Psychiatry & Psychotherapy Podcast - Listening Psychodynamically

Episode Date: December 2, 2022

In this episode, Dr. Puder discusses the importance of dynamic listening with patients in order to alleviate guilt, shame, and self-disgust. Building connection with your patients is a crucial element for mental health professionals, and this episode dives into the best practices that build connection through dynamic listening for the benefit of the patient.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds.

Listening as a therapist or a psychiatrist increases connection. It focuses on attachment, the interpersonal emotion, and looks for what is strong and adaptive. With increased connection comes the ability to better tell our story. The shame, self-gilt, self-disgust, and fear of not being enough or being found out melts away as we listen for the adaptive reasons behind thoughts and actions. When someone feels connection in the midst of their most distressing memories and thoughts, they will feel less alone, less isolated, less like on a cold island. I imagine a cold island of a memory in the mind,

floating around with a person trying to stay as warm as possible. I've been reading the book of The Endurance, which is like where a bunch of men who are trying to explore, Antarctica got stuck on ice for years before they could escape. And it's kind of that picture of a memory that may have been traumatic, that lacked attunement. And as we listen, we're invited into that space, that sacred space, I would say. And we're also coming up against things that would keep us from exploring. it may be the patient's fear, shame, self-hatred, all sorts of defenses, conscious and unconscious, and to protect in an adaptive way, of course, for adaptive purposes.

So in this episode, which is the beginning of a series, I wish to share some techniques in the most practical way I can possibly describe it. with as few theoretical abstractions as possible. This is the beginning of a series on psychodynamic psychotherapy, which is one of the most evidence-based psychotherapies for mental disorders, including anxiety, depression, personality disorders like borderline personality disorder. And the way that I teach it focuses on the things that work across psychotherapy modalities, sometimes called common factors.

So in this episode, we will talk about listening and listening deeply, listening psychodynamicly. We all want to feel heard and understood, and we can all grow in our ability to give this gift to others. Maybe one of the biggest struggles anyone faces is to not feel heard and understood enough. Good listening is a gift, something unusual. Some patients I have seen have never really felt listened to. If you have done therapy for years or been in therapy yourself for years, you might know what that means. Being heard, being fully, truly understood, or understood more fully is a yearning that I hope this episode gives you. A yearning to both give it to others and maybe a conscious understanding of how deeply you desire,

yourself. If some things here are new, I recommend listening to it several times and even having discussions with other professionals, feel free to disagree with what I say. But teaching it sometimes can help you process it in new ways as well. I have been teaching this class for years to residents, and I know that every time I teach it, it reminds me of what is important. Listening in this way will take everything you have. And what I mean by that is, although we value listening in this way, although we love doing it, it brings you into contact with your own emotions, maybe fatigue, maybe a neediness that will stretch you in new ways. You will yourself need someone to give you this gift as well. And with that, let's get into the episode.

Welcome back to the podcast. I am presenting today, and I have no conflicts of interest, myself, on listening and listening as a therapist. This will have some psychodynamic foundations. This is a lecture that I give on psychodynamic psychotherapy. And if you guys enjoy this one, I may continue to do the whole series on psychodynamic psychotherapy that I give to the residents at the university that I'm in. involved with. So let's just launch into it. Listening as a therapist or as a psychiatrist or both is an active process. We allow the patient to be the authority on their life and we are the student. So if you're a physician, you're moving out of kind of a more doctor role into a student role once again. As Aristotle said, hearing contributes most to the growth of intelligence, and hearing is crucial for receiving communication. And I might note Aristotle was the famous teacher of Alexander the Great and impacted his career probably incredibly. I love this quote by McWilliams. It says, listening in a professional capacity is a disciplined, meditative, and emotionally

receptive activity in which the therapist's need for self-expression and self-acknowledgement are subordinated to the psychological need of the client. This means what we're doing is we are listening in a way that is rare in our day and age, I might say. it is listening not for your own, you know, needs, but for listening primarily to the client's needs, and kind of subordinating your own, which is meditative. It's a meditative task.

