving more advice, succumbing to the desire of the patient maybe to receive the advice initially, but then maybe they get, they feel infantilized. Yeah, and I think feeling, feeling very uneasy and questioning yourself

and not feeling good about the interaction, those are, you know, post-enactment, I think those are all, you know, signs like, you know, what was I doing there? And this was as much about me as it is about the client. Okay. I think a lot of the literature on enactment is to reduce the shame of the, the shame of the clinician, like, this is normal, this happens, everyone has this, you know, process it afterwards in an effective way with the client, and that leads to really good change. At least that was my sense when I kind of...

Yeah, the ongoing assumption is that, you know, it's all grist for the mill. But people say that about a lot of things. People say that about multiple relationships when I talk to people. I think we have a tendency, I think one of our greatest weaknesses is that we have a tendency to rationalize things that we do that are not therapeutic. Like seeing a couple, seeing them as a couple, then seeing each one individually, and then often like seeing other members of the family, essentially becoming like the concierge, the mental health concierge for the family. and I think that that does not end well. It's not advisable. I've talked to clinicians who do that, and they just say, well, you know, I know things I shouldn't know,

but, you know, I just sit on it, and it doesn't impact the treatment. And, you know, like if you're seeing both people in a couple and one's having an affair and the other one doesn't know it, and the spouse is lying about it, but you're treating both of them, and you know that the one is,

that the husband or the wife is cheating. But you can't say it because, I mean, to me, that's crazy making. It's crazy making. Yes. And I think it's the same thing with enactment is that we like to think because, again, I think, as you pointed out, because it offers us the opportunity to re-engage and get some relief, there's like this emotional storm that happens in the relationship. And both people are somewhat relieved and sometimes can be very relieved that they're now re-engaged. And all the people who talk about enactment say this, too. The downside of enactment is that sometimes these enactments can be very hostile, very insulting, very disruptive, and it can be very, very difficult to come back from.

Okay. So we're now rewinding to kind of like your case, and your case is that disengagement precedes enactment. And so we have to become aware of that disengagement. Tell me about this. Okay. Yeah, well, again, if you look at the case examples, I'm a voracious reader, you know, and whenever I get an idea, I think, okay, I'm going to read all I can on this, and I'm going to see, I'm going to test my hypothesis, you know, to the extent that I can through looking at other people's case reports. and I just I did a book review not long ago, but well-known analyst who was giving such a case where he was talking about how this patient just kept bringing up this boring, repetitive complaint about, you know, a family member.

And he was just getting so disengaged, so bored, so irritated by this person. And he couldn't get him off that dime. Yeah, just always was doing that, getting kind of whiny about it. And he talked about being disenged. engaged for months and even consulting with people. And his consultant said, you know, I think maybe you should tell him, you know. And but he was afraid of hurting him. But then he finally did.

And this is, this is quite often, if not always the case. He actually didn't do an enactment. He avoided enactment by actually getting a hold of his feelings and finding a constructive way to tell the patient. You know, like, what is the deal with you talking about this family member all the time? And, you know, I'm finding myself being disengaged. And I forget what else he said, but the patient said, wow, this is the first time I've ever felt close to you. Or this, I often quote, Steve Mitchell's famous case. In fact, we were just talking about this at the I-A-R-P meeting.

and people love this because it just seems so out of character for Steve Mitchell, but it was funny, is that he had a patient who was criticizing him a lot as she became more independent of him. And she had been quite adoring, you know, and they were very close, but she was becoming very critical. And he said, I found myself getting very angry and having negative thoughts toward her. But because of my therapist guilt, I became even more solicitous and empathic torture,

which, of course, irritated the patient because patients who are continually provocative are looking for a human response. I think we overlook that so often and that we think that it's the better part of wisdom to remain passive and unresponsive when actually we're thwarting the therapeutic effort in doing that.

So along those lines, she became even more you know, aggressive toward him. And then she finally, she said, he said finally, you know, if I weren't your therapist or she said, she said, what, doesn't this bother you? Why aren't you getting angry? He said, because I'm your therapist. And, you know, it's my job to, you know, manage this or whatever. And she said to him, remember, they have a longstanding relationship.

And she said, well, if I, if you weren't my therapist, if I saw you on the street, something like that. and I talk to you like this, what would you say? And he saw it for a minute and he said, I'd say, fuck you. Okay. And they both, she laughed. They both burst out laughing. So it confuses me a little bit because I'm like, okay, what's the difference between,

you said in an enactment, the therapist may burst out with some emotion. Yes. And in this pre-enactment, how to deal with disengagement, you share emotion that you're having. Right. Right. So what is the difference between those two things? Well, I think I understand why you're confused, because an enactment, and this may seem like, you know, hair splitting, but an enactment would have been if she was actually in the act of criticizing him. Mm-hmm. He said, fuck you.

I mean, that would just be enormously disconcerting and inappropriate, right? But instead, they were having this meta moment where they're both standing back and looking at the relationship and what's happening. And she's saying, I can't believe you don't show any anger. And he's admitting that he does feel it. And then she's saying, well, what would you say to me if you weren't a therapist? Like, how angry are you? So they were actually engaging. But in enactment, which often occurs is that the therapist does not do that, does not get to that point, and will act out and say something sarcastic or use an obscenity, or do something with rage, which then is destructive.

Their conversation ended in laughter because they had been talking about, okay, what's really going on here. So I had yeomen's on, and I know you listened to that episode. Yeah, I did, do. And Frank Yeoman's was talking about how sometimes he'll say something when he has countertransference. Like there's anger in the room. Yes. Or there's corruption in the room, right? Yep.

Is that enough, right? Is that enough to say that it's in the room? Or is that it seems like you would say something more specific? I guess I'm trying to distill like, what is this approach that you have? And how would you differentiate it between that? Well, in the room, I think, lacks. ownership. I mean, I understand it's an attempt maybe to diffuse the intensity, perhaps, of the anger. I don't know, but hatred in the room just doesn't do it for me. I just, I'm more in favor of

some direct communication. And I'm not saying he should have told that patient that he hated him, which he said, I believe, on the podcast that he did in those moments. But I think he could have, from my perspective, I would have recommended talking about that he could feel that this guy hated him. And in the moment, he could say that, I'm getting the feeling that you hate me right now. And then the patients could say, yeah, I do or I don't. And are you hating me? Well, but what would you, if the patient didn't bring up the question of, you know, the therapist hating him, what would you disclose?

or how would you disclose if you felt hatred towards the patient? Well, I think hatred, I've made this point, I think hatred doesn't arise that often. I think a person has to be, in the moment, to generate hatred has to be pretty abusive. Short of that, I think hatred is more likely to result from suppressed anger and frustration over a long period of time. So I don't think hatred is a commonly,

you know, used disclosure, and it certainly isn't by me. I've used it maybe one or two times in my 40-some-year career. So I would not, but I will say, you know, I will say to a patient like this patient I talked about who was insulting me, I will say, you know what, I'm really getting irritated by you continuing to insult me. Now, obviously, you're very angry with me. so but insulting me is not winning me over it's not getting you know you're not achieving your goal of influencing me by insulting me that's alienating me so can we find a way for you to talk to me about your anger or disappointment hurt whatever that doesn't involve insulting me and and I think that can be very productive because the person who insults me is also insulting other people

you know, the person who continually insults their therapist. And bringing that to attention and saying, this isn't good for our relationship. I don't like it, you know? I think that that's constructive and helpful. So I was thinking about, okay, so disengagement and how does that show up? And I made a list of disengagement things

to kind of like look at and see if you have any other ones to add. because we're talking about, so in this relationship with a patient, you as the clinician start to feel disengaged, maybe because you have unexpressed frustrations that have built up, maybe because there's unspoken things you haven't brought in to the here and now, what's going on. And so maybe the clinician could become less spontaneous,

less engaged, having to pretend to be warm, don't find themselves exploring as deeply as they could with a client, allowing endless tension, not pushing back on demanding behavior, pretending to be present, but feeling bad that their mind is often leaving, dreading sessions, finding themselves more quickly to give advice,

you know, kind of more superficial engagements, any other. or any sort of differences that you would add there? I would add some of the points that Lang's made many decades ago. He was one of the first people to outline the fact that anger has to go somewhere and that therapists often become very passive aggressive when they're angry, which further, you know, destroys the relationship or denigates it.

And he'll give an example, like the patient you dread to see, like you'll be late or you'll be late for that session, you'll cancel and reschedule a lot with those patients. You'll fail to, with the repressed and guilt over the anger, you'll fail to keep proper boundaries or collect fees. You'll make interpretations that are somewhat insulting, either to the client or his or her family members, that alienate the client,

so that there's a lot of passive-aggressive behaviors, too, that therapists can engage on when they're angrier. Okay. So, okay. So if as a clinician you're feeling this, then there's the potential, according to your theory, and I actually think this is really good clinical wisdom,

that a possible enactment is brewing if you don't become aware of your own subtle anger and then find a way to get in touch with why you're angry. And possibly the reason, you know, anger is not a good or bad thing in my mind. It's a way of overcoming an obstacle. The obstacle is the disengagement. It's there's something that's not being expressed, something that's not being addressed. Maybe you're not being as truthful as you need to be with the client about things in their life.

Yeah, absolutely. Absolutely. I think you nailed it completely. Okay. And so that truthfulness with the client, I want to zoom in. on that. Okay. And, okay, so this is, this is something that I think, um, you speak about really well in, by the way, get this book. Also, you can actually listen to the first chapter. There's a podcast I found where it's like the whole first chapter of the analyst vulnerability is there and it's great.

So if you're thinking about like what I like this book, you could listen to one chapter and it'll totally, it'll totally draw you in. Okay. But the, the thing, that we're zooming in on right now is how to be truthful. Okay. Yes. How do we be truthful in a constructive way, in a caring way? And one of your things that I've sort of been challenged by is if you don't feel like being empathic, then pay attention to that moment, right?

Yes. Okay. So what are some of your thoughts on ways to be truthful or how close to you? clinicians fail to be truthful in these moments of tension. You know, and maybe, maybe, um, maybe the better question is this, okay? I talk a lot about reflective function. And to deepen our own reflective function in the midst of our countertransference is, I think, the first step to, like, for us to, to maybe become less emotionally aroused by the countertransference. And you talk a lot in your book about the type of clinicians and that become clinicians, right,

parentification, depressed mother. And so one of the things that I think is actually, that you're doing in the book that you don't even talk about doing is by engaging our story, as clinicians, our own story, in the midst of the countertransference, is deepening our own reflective function? Absolutely, yes. Yeah, I think I say that I wish the analyst vulnerability was the last book I wrote.

I mean, the new technique's book is a second edition, so I don't count that as a new, entirely new book. But my last big idea recently was the analyst's vulnerability. And I say, I wish I would have had the understanding to write that book first. Okay. I wish that would have been my first book because it's the starting point for everything, I think, which is understanding all the dynamics that result from us having been parentified children. And the point in the book is that it goes beyond the usual discourse about, oh, which

many people have noted, well, a lot of therapists had depressed mothers. Okay. Winnicott famously said his job was to keep his mother alive and his depressed mother alive. And so, okay, yeah, we probably all had some kind of depressed, you know, family member, probably mother, maybe had to tend. But there's never been any dialogue about, okay, what are the repercussions of that then? How does that impact not only our vocational choice, but how we think about the work, what residue of feelings and motivations we have that impact both our theoretical formulations and our technical choices and decisions? And how that gets passed on from generation to

generation and doesn't change because we're inadequately aware of and encouraged to examine our own motivations and needs and how they impact our daily work. And that's the starting place in my mind, as you pointed out, that you can't really manage all of your feelings consistently and well to the advantage of the patient if you don't have that self-reflective function and that high degree of self-awareness. Now, ideally, in the analytic world, that would come from your long-time personal analysis, right? That's the idea. But in reality, that doesn't happen very often, because, like, for me, my analyst refused to get angry with me, ever. And I found myself, as a young person right out of training going to analysis, I felt very frustrated by that.