Here's another quote, most of the ways that a therapist talk during the clinical hour are intended to demonstrate they are listening. So we talk, I would say the majority of my talk, is to show that I've been listening and not just listening to the here and now moment

of the client, but listening across moments, across sessions. I'm pulling things together, showing deeper levels of empathy, hopefully, that are experienced as, is pleasurable. So we listen to the moment to moment change in emotions.

We try to enter a bit into their feeling, to be present with them, to mirror the emotion and feeling, to use their own words. We ask them to find their own words. We don't assume or put on the patient our own experiences as much as possible. If you don't get why there has,

having a particular emotion like sadness, then we may stay with it, ask them more questions, have them deepen our understanding of it. Once a patient feels truly understood, their affect will change. When people feel heard, deeply understood it is pleasurable.

And so it's normal in a session, even if it's like a very heavy content session to move into a place of positive emotion. The appropriateness of an intervention or therapeutic stance should be judged by the criterion of whether it increases

the patient's ability to confide to explore more and more painful self-states and to expand access to more intense and more discriminated emotional experience. In other words, to elaborate the self. It was another quote by McWilliams. And I love this quote because, you know, if you are doing therapy right, it allows a

patient to continue to explore. It's not that they're just continuing to explore things that they know they want to share, but things that they maybe didn't even have access to. They didn't even have access to them until you listened in a way that reduced shame and fear. And that allowed them to elaborate themselves, right, to elaborate the self, to talk about themselves in deeper ways. I'm going to go through a couple different emotions and how I might explore and listen to them. So shame is, you know, the patient may look down. They may have a hard time getting words out.

They may say they feel uncomfortable talking about a certain subject. they may say they feel something like I feel bad or I feel like I am bad, right? I want to understand why talking about this must be difficult. And I want to understand and maybe even spend more time on the difficulty of talking about it rather than what is to be talked about. and it's okay if you never get to the thing that the shame is concealing. I would say spending time just, if you can, sitting with someone in the midst of their shame, hopefully empathizing with them and making them feel less lonely in the midst of their shame is very powerful. Perhaps as you talk about this, you feel uncomfortable.

You know, if I'm sitting there with someone and they're, you know, it's like, it's hard for me just in a audio monologue to express what I may say because it's like it's intuitive or it's, it's real, this is a real relationship. But the gist of it is that I may say something like, it's understandable that this is really, really hard to talk about and you're entitled to have a difficult time talking about this. I want to find, if possible, the adaptive function to the difficulty in talking about something. So I'm finding the adaptive function of their being shame. So for example, let's say they're a new patient and they're having a hard time telling you

their story. And let's say they had a great experience with a prior therapist. You might empathize with how difficult it is to switch to a new provider. it's a common experience to have a hard time. And as you're talking to me, I imagine that it's both a grief of not having your old therapist, but also a struggle to want to tell the things that you imagine the old therapist may know.

I think it's adaptive to be hesitant to share. and it's okay to not trust or to be slow to trust. So there's a number of things that may be said to kind of like show them that it's okay to be where they're at, right? It's like it's okay if they're struggling. And that's a pretty general, a general thought. It's like it's okay to be where you're at in the session. and I'm not looking to push you to share this thing that you feel super uncomfortable sharing.

Be aware and very cautious when asking why questions. So, for example, why do you feel that way? Why do you feel angry? Why, you know, why do you come in today? It's like all these why questions are very unhelpful. And I think it's because if you think about like how that feels for you, how that would feel for you, it's often kind of like coming from a place of you want them to explain something

that maybe they don't know how to explain or they feel now they have to justify their existence or justify themselves. And so I want to be very careful when using why questions. And this is once again how to maybe be present with someone who's already feeling shame or already prone to shame. it's like, which by the way, most of us are probably. Why can communicate disapproval? Why do you feel like that?