And sometimes I would try to provoke her. angry just because she wouldn't show those feelings. And I remember one day I was kind of insulting to her and I came in the next morning for my session and I said, you know, I'm really sorry. I feel very bad about, you know, some of the, you know, I was, I was being unnecessarily. I was kind of frustrated with you and I got a little nasty there. I want to apologize for that. And I could tell you were angry, getting angry with me, you know, the purse lips, the tense face, you know, I mean, it's bad, You know, the face says it all. Micro expression,

micro flashing of the eyebrows down and together here. Yeah, exactly. So I can see her like gritting her teeth. And she just went into absolute denial. No, no. No, I understand. It's because you have this frustration from your childhood and you were feeling this and just like talked it away.

And I said, you know, I don't want that. And I don't think it's helpful to me because it doesn't help me to man. manage my feelings and be accountable and responsible for what I do. That would be called hypermentalization or almost like an intellectualization, right? Because it's moving further away from her own emotional experience and kind of projecting it on you. And that one, and like as Paul Watel says, you know, he doesn't, I think one of our functions is to help our patients see how they're repeating whatever negative behaviors that they have in the world. in the session. And it's depriving, it's depriving the client of the opportunity to get that feedback. If she would have said, yeah, you went too far and, you know, I care about you, but I was

really angry. I didn't like the way you talked to me. That would have been so much more beneficial and therapeutic for me than for her to rationalize my behavior. Right, right. So, okay, so one thing I was thinking about is like as a clinician has some countertransference, right, they're starting to get frustrated. Maybe they don't even recognize the frustration. So maybe they're getting disengaged. Okay. They're feeling more disengaged. If you were to ask them, why are you feeling disengaged? And they were to say, I have no clue. You're the therapist. You tell me. Yeah. That's actually a negative one in the reflective function scale. Okay. Right. Because it's like a denial. And it's like, it's like a, it's like the antithesis of reflection is like, it's kind of like attacking.

the person asking the why question, right? And so your therapist went, wasn't quite that bad, your therapist was kind of more like around a three or maybe a four. There was some projection on you. Like, this isn't my issue, it's yours. You're just imagining me angry. I'm not really angry. I'm the Yoda. I'm perfectly calm in all situations. Yes, at all times. At all times. Yes. I'm, you know, continue to idealize me. Actually, Pure idealization is actually a three. So it's still, you know, this is a nine point scale. And so what we're trying to sort of,

or what you're trying to sort of elicit, what we're discussing here together, is by engaging our own developmental story, we can increase our reflectiveness, right? Absolutely. So first of all, to recognize the actual motion might be anger, that's okay.

Yeah, normal, human reaction. Now, why do we feel anger? maybe the patient, and you're describing multiple situations, the patient may be attacking you, maybe devaluing you, right? That may make sense of some of the anger, but there may be issues of why it would be hard to express the anger. If you had a depressed mother, if you had a mother where you couldn't be angry with. Or if you had a mother, some of the people I've treated had mothers who would get very angry or would guilt them and cry,

why are you being mean to me? You know? So, like I said, the thing we don't look at is how powerless we were. You know, there's a, we might have felt powerful at certain times and special

because we could intervene in our families of origin. We could succeed in soothing or entertaining or, you know, diverting some conflict. And so it became, it was intermittent reinforcement,

I like to say. So we could feel, feels successful and special at times, but ultimately, as Searle said, we were doomed to failure. And that failure to actually heal and change the family situation leaves us feeling inadequate. I think it leads to early career people, especially feeling like impostors, and feeling guilt about anger and wanting to dissolve it, you know, and transcend it rather than own it. Right. It's a like Wachtell talks about like that then this anger is not allowed, disallowed, you know, it's not allowed, it's not, it's disavowed anger. So we have to get in touch with that disavowed anger.

And other things, frustration, helplessness, you know, and as I said, we weren't, we weren't in a position to confront our families, you know, that just wasn't possible and or desirable because that wasn't our role. Our role was to make peace. And so I think one of the arguments I make is that we naturally take that sense of powerlessness and passivity into adulthood and into our role as therapists. I say therapists are very, very often, very passive, excessively passive. Okay. Okay. So this is the perfect segue, I think, to a role play. What do you think? Okay. Okay. All right. So I know you treat a lot of therapists. and so I'm going to be polling from different themes of your book

and kind of trying to get from you how you would actually help the therapist in the here and now. So let's say this is actually a patient of yours. Okay, who's a therapist? And so, okay, so here, shall we just jump into it? Sure, go ahead. Okay. So I've been thinking about your book

and I realize that I'm having a really hard time confronting a patient. I feel very detached from this patient. I feel really guilty about my detachment. You know, I had this mother that was depressed often, and maybe I'll get more to, like, what are the things that are coming up for me about that story? And I know I was a peacekeeper, and I know that I was her confidant,

but with this client I'm having, this older female client, I'm having a hard time. having boundaries with her. She's calling all the time. I'm taking her calls. It's taking me away from my family. And I'm feeling a really hard time,

feeling positive towards this client now. Well, it's understandable because she's intruding on your personal life. And what feelings are you having toward her as she's doing this? And as this continues? I'm feeling a lot of guilt that I am failing to save her.

I'm failing to help her. I feel like no matter what I do, it's never enough. So I'm feeling a lot of like self-criticalness. And so I actually had a dream about this last night, or I felt like it was maybe about it. So maybe I'd just tell you the dream. Sure. So, okay, I'm in a cabin with a couple patients, and a bear is at the front door.

It's clawing, it's clawing its way through. It finally breaks down the door, and then I have a gun. And I'm feeling frozen. The bear's about to attack the patience, and I shoot, but I end up shooting my own foot. and the bear freaks out runs away and I'm bleeding and I sit down in a circle with the three there's about three patients or something all older females and I'm having to listen to them while I'm bleeding out and I'm doing a very poor job because I feel but I feel upset that I'm listening to them but I'm also upset that I'm bleeding out and I'm not doing anything

about it. And then I realize one of the patients is not my patient, but my mother. And I focus on her, and all of a sudden, she falls over, and I start doing CPR on her.

And then all of a sudden, the cabin, there's like a sinkhole or something, and we're falling into the hole. And that's when I wake up with this kind of, like, jerk with, like, That's a powerful dream. So my always my first question, of course, is what do you make of all that? How do you understand that dream?

I sense that it's illustrating both my, some of my childhood of even when I felt like, I didn't have a lot of capacity, or I'm bleeding out, so to speak. I would just listen to my mom. So, you know, after I got out of Pizza Hut working at 11 p.m., making sure my brother was put to bed, I would sit there for like two or three hours listening to my mom, talk about her day, things like my dad's infidelity, my dad's... you know, current boyfriend issues, weird sexual things. I didn't really want to hear. And so I had the thought in my mind, like,

sometimes I would just kind of space out. Sometimes I would like, so these are the kind of thoughts that come to my, I'm associating when I think about this dream. Yeah. Not wanting my brother to have to listen to her, so I'd put him asleep and then I would listen so that she wouldn't, talk to him, so at least he would sleep. The compassionate sacrifice, yeah,

as finer, yeah. But it's terrible, terrible burden for a child. Yeah, and I think, I don't think I, you know, realize that and that when I was going through it, but now when I look back, I'm like, gosh, this is really, like, not healthy.

That's very unhealthy, yeah. Well, you robbed of your childhood as Alice Miller, you know, has said, and store, and it's interesting, so much of this was initially written about, you know, in the 70s, and yet it just all died. We'd ever picked up these themes, but he talked about it, and Cyril's talked about, too, the inevitable rage that results from that, you know, the anger, the resentment over having been robbed of your childhood. And that's what therapists feel a lot of guilt about, and it just sits there, because it's not never addressed often even in their own treatment is the resentment and the rage they felt in addition

to the compassion, right? It's not instead of. It's not like you really just hated your mother for there's this natural ambivalence that arises from being the parentified child. You're special. You do everything you can. You desperately want them to be okay. You love them. And at the same time, you've lost your childhood. And you're unfairly burdened. on a daily basis and have no power really to change that. It's Prometheus on the rock. It just happens over and over again every day

and you just have to keep addressing it. And that's a great burden for anyone. Yeah, I'm like, as I'm listening to you, some of these names, I've not read these things and I feel bad that I haven't read them yet. And maybe if I had read them, maybe that would heal me. No. What he hills you is getting in touch with and not feeling guilty about your rage.

You know, it's hard to feel guilty about, it's hard to feel rage at someone, at your own mother, for example, who you love and want to restore. And I think the only route to resolving that, it's not reading something, although the reading helps when you see compatible views and conclusions. but the route is to really internally experience that rage like in the dream. It's the bear coming in the room and your patient is now the bear coming in the room that you want to shoot. But you can't shoot the mother, so you have to shoot yourself instead. I'm feeling guilty or it's really hard for me to even come into these sessions knowing how great of a therapist you are for me to, share how hard it is for me with these patients. You know, I feel some level of a fraudulent imposter, just even struggling with this. Like, I feel like I shouldn't be a therapist if I'm having

these thoughts, if I'm having these kind of dreams. I think that's rather harsh, David. I don't, I wouldn't say that. I think that. I worry that. that you secretly feel critical towards me, even though you're, like, putting off that you don't feel that right now? I don't know. Like, I'm... I'm actually not feeling that at all. In fact, I'm feeling sad for you that you had to do this,

like, work till 11 o'clock at Pizza Hut and then come home and tend to your mother for hours at night. I think that that's sad. You know, and I feel. a lot of compassion toward all the therapists who feel guilt about their anger toward their mothers and other family members that they had to take care of. I think it's a natural thing, but it's all, you know, it's natural to be upset about it. It's natural not to understand it. It's natural to feel somewhat fraudulent if you're a therapist and you feel it. But I think those are

the things. It's also a natural that you have those feelings, you know. And I think it's a failure in our training and our, you know, the whole ethos of our profession that we have never adequately addressed how natural those feelings are and how they can be easily stimulated by our patients and how paralyzed we can get with a patient like this woman who demands these calls from you. And, you know, it's easy to get into a situation like that because none of us are going to say, well, I would never talk to a patient in crisis on the phone, right? I mean, we all do it. We all have done it.

But in some cases, that escalates, particularly like with borderline patients, that will escalate to a call and another call and another call until the situation is out of control. And at that point, the therapist is so frustrated and angry and having such angry thoughts, like I'd like to blow this bear up with a gun, you know. And that becomes guilt-producing and disabling. and you just kind of sink into the quagmire of that transference, countertransference situation. Yeah, I think, I don't know if I resonate

with being the one to shoot the bear, like the bear is the patient. Like that feels very distant for me. I know it's in the dream. Okay. All right. I don't, but I think, I think I feel more, when I'm talking to this person, I start to kind of just think about other things.

You remove yourself. Well, it's like it's more, it's more of like I'm aware that my mind is jolting elsewhere. And it's not doing that with all my clients, just with this one particular person. Yeah. And it's harder. Another interpretation for your dream is that you're shooting, the bear is actually your own anger. Yeah, okay. And that's what you want to shoot and destroy is your own rage.

So that's another possible interpretation. I don't know if that resonates with you, and that you disengage to avoid that experience of rage at your patient. I feel with this particular person, it's got into a point now where like three or four extra calls per week, but I never feel it's enough and I feel I felt it exquisitely

when I was on vacation and it was like I was getting and then my wife and my is kind of like who's calling you all the time. Oh sure. And she's starting to get upset at me

and then I have like two people that are kind of upset at me and then I'm like just trying to manage the mutual upsetnesses. Yeah. But avoiding confronting the issue. Okay.

I mean, clearly, I mean, I always say that the way to measure whether there's any kind of additional contact has been helpful is if the patient, you know, ratchets down, calms down, you know, and does better. doesn't mean they won't ever need another phone call, but it's always a negative indicator if the demand for calls or attention outside of session escalates. If it escalates, then you're placating an aggressive patient and not dealing with the real situation at hand, which has heard that patients need to control you to be intrusive, and that somehow is a repetition of her past and things. that she does with other people. But she succeeded in, you know, bullying you into submission to accept these calls on the basis that she needs them. But if that were true, if she really

needed them and was benefiting, they would decrease in frequency, not increase. So I think this is an out-of-control situation that needs some new intervention. Okay, so I tried to, I tried to say like, hey, I'm on vacation. I, you know, let's schedule an extra session, but then the emails keep coming or the phone calls keep coming, the texts keep coming. So I said, hey, if you continue to call me, I'm going to have to block your number. You can email me. And then I had to block her.