I don't know. You're the doctor. So it could lead to them being bristly towards you. So just avoid why questions altogether. You know, what comes to your mind as you say that? This is one question I like to ask. It's like, it's like, well, it's just like what's floating around in there while you're saying that.

It's like, yeah, let's just hear what's there. So, okay, moving on from shame to anger, when you're listening to someone and they are expressing anger, either a micro-expression of anger, you know, quick down and together of their eyebrows, pursing of their lips, or maybe they're just actually using words like, I'm frustrated, I'm angry. It could be helpful to look for the adaptive function, for the anger or just to state the adaptive function. It seems like you're angry here as a goal to protect you and your family.

That makes a lot of sense. Your anger has kept you alive and that's powerful. It's like life-saving. People feel guilt about being angry and often they express a micro-expression of anger as they express their anger towards themselves, they express it as like guilt. And the guilt is the turning of anger on oneself. And so they're turning the anger that maybe they needed to overcome some obstacle.

And instead of overcoming the obstacle base, because maybe they feel shame or they feel some bad feelings. Now they are pointing that anger on themselves. In anger, listen for the goal that existed before the anger came up. anger is the energy to overcome the obstacle. So we all have goals that we have, and we're moving towards the goal, and then an obstacle comes up,

and the first emotion we feel is anger. And so anger is adaptive, anger is life-saving. It's there to protect us, is there to protect others. It's a good thing. And so I don't see it as a lot of people do, that anger is always bad. I mean, how many times growing up have we heard the comment, don't be angry.

If you've heard that tens of thousands of times, maybe it's hard to even consciously experience anger. And so there could be a lot of shame surrounding the feeling of anger. And if you're someone who has a high amount of shame surrounding anger, you may score very low on the subdomain and neuroticism of the anger subdomain, whereas you score maybe average or above average and everything else, you could also be a higher trait agreeable. So it's hard to differentiate yourself from others. It may be harder to get in touch with your desires or emotions.

So a lot of patients come in without much access to a conscious understanding of anger. Often, patients will have anger towards you or towards me, you know, and that's a good thing. It's a good thing to be able to explore that, to listen to that. And it can be very hard for them to express it, so it may be coming out passive aggressively, like little jabs, you know. I have a patient who doesn't listen to my podcast. I'm 100% he doesn't listen to it. And for the first couple years of therapy, he would be constantly just doing these little jabs to sort of diminish me.

And we finally were able to kind of start to talk about it whenever it came up. You know, it's like, well, I don't want to have to feel like I need therapy. And there's something in me that wants to differentiate. And that was on one level and then another level was, like, I feel angry towards my parents. you know and like so some of the anger that he was unable to manifest when he was very young would leak out towards me and that was of course his transference towards me being a a person in his life and and then we're able to explore that and subsequently he has moved through the anger into like attachment where he's thinking about me and worried about me

It's instead of anger, it's more like, you know, Dr. Peter, I know you went through a hurricane. Are you okay? You know, I just want to check in on you. And so there's concern and that's actually developmentally a good step for him, of course, because it's going to play out in all sorts of attachments. Attachments with other people, other friends, maybe in future romantic. relationships as well. Anger often seeks to control, and when the anger is not pointed at overcoming obstacles, listen to where it is pointing. So if you're like not directing the anger directly at

obstacles, it may come out in just a controlling way where it's like seeking to control the environment. And that can be adaptive too, right? It can be adaptive to want to control your environment, to want to bring order to chaos. Sometimes this would be called a reaction formation when it's like a defense where the impulse is pointed in the opposite direction. So for example, maybe you're upset at your partner and you do something good for them like,

clean the house. The defense is, by the way, adaptive and helpful and should not be shamed or pointed out in a way that would make the person feel less for having it. Like, we don't want to, like, just purely give intellectual insight to a patient. Like, if you watch in treatment, he was always just giving intellectual insight. And sometimes it was, like, caustic. It was like a jab.