And then the emails keep coming. And these are long emails. It would take me like 10 minutes. I think I recorded my time to read the email one time, and it took me 10 minutes just to read the email. And the emails just kept coming and coming and coming. I know speaking of Frank Yelman, as you've interviewed him and Kernberg about TFP

and Transference Focus psychotherapy. And you know one of the basic tenets of that program is limiting extra out-of-session content. contact because it's something that often happens with borderline patients and it's not helpful or therapeutic. And you just simply limit that and say no. So what are your thoughts about doing that? I mean, I think you've lost your authority when you have to block her number.

My thought is I feel guilty that despite having the knowledge I'm not the knowledge doesn't seem to be enough your guilt is greater than your intellectual awareness that this is not therapeutic ultimately

the guilt is driving the guilt is thick in in this moment. All right. What do you think of the role play so far? I mean, I'm like... I think it's pretty good. I think it's pretty good.

And I think I don't think this is a rare, you know, event. I don't think you're presenting something that doesn't happen every day. But I would say, and I do say to my supervisees, if I can't help them through that to understand that what they're doing is actually counter-therapeutic. They are submitting masochistically to an aggressive patient. which only reinforces that behavior. And one of the tenants about TFP I really agree with is that limit setting is just extremely important.

It's vital to a successful treatment. And I tried to help people to see that if it's, and it often helps, is what you're doing is not helpful. What you're doing is not therapeutic. What you're doing is reinforcing and reenacting a sadomasochistic, you know, relationship. and that is not in any way helping, not only is it not good for you, it's not good for the patient.

And if you really can't work your way past some of that, I would advise you to go back into your own treatment to discuss how that is. That even with the knowledge and acceptance that you're feeling this, that it's not therapeutic, it's not good for the treatment, that you still continue to do it, I think it means you've got some things still to work out.

right which is why in the role play this person is seeing you right no i i i think this is so important to talk about i'm awesome mentalizing like if i had a client that was like listening to this this might be really uncomfortable right and and they might understand why i have what we call the frame and why i don't you know do sessions outside of sessions right like i don't do email therapy and it's harder to rewind. Like if you've, if you've extended yourself, if you've gone into an enactment, it's harder to rewind and build a frame. It is. It can be acutely painful. So it's easier to kind set out with the frame of like, this is how treatment takes place, right? Absolutely. Yeah. Like I don't, I don't communicate with people on vacation. So when people say, can I call you, can I email you? No.

Okay. No. And if it's someone who is really in severe distress, so you can have a backup person that they can contact. Yeah. Right. But can you call me while I'm on vacation with my family? No.

I actually have, you know, I have a small practice here. And I'll put, if I have certain clients that I know vacations are hard, I might have them schedule an appointment with, or just like, hey, you can schedule an appointment with one of my other clinicians while I'm gone. Yeah. As like preemptive, you know,

just this is something that I've learned and doing private practice for a while. So the dream, let's go back to the dream because I feel like there were some themes and I feel like as a

as a person in the midst of the therapy, I wasn't wanting to fully like make it easy for you. Right? So I was like, I was not like fully reflecting on this in a way that was at the highest level of reflective function. You know, which is...

All right. Right. But this is a perfect illustration in my mind of this dynamic, which I, you know, I lead cohorts with psychotherapists. You actually came to a special event and talked at one. Thank you so much for that. It was wonderful. And I've seen this trend a lot where the therapist can beat themselves up.

shoot themselves. And so I felt like it just came to me this like image of like what this would be like, right? Well, the classic phrase, I shot myself in the foot. Yeah, yeah. And I was thinking, yeah, I had a patient once that was in Vietnam. He's probably passed away by now, so I don't mind sharing the story. He had shot, he was in the middle of a firefight and his trauma that he had never told anyone. You know, there's always the trauma that the vet will tell everyone, you know, that there's the trauma they don't tell everyone. Yeah. So that the trauma came out when I was talking to him and his foot started twitching violently during the discussing of this firefight. And it was because he had accidentally shot one of his own guys in the foot during the firefight. And this was his

guilt. This was his moral injury. So this is coming to me while I'm talking about this story. but it's like this kind of like idea of this this intense like you know you're supposed to be defending and instead you shoot your own foot or your colleague's foot in it's it's an illustrative picture of this masochistic nature right of here's this yes the anger that you should have maybe towards the bear or the bear's anger right is so disavowed that you turn the anger on yourself and you shoot yourself in the foot yeah i i couldn't have said it better. That's exactly what happens, I think, every day in therapy. And then you're bleeding out, and instead of tending to your own needs, your own emotional needs,

you're continuing to take care of other people, right? And unfortunately, like, I mean, this is, to some degree, we have to do this as doctors. It's like we're enculturated into this. I have so many doctor patients, they're on call, they're in the middle of the night, they're exhausted. yet they're continuing to take care of other people. It's like this is the role, this is what we're enculturated into. And there's intense meaning and purpose in that, right? Exactly, right. But some of it is, I think, an illusion, you know.

Go ahead. I think, yeah, I think if you're on the phone all night with patience, and also to the detriment of your marriage, partnership, which... Absolutely. I mean, you might feel that martyrs, you know, glory and superiority. But I'm so wonderful. You know, I'm so giving.

I could do all this. And again, I think that's fleeting satisfaction. At the end of the day, if you realize that's not really helping anyone. Right. How are you ever really going to authentically feel validated? I don't, I think it's an illusion. Okay. So 100%.

the masochists, uh, death ground of sorts in my mind. So we, we think about like the worst possible situation. For like, for the narcissist, it's like the fall of their image, their public image gets shattered, right?

Newspapers, legal battles, people calling them awful things in the news, right? This is the, they've lost their job. Aging and loss of power. Right. Loss of, the psychopath, the loss of power. The loss of control, right? They control this empire and it's taken from them,

right? That's the psychopaths, we're saying. The massacist's worst thing is the loss of meaning. And so it's incredibly meaningful to suffer for other people. Yes. But so to be told that suffering is meaningless could be a threat to themselves in and of their own, like, personhood. That's a really interesting point, David.

But I think that our job is inherently one of suffering regardless. It's we can't eliminate suffering. When we sit in a room all day with other people who are intensely suffering, we are experiencing suffering. In fact, I'm sure you've had patients and I've had many patients say, you know, are you really okay with this? Can you do, this isn't hurting you to be with me when I'm suffering so or I'm so depressed. And, you know, it's, I won't go into how I answer that, but I do. But the point being is that suffering is part of the job that we've chosen, and there's plenty of masochism right there and meaning. And it is meaningful, really.

There is something somewhat. There's something kind of spiritual and can be very deeply meaningful about sitting with a suffering person. But I think when we extended to the idea that it's our job and our responsibility to save them from that suffering, that's when we fall, you know. And I would say suffer for the right reasons. Yeah. So to suffer, you know, for, to suffer in never expressing any frustration could be not the right type of suffering. You may need to suffer by learning how to express the frustration in the right way, right? Right.

And that, so to suffer in a way, to that is not meaningful is the challenge that we have as clinicians as we grow. So earlier on, there may be clinicians out there who are listening to this who are like, okay, I'm on the call

with this patient, but they really need me and they need me multiple times a week and it seems to be what's holding them together, right? Yes. And I think what your challenge is, and it's a good challenge, is that maybe the suffering needs to be

in the difficulty of putting up the boundaries that then allow the patient to grow in the right way? Absolutely, yeah. I mean, you said that perfectly. Absolutely, yeah. That we can, we don't really help our patients with their suffering by treating them like infants, not acknowledging their sense of agency,

their potential for managing their own feelings. That if we are constantly being the person who sues them and comforts them, it's like people who say, who always want to pick up their baby in the second of cries, you know, is that I remember I was treating a woman who ran in daycare and had advanced degrees in childhood, you know, education and development. And she said one of the hardest problems she had with parents who brought their kids in

is they say, well, you know, if my baby or my toddler cries, you will pick him or her up right away, right? And she said, well, no, we don't do that. We give them a little bit of time. We never let a baby scream and, you know, be out of it. of control. But children learn to self-soothe. It's a natural process. Yeah. For the first three months, yeah, pick up the baby. Right, exactly. But after that, you give them a little time to try, and then it's only if they can't manage that you pick them up. And otherwise, you deprive them of the opportunity to self-suit. And I think we make that same

error as therapists. We rush in to try and soothe our patients rather than being there with them on that journey toward acceptance of their feelings and the ability to see that they're no longer helpless children and that they can learn to manage their own feelings. Right. It's like, so that we're caretaking instead of empowering. Right. So the goal, there's plenty of suffering and just sitting with people that are really, depressed or really anxious. Like that is that in and of itself is is is is plenty. Having having boundaries and then having your own being aware of your own gratifications. Yes. And this is one of the other big sort of kind of unique things that you talk about. A lot of people are not talking about

as therapists were entitled to some degree of gratification, right? Most would say well, financial gratification right of treating patients. But also, you know, it's incredibly meaningful to hear people's the depth of their stories, the depth of the, you know, for me, it's like it's gratifying to feel close to someone and hear the depths of their, you know, their mind, right? D. But what other gratifications are we allowed to have? Well, I think, you know, again, I don't like to say like I'm the sole, you know, proprietor of this point of view. People have mentioned it. It's never been taken up seriously enough about dealing with our needs and not only our negative feelings and how do we deal with them, but the pleasure that we get.

And to be able to say that without feeling guilty. I mean, most therapists will agree that they have tremendous sense of intimacy, getting their intimacy needs met. And sometimes actually too much so to the detriment of their other relationships. and people have a hard time sometimes retiring or giving up their practices because there's almost nothing in the world you could do for a living where you get to be intimate with people all day long. I mean, and that that's tremendously gratifying for us. Most therapists will say they don't like small talk.

They're not often they're not very good at it. And it's just like... It's, yeah. 100, yeah, absolutely. Small talk is like, yeah, and I've had a lot of people who say that before they became a therapist, it's like they had a hard time in their adolescence having small talk. They wanted deep, meaningful connections for the decade and a half before they became a therapist or whatever. They weren't, and it's like finally when they became a therapist, they were like, oh, wow, these are my people. Yeah, exactly. This is what I, this is what's meaningful for me. This is, so, it's okay to say that there's meaning from the intimacy that we have with them. We don't have to be martyrs to get meaning, you know, and that we're helping them, but they're also helping us.

They're giving just that depth of all the things you can talk about, all the things you can say, that you never would, those conversations that I have with my patients that I go really deep with them, the conversations I have all day, I would never have out in the world with almost anyone. And, you know, it's, it keeps you in touch with your humanity in a way that's just, and also this whole spiritual sense of us all being connected, the way we're connected with our patients.

I mean, it's deeply gratifying. And I always say every patient in mind who's really significantly improved, you know, and changed their life, they've helped change my life, too. They've made me not only a better therapist, but a better person. and a more kind of person and a more empowered person so that all of these things become mutual to a degree and that it's I've matured and I think developed in a way that I never could have if I weren't a therapist

plus there's also just the pleasure of being with someone who you like for someone who's funny somebody who can be playful with you someone you know the times you get to just laugh and recognition someone, the idea that we're both on that road toward trying to embrace the truth, even if it hurts, it's just nothing, it's a rare event. It's a hot house, I always say it's a hot house relationship and the hot house can easily, the temperature's wrong, things can go bad very quickly. But if you can maintain that, it's, you know, you get this beautiful orchid. One of the things I've heard from you that I didn't hear from other supervisors I've had in the past is that you should enjoy the clients you choose to work with.

You should be interested in them, be curious about them naturally, like, or that you should somehow select the type of person. And you shouldn't feel guilty about that selection. Tell me about that and tell me how you do that. Okay. Yeah, I get a lot of questions about that. because, you know, people early in their career or people who are in clinic groups or, you know, agencies, it can be very difficult to select their own patients. But I always say to the extent that it's possible for you to do it, like don't take people

just for the money, even though you have your school debts to pay off, and I'm sympathetic to that. And for the simple reason that the treatment will not go well. And I unfortunately used the word like originally, and I regret using that word, because people think I mean it in a superficial sense, like you should like everything about the person. And of course, when people come to us who have, you know, maladaptive behaviors, we're not going to like or approve of everything they do or say, nor should we.