It was, like, in my mind, Hollywood, you know, it's, like, not helpful. So having compassion for the defense itself is very important. seeing the defense as adaptive and the role of the defense. So it can be very adaptive to have anger and then instead of being able to consciously register it, feel it to have the defense move into intellectualization or rationalization or whether then thinking more abstractly it can be hard to connect with someone like that, right because it's easier to connect with emotion but to see that as helpful in regulating emotion with the person and to appreciate and to not feel upset at them for having those

defenses i think is is very important okay moving on to sadness sadness is something that is often associated with a loss, a loss of something. You know, it could be a loss of a loved one, but it also could be loss of an ideal, a loss of a dream and aspiration. Let's say there was a goal that someone had. And then something happened where the anger was no longer able to move them past the obstacle towards the goal.

So they would need to grieve the loss of this thing. Grieve the loss of this maybe ideal family that the desire to create or grieve the loss of finding that perfect partner. I mean, there's a lot of different types of grief that could come up. And I'm not trying to put on someone else something that isn't there. I'm trying to sort of observe what is there. and I'm observing it and allowing them to teach me and to help me understand on a deeper level

what's going on. There can also be disgust. We can listen for disgust. I'm wondering, as someone experiences disgust, what is the adaptive function to the disgust? So if the person feels a revulsion, That's another word I like to use for disgust or empathizing disgust,

revulsion towards something. It's like, could that something be poison in their mind or in their body? So we'll feel disgust towards different things, and that can be an important thing to listen to and to put words to let them know that you hear them to understand them. When someone is experiencing fear, perhaps the adaptive function fear that we could listen to is like how it's helping them, how it's protecting them.

You know, sometimes when we have that fear response and it gets really intense, we may actually dissociate, get lightheaded disconnect. And that can also be adaptive. That maybe it's not adaptive in the moment that it happens, but historically it could have been adaptive or at least across people, animals, it could be adaptive, right? So there could be deeper adaptive functions that maybe aren't manifesting, but that intensity of fear. Or maybe when they're feeling fear and they describe it as anxiety, you know, what is, could it be more than fear and anxiety? Could it be excitement?

You know, a lot of people will miss that actually what they're feeling is excitement, and they'll call it anxiety, and somehow that changes it in our mind. Okay, so moving on from emotion. I think I might add here pain because I've seen pain is both expressed on the face as a microexpression, but also when you see pain, it is a visceral manifestation of emotional content, usually in the context that I'm seeing it. It's so helpful to be present with someone in the midst of pain. Like whenever my kids get hurt, it's like, how can I be present with them,

give them body touch hold them you know and then put words to it of course that would be painful you know hitting your knee on hitting your sister's knee to your nose is painful let's get some ice on that and so moving to help them it's powerful okay so those are the the emotional reactions and how we might listen to them and so now we're going to going to move into listening to resistance. And I'm, I'm going to do a whole episode on listening to resistance. And I don't even know if I like the word resistance. I think that's the classical psychodynamic word. They might define resistance as like anything that's moving you away from moving forward in life, right? Or anything that's moving you away from discussing certain content.

and instead of seeing it as a negative thing, I like to see that it is helpful just to talk about and to focus on resistance over the content of what they're resisting talking about. So for example, they may feel something that is inside of them if they were to speak it out loud would cause you to think less of them, and they would have incredible shame.

And so they are feeling resistance to sharing it. I find it so much more helpful to talk about the difficulty of talking about things and talking about how they might perceive me in hearing the content of what they're about to say. and then to empathize with the distress of that, very powerful. And when that happens, it's like, oh, excellent. This person is okay with me having apprehension about talking about something. And we are together, and I am not lonely, in the midst of the difficulty of talking about something.

It's hard to feel shame and togetherness at the same time. So it reduces shame. It's hard to feel lonely and connection at the same time. So if we're connecting, they'll feel less lonely, less shame in the here and now of the moment. And I think that's really something, it's like, if you've never been in good therapy, it's like, that's something that's really hard to get in just self-help books. It's like another person present with you in a way that is togetherness, close, listening for you. And I've had one patient recently. Newer patient said something like, I'm just fearful that you're just saying things

because you've been taught how to say things and you're good at that. But you really secretively are judgmental. towards me. And, you know, because of my training, I don't have to get judgmental towards that statement. I don't have to correct that statement right away and say, no, I'm not going to be judgmental towards you. I may empathize with the distress of believing that. I may be critical towards them. You know, it's adaptive for them, maybe historically, to have some hesitancy, to share something with their parents because maybe what they would experience is judgment or shame. And so I'm patient with them.

And, you know, if I had judgments, if I had criticalness towards patients, I would process that with a therapist myself. And I think that's the benefit of doing some ongoing therapy. It's like, it's like you grow while you hear different things. And I can honestly say at this point, I feel very little judgment. I would say 99% of what my patients are telling me. The 1% that I feel judgment towards is often things that trigger me in unique ways that are unprocessed, which after, gosh, it's been almost eight years, 10 years of therapy, personal therapy.

It's like there's not a lot of things that I haven't processed. the number of time. So do I feel actual judgment? Like, can I honestly tell a person that I will not feel judgment towards them? It would be ideal for me as their provider to not feel any judgment, right? But what I'm saying is that often these people

have felt so much judgment that in sharing anything critical towards you or anything that's like as they start to share some things that they consider very shameful, they may, the intensity of their fear of your judgment is so much further than anything that you would possibly think about. I know like in psychiatry hospitals, you know, as a resident, we used to have some like dark humor about patients and stuff. and I think as I've kind of grown psychodynamically, you learn that patients are so much more like yourself than you ever realized.

Like pretty much so many things that my patients have gone through. If I have not gone through it myself, then I've experienced and gone through it with other patients or with, you know, exploring my own mind. And so it's like there's a, there's something that starts to happen where you're maybe just not as surprised anymore or you're not like shocked or, you know, the normal things that seem like taboos,

you can kind of like understand them a little bit better or make sense of them or, you know, and also in the context of the person's life, it's like you can, even if they're doing something that's very harmful for themselves, you know, do I have judgment for them or do I see how they're doing the best that they can and maybe they're having some reaction formations or maybe they're working out some of their trauma and life, you know, and so I think there's, there's an ability to have some compassion towards them. And so I guess what I'm trying to say is that as I'm listening, I want to hear them talk about it and they may imagine that I may think critically of them, but what I'm really trying to do is I'm trying to understand the

holistic and the completeness of their life and to understand it in a way that is not condemning them or judging them. It's like it's the opposite. I'm trying to see how they're doing the best that they can and given the set of circumstances that they've had. And often there's a lot of courage and bravery in all of my clients. So I guess what I'm trying to say is I'm not just saying things for the sake of saying them ever. Like I would never want to say something that I didn't believe.

It's like I'm trying to be as honest to my own internal experience as possible. And this is where I think you have to do your own work, right? You have to because if you're getting triggered, it's like 100% necessary to work through the things that would trigger you. Okay. More on that in the future. So the next big category is listening and noticing recurrent themes and patterns. There can be themes and patterns of like attachment. There can be themes and patterns of like how they process emotion, emotion regulation. There can be themes and patterns of how they relate to you.

that come out and we're listening to those patterns. And we're trying to help them make sense of it in a way that's empathic and not just, it's not a pure intellectual awareness of the pattern. It's like so many of my patients, especially if they're providers, it's like they already know the pattern. They already know this is what happens.