So I don't mean like in that sense of, oh, this person's so nice, this person's so much fun. I mean, I've really altered that view to say, it has to be somebody that you can see yourself engaging with. And that you can see, I ask new clinicians to say, try to imagine this relationship down the road. Imagine yourself longer term with this person if you do a longer term treatment. And how do you imagine that going? And what do you think even that you could get from this patient? What does this patient have to

offer you? Do you think? Like I'll note that a patient who's very insightful and deep, I think, oh, wow, this person, I could be really insightful and deep here. You know, this is an opportunity for me to do this. or a person who has a great sense of humor or insight. It's like, wow, this could be moments of joy for me during my day, even though I certainly wouldn't stay with humor throughout the session. But, I mean, this person has things that I find that I respect, and even people who can be very obnoxious can also be very uplifting and you can have a transcendent experience with them.

So I don't mean like in the popular sense of lake. I mean, can you imagine a meaningful, gratifying relationship with this person to some degree and that you can maintain curiosity and interest in? And if that doesn't exist in the beginning, it's like any relationship. If you're not interested or engaged in the beginning, that's not going to get better. That's going to get worse. And when people say, well, I feel guilty in that except in that patient, and I worry, well, who will treat them? I say, there's someone for everyone.

And there is. It's just like saying, well, if I don't date this person, who will date them? You know, people find someone. They will. And the people that you're going to be successful with are the people that you can be engaged with and interested in and have feelings for. And if you don't have that, don't treat them. Because taking someone on that you don't have that with, I like to invoke ethics. You know, if you want to be relieved of your guilt, understand that ethically to take someone on who you can't successfully treat is not viable.

It's partially an ethical decision. Am I going to take this person on who I don't feel good about? I'm not that interested in. I might even have some feelings of revulsion or disgust for. I'm going to take that person on and they're going to stay potentially for a long time, spend a lot of money, and for what? because if you're not engaged, there's no therapy taking place. Do you think that's something that

is kind of like a luxury of being a well-established clinician? Because I feel like, you know, for a lot of the people who are listening, they're starting their practices, they may not even fully know who they're not going to work with well, right? Well, again, that's an excellent point, David,

is that you do learn that over, time, you learn for the signs so that you don't get into deep, you know, you're in for six, eight, ten, twelve or more sessions, and you suddenly realize, I can't stand this person. I don't even, I don't want to see them. That's more problematic. And I think you're right. It's something you definitely learn over time. You learn through your failures.

And I don't expect early career people to never, you know, I certainly made those mistakes. I certainly took on people because I had an open hour, honestly. I took on, that I was questioning, I took on people who were suffering and I thought, oh, I can help them in my grandiosity of youth and discovered I couldn't, I couldn't help them any more than the five therapists that they saw before me. And, you know, you do have to learn, you can't be taught everything or have everything resolved in personal treatment. There's a, you know, there's a learning curve unquestionably. And we all still make mistakes every day. but you have to make more major mistakes when your early career, I think, to learn. And I wouldn't fault someone for that. I think the point is, do you learn from it?

Do you say, wow, I guess I've learned that if I feel this way with this patient in the beginning, this isn't going to go well? Or if I treat this person with this disorder that I can't relate to at all and I'm not sympathetic to, I'm not going to do a good job. So you do learn over time, certainly. and you get better at finding a way to not treat that person to say no to screen for them. That's a skill set in and of itself. Yeah.

And I would say if you're a patient listening to this and you've had a clinician say that they didn't want to work with you or that they refer you to someone else, don't feel bad about that. They probably have their own reasons that are beyond you. Right. And it's probably a gift to you to refer you out. And, you know, I think I'm curious. how many, like what percentage of patients you take or not take it? You know, and maybe this, this phase of your life isn't a good phase to look at for that question, but maybe like 10 years ago,

what percentage of patients would you tell like, well, I think you'd probably be better fit for someone else or this particular person? I would say probably, I probably took about 80%, which is high. And I do, that's the other thing. I take pride in my retention rate, always have throughout my career, that's a good sign too. If your patients stay with you and get better, you're probably making some pretty good choices about who you're treating. If you, given that half of people leave after the first one or two sessions, statistically, if you're able to get people to come in and stay and make progress, then, you know, again, your decisions are probably pretty good. If they're leaving a lot, they're no-showing a lot, and not just a single patient, but across

patients, then you have to question, like, selection at the very least. But I think that part of the reason I had such a high retention rate is that I do have a website. I always encourage people in private practice. Have a website that describes who you like to treat, you know, how you work, and that will help in the selection. People who don't want that are be less likely to call you. And over the years as I became known because of my writing and speaking, I tend, and that's still true, I get a very high quality of supervisee to start with, you know. Yeah. And people I'm, like, delighted to work with. Right, right.

And patients who know what I do, know who I am have maybe even gone in and read some of the things I've written. Yep. So they've already worked on the match themselves as kind of like a pre-match that occurs if you're well known. yeah absolutely yeah i i sometimes have given the advice to young clinicians write articles on the patients issues that you really enjoy treating yeah yeah that's good advice put those out there in the world or like um for like some of my young clinicians it's like okay if we're going to design an episode who's the if you wanted to get referrals you know from a particular type of patient let's work on that pain point that would lead to that person

coming in, right? Yes. Yeah, so I imagine at this point in your career, you find, you've kind of written about clinicians that have depressive mothers and parenthification. You probably find that type of person coming to your office more commonly, just by the very nature of talking about it, right? Well, I say what prompted the analyst's vulnerability was that it was actually the opposite. As I became better known, I was getting more and more therapists coming to me for treatment.

And I realized that the parentified child and the guilt and the fear of conflict, the fear of doing harm, was really, you know, omnipresent. It wasn't just some therapists who felt that way, like virtually every therapist I treated felt that way. And with varying degrees of severity of parentification, you know. But I thought, wow, this is something that we never talk about. And I was just stunned. And I thought, I need to write about this. So the writing about the guilt, the feeling like a fraud, the martyrdom, all those things emanated from my experience, treating clinicians, not the other way around.

Yeah. And I've seen as well a lot of clinicians have had that therapist role with their parents. I had this one person, Dr. Johnson, once say to me, kids, natural leaders, leaders that we see as adults, you know, that are leading, probably we're organizing on the playground, leading, you know, organizing everyone, organizing the game, right? Natural therapists were probably listening from a young age, right? Like they have, they had years and years of experience.

of doing that, playing that role. Well, I think we were naturally, I write about the fact, too, that we were selected in our families to be the peacekeeper and the soother and the comfort because we had those natural abilities and strengths. Right. So there was something. And then that was cultivated and utilized to help the family and then, you know, the rest is history. Yeah. Yeah. And, you know, for people that have role reversals that have those things, it was in the story, right? Earning money at a young age to support the family, taking care of the younger brother, listening to the mom talk about sexual things, weird things, right? Yeah. The mom would say things like, you were the only one that understands me.

Yeah. Hence the specialness and the narcissistic gratification. Yeah, like the ideal, being ideal, being idealized in the masochistic role. Yeah. Yeah, it becomes, this is how I have value. This is how I have value. This is how I get positive attention. What little positive attention there is.

You know, and then that becomes reinforcing. But it's interesting, that can often lead to a lot of tension between siblings. it's it's a you know i think i think i've always seen it as a powerful role but it's also a powerless role as you mentioned yes because you don't really have the power as a kid to make your parent better right it feels powerful in the moment when you can soothe them or you know yeah be successful in that moment and you get praise for it but ultimately you were destined to fail and then you know And even a lot of people like Andrea Salenza and many other people talk about then how we have to, our role then is we're really trying to redeem ourselves.

And Searle's talked about that too. We become therapists so that we can repeat that past and succeed this time. There were no different than our patients in that respect. And that every, in every treatment, we're repeating that. We're going to be successful over time in a way that we weren't. And that's part of why we can often easily get frustrated and angry. with patients who are not cooperating with that agenda and not getting better as fast or in the areas where we want them to or need them to.

So to redeem us. Right, right. And I think not to feel guilty about that gratification when it's done well within boundaries, when it's done well with patients that are getting stuff from us, right? Yeah. Oh, yeah. I think, and Cohen makes that point. If we're, if we are getting gratified in the service of the patient, you know, that and in their improvement and acting therapeutically, why should we feel guilty about being gratified in that process and being enhanced ourselves personally in that process? Yeah. I think this is a really good place to maybe kind of start. to wrap up our discussion. I think this was a really good discussion.

I think there's obviously a lot more that we could learn from you, but they get one and a half hours of conversation to start them on this journey. What would you say kind of in closing to, if someone's listening to this and they're like, gosh, I have a lot of improvements to make, not sure where to start, what would be some of your kind of closing, encouragement? Well, I, you know, I always encourage people who, you know, these days many people

say they don't at the time or they can't afford their own treatment. And unless they're becoming psychoanalyst where they have to get their own treatment, I'm a bit concerned that so many therapists are practicing without any of their own personal treatment. And I think that's a mistake. I don't know how you can adequately be sufficiently aware of your deepest feelings and conflicts if you have not gone for some type of long-term treatment. Doesn't have to be analysis, doesn't even have to be an analytic clinician in terms of what the research says,

although I recommend psychodynamic approach, of course, because that's what I do. But I think any long-term treatment offers that opportunity potentially. And if you haven't had your own treatment, you are not, I think it's almost impossible to be sufficiently aware of the different conflicts and issues that you have

that are going to be stimulated by your patients. Yeah, 100%. Yeah. Totally agree. I'm, I've had the opportunity to hire clinicians over the years. And if I get a whiff that they've never done their own treatment, it's like, I don't know if I can refer patients that are calling my line to you if you've never done your own therapy. Well, you know what happens, David, is that when the patient, you know, regresses and starts, you know, expressing. all this deep feeling.

Right. And, you know, sobbing and being anxious and, you know, like calling, is this okay? Looking for an explanation of what's going on from the therapist. The therapist freaks out that therapist can't educate the patient about the process because they've never been through it themselves. And they often think, they often take regression as decompensation and put and shut it down, depriving the patient of their opportunity to have their deepest feelings that they can't show anywhere else, and depriving them at the opportunity to be vulnerable.

And so I would say if you haven't had your own treatment, don't try to do deep long-term treatments, because you won't do it well. Yeah, some of the clinicians that I've seen over the years that get in the most dire situations with patients, never did their own psychotherapy, depth psychotherapy, and then started seeing a client twice a week. And one of them ended up in an affair, a female client. And I think it's, yeah, it's hard to not get into what you would call, what was that countertransference, what type of countertransference?

Countertransference diamonds. Countertransference, diamonds. But I think what you're talking about is like, it's harder to not be disregulated yourself in the midst of a very disregulating patient if you yourself have not gone through the process. Yeah, of allowing yourself to be dysregulated, you know, allowing yourself to face your own. And I can say, I mean, I was astounded in my own treatment. I remember saying to people, I had no idea how crazy I was.

I mean, it's like you could be really hard. functioning, but when you start you're going in for hours a week and reassociating and having this relationship, I mean, and Mitchell, and many people talk about that. All of us have, and Rosolo and his revised

discussion of regression, it's like all of us have that potential, and it's not, it's not because we are hiding a traumatized child necessarily at all, is that that vulnerability and that those intense feelings are part of the human condition.

And as we become adult, we learned to socially, you know, put that aside even to ourselves. But it doesn't mean it's not a sign of severe pathology for those intense feelings and longings and sadness to come to the surface. And if you have to understand that and have been through that yourself. Right. Yeah. Yeah. And it can be a little bit disregulating to look. I actually think reading your book, I can see that being a little bit disregulating because it's like, It's like here's a lot of nuggets of what happens and what's truth, and it could be disregulating to challenge,

beliefs, challenge, like, things that have, thoughts that have protected you. But inevitably, truth is a good thing to expose yourself to, like a behavioral exposure to your own internal world, to the reality of what's going on between you and patients, so you're not like just colluding with the conspiracy of mediocrity. Or joining their panic

and desperately trying to fix them or shut them down. Right. To stay, yeah, it's like if you feel that panic, how do you expose yourself in situations, two situations over time that allow you to not feel

as panicked, right? Just like, there has to be incremental exposures, which to some degree is your own personal story and your own depth. Yeah. Yeah, over time, you just go, oh yeah, I know what this is. Yeah. Awesome. Well, thank you so much for your time. This is, I think this is a good place to kind of wrap it up. Yeah. Well, it was great fun talking with you. Thanks for inviting me.