It's like, it's distressing. It's like, they don't, necessarily need the intellectual insight. They would have gotten that already. They've read a lot. It's like the togetherness with them in the midst of showing the adaptive nature of being compassionate with them. That's beautiful. Okay. The next big theme in each of these themes is like a sub-hour that I could go into if you guys want. The next big theme is listening to developmental themes. Before verbal language comes,

connection is non-verbal, right brain to right brain. It's emotional attunement. It is moving attunement. Like there's movements that we do together. There's a dance of sorts. you know, if you think about like kids before they're verbal, a lot can be communicated in a nonverbal way. I think it's unfortunate that some adults think that you don't really start connecting with a kid

until after they can talk. It's like, no, you can really mirror and connect, and kids want to mirror and connect in a nonverbal way. And so in this non-verbal listening, or in this listening to developmental themes, which are often non-verbal, you maybe create a holding place for patients in which they can play or have a transitional space

or play space where they can explore thoughts, feelings. Like I'm saying, often they're very non-verbal. A non-verbal attachment emotional response is often very black and white. It's a very strong anger when it comes out. It's a very, it's like, it sounds different. Like if you have a partner and you don't feed, or if they don't have food and they're worn out and they're tired, they may get into a very black and white space. And in that space, it's like the words that are said can be very harsh and off-putting.

Maybe they're, if you can blur your eyes and see that there's an attachment language, their attachment language is showing distress. It's showing desires and wants, but it's like, it can be hard to attune to that if you're not used to things coming out in attachment language. Attachment language meaning it's like pre-verbal. But they're trying, it's like there's a part of their brain that's distressed and the verbal part is talking from that, but it doesn't make sense in a way that like a normal conversation or would.

It's like a distressed, like it's emotional distress. It can be all black and white. You never loved me. It's like, well, your left brain is like, well, of course I loved you. And here's the examples. It's like, no, you didn't. It's like in that state, it's best to attune without getting into your left brain. So the attunement may look like.

It's very distressing to think that I never loved you. It's very distressing to think that I am here critical of you. Because that is the ointment or the medicine for the attachment to stress. Okay. So, by onset, assume an attitude of revelry, like a good maternal object, receiving toxic stuff from the patient and giving the back the content in a detoxified form. So sometimes we are bringing in the content that someone is giving to us and we're putting words to it in a detoxified form.

It's like, it reminds me of when I was first giving my daughter baths when she was super young, pre-verbal. And unlike the womb, which has sides that you can push up to and there's a, you know, it feels good to be able to push up against the sides of the womb, feels normal. The bath had, was disorienting because you could, she could move around and she could, um, flail her legs and arms and just be moving in water, right?

And so it was very highly stimulating. And both of my kids had colic, and so I know what it's like to have two, three hours every night of crying. So this is a kid that's already super sensitive to stimuli, and now I'm feeling that chaos or that dissociation has, My daughter looked up at me, and I remember taking some deep breaths and thinking to myself, this is kind of like therapy. Like, I'm taking in this dissociated, stressed out affect, and I'm breathing back calmness, right?

And it's a muscle. It really is a muscle. And if you don't have a very strong muscle for that yet, that's okay. That's okay. you can grow that muscle. So you're creating that sort of holding place, as Winnicott called it. Okay, so the next big category is

to listen to the patient's idiosyncratic meanings. And there's a quote by, Leo, so that is, it is as though he listened and such listening as his enfolds us in a silence in which at last we begin to hear what we were meant to be. And I love this quote because it's just a representation of the beauty of good listening allows the person to be what they were meant to be.

It's kind of like the listening brings forth the self. and the way I understand that is like if a child is not attuned to they are pretty far from their emotional desire, emotions, you know, they're pretty far from that. And as you attuned to it, they become more able to see it in themselves.

But also they become less, they feel less shame around emotion or around desire and they can feel it more freely and then they can feel more present with it and they'll feel that when you're not around more consciously in a way that's not distressing. And that really does help the self come forth. Everything, I believe, everything that is said has meaning. Nothing is trivial. Sequences are connected with thoughts and feelings are connected, what is not said has meaning, and the things that come forth in their mind during

sessions have meaning. So often I'll have a resident who's like, I don't understand why they keep talking about this or that. And it's like, we go on a quest together to think about the meaning of what it might mean. A good example is we do like a termination seminar where we videotaping the residents talking to patients about how, you know, the therapy is coming to a close in like three months. And often what will happen is the resident will mention it, and then the patient will quickly change the subject to other losses that they've had in their life. And it's like the loss of the resident is so significant that it's causing them to reminisce and go through different losses that they've had in their life

and process them and want attunement for them and want to be known what those were like. And it has meaning. It has meaning. So everything that they say has meaning. And imagine approaching someone with the mindset that what they say has meaning. inevitably they will feel meaningful they will feel that that their thoughts are important and they're there for good reasons so

listen to their idiosyncratic meanings okay listen to the patient's interpersonal relationships so how was their relationship with their primary caregivers growing up their relationship with their friends their relationship with past therapists,

their relationship with coworkers or bosses, how do they attach? How do they feel connected? How do they feel when there were lapses in attachment? What happens in the midst of intimacy? All of these are very important things to explore because so much of life is connection. So much of life is interpersonal,

intimacy. So much of, you know, the successfulness of the work that you do together will be on the meaningfulness of future relationships or the ability to connect with more people and in a more meaningful way. I've seen this in some of the patients I've had for long-term therapy. It's like they have richer friendships and relationships. The nature of abuse is to isolate and to make them fully immersed only in your relationship and to create where you get all of your psychological needs met and they get none of their psychological needs met

and you are the source of attachment and that allows for that abusive control. That's the nature of a lot of abuse. And so imagine the opposite of that is that they have more fruitful and meaningful relationships with a multiplicity of people. And I share that also because you should be able to see when that happens in their relationship and to maybe listen to that or draw attention to that. It's like if a patient enters, I've had this a couple hot times in my career. where a patient will enter into abusive relationship and then start to split me and the patient

because they want to be the only one that is connecting. And then they'll tear the patient away from their family and isolate them. Unfortunately, I've seen this where it's like something where you can't stop it. I think I'd be better at stopping it now, but until you're aware of that abusive dynamic, it's more difficult to stop it.

Okay, as we listen to the interpersonal relationships that they're having with other people, we're also listening to the interpersonal relationship they have with us. And I had a patient ask me, like, why is that important? And it's like, well, because, you know, as we have trust between us and as you feel connected and not lonely in sessions with us,

as you explore traumatic topics from your past, it's like that trust and that loneliness for those specific traumas will be experienced differently. It's like imagine bringing out a memory and now inserting into that memory a loving person. In schema therapy, they do that directly, so they insert the therapist into the memory.

It happens differently in different therapies. I think what's important is that you have that trust and connection while they're talking about the memory. And if the memory is suitably traumatic to cause a trauma, to cause dissociation, to cause shame, they will often, in the midst of the memory, have challenges in the interpersonal experience between you and them of sharing it.

And so that is really where I would say, you know, the work of therapy is like very unique. And I would say maybe a more dynamic focus would be to be able to talk about that, the transference in a way that decreases shame, decreases anxiety. Okay. Here's a quote by Dr. Tar, my mentor. He said, I participate. I respond. I react to my patient. his or her verbal and nonverbal communications.

At the same time, I observe what is going on, what the patient is saying, what he or she is not saying, evidences of anxiety. I become aware of what I'm thinking or feeling and where, if anywhere, the interchanges are going. I am participating and observing and wondering how to best formulate to the particular patient, what I observe.

So that's a quote by Dr. Tarr. And you could see there's that presence, like coming back to how do I express what I'm observing? I listen in a way that notes what the patient is trying to say about your relationship. So listen in a way that notes what the patient is. trying to say about your relationship. You know, it can be, there can be a lot of different topics that stir up emotion and feelings

about your relationship, and they may try to hint at you. And if you're not looking for the hints, you may not see them. The patient may say something like, I feel lonely when I'm with people. Maybe that's a hint that they at times feel lonely when they're with you. as the therapist. And of course, you wouldn't want them to feel lonely, but maybe it would be good to explore that to have them put words to it

if they feel even slightly lonely or if they feel not lonely. You may say something like, I want you to know that if there are any times where you feel more lonely in our sessions, it will be valuable to help me understand what is going on between us. It's valuable to put words to that loneliness.

if they bring up that they feel lonely, they may be talking about a memory where they felt very lonely. And in a memory that feels very lonely, they may feel some loneliness in that memory, in the here and now, even though they're with you, and empathizing with how distressing that would be

to feel lonely can be powerful as well. There's another quote by McWilliams. my work during this arduous first year consisted of containing my own distress sufficiently that I could provide an environment in which Ruth could continue to tell her story. And so think about this patient that McWilliams had where it was like, and we all have these patients maybe,

where we become distressed to some degree by hearing their story. You know, it's very troubling content, imagining yourself in that scenario, imagining your family in that scenario, is very, very distressing. And so managing your own distress sufficiently could be the main task of the work together.

And I would say getting some good supervision, get some good therapy of your own to help you do that. If you can think about the therapy relationship as essential to the goal, of the treatment. And you will also, I think, be able to weather through the storms of the ups and downs of a person's life for like longer term work.

And I don't know how to teach that without you experiencing it. You know, it's like so many of these things you have to be in the midst of and process through yourself with someone. And so if you're going through this, like reach out to a colleague if you don't have a therapist or supervisor, hopefully process through the distressing aspects of it. Okay, finally, listen to the exploration of fantasy life and dreams. So in psychodynamic therapy, we value fantasy and dreams because they give us a glimpse into the unconscious,

they give us a glimpse into what is going on on a deeper level. and so we want to pay attention to them both the details and the emotions the way they tell the dream they tell the fantasy the emotions they feel in the here and now about telling the dream

and we want to focus on decreasing any shame they may feel telling you about the fantasy or dream and we want to focus on helping the patient free associate particular portions of the dream of fantasy when a particular image

or something comes up in the fantasy, like, what does that mean? What else comes to their mind? Does they think about that? And I might conclude there, it might be difficult if they have, like, let's say they have a desire to be hugged by you, right? Which is like during COVID,

like probably pretty much everyone has the desire for some physical touch, a hug. And it could be distressing to have positive emotions towards you, the therapist, and it can be helpful to explore those feelings, desires, with words. Positive transference is a part of what makes good therapy work. And, of course, we have the boundaries of therapy that allow us to continue the work.

But it can be good to empathize with both their distress in having maybe some positive, overwhelming feelings, but also in empathizing with the desire for human contact. It's like, of course, you desire human contact. It makes sense. It's a part of being a human to desire human contact. So within the exploration of fantasy dreams, you may come out in some transferential way,

either positive or negative. And within that, there may be distress, with the patient having those thoughts or feelings. And so it can be helpful to help them process that. And it makes sense of that in a way that is empathic and showing the adaptive nature of it. And they're, yeah, it's something that if it's overwhelming for you as a provider to do, then that's definitely something that you should find some good supervision for.

Okay, so this concludes my initial lecture on listening, listening deeply, listening dynamically. It's an active process. If you want, we will have these notes on our website, Psychiatrypodcast.com, and I hope that you guys are having a good holiday season. I am looking forward to continuing to unravel some of these things that I find. deeply meaningful. And I find that teaching people how to listen deeper, it's like, oh, so gratifying, right? I've had a number of people that have been treated, you know, by a good therapist for a number of years. And then their friends are like, oh, they listen so much better. There's something about

being in therapy that makes you a better listener in an ideal therapy setting. And I think as providers, It's like we learn very quickly how our own experience is bleeding into the session and we can learn to listen to what is more coming from the person than our own stuff. So I hope this has been helpful for you. You can always shoot me a message on Instagram. If it is, say hi or shoot me an email. It's easy to do through the website. All right.

Take care. You know,