Psychiatry & Psychotherapy Podcast - Nancy McWilliams on Shame, Transference, Personality Disorders & Becoming a Better Therapist

Episode Date: July 17, 2026

In this in-depth interview, Dr. David Puder welcomes renowned psychoanalyst and author Dr. Nancy McWilliams to discuss essential clinical topics from her seminal books Psychoanalytic Diagnosis and Psychoanalytic Psychotherapy. Dr. McWilliams shares practical wisdom on working with shame in therapy by emphasizing self-acceptance over mere self-knowledge, along with powerful insights into transference, countertransference, and projective identification. The conversation explores how different therapist personality styles influence clinical work, strengths, and vulnerabilities. Additional highlights include building love and trust in the therapeutic relationship, protecting the therapeutic frame, setting early boundaries, and real-world guidance on handling stalking and boundary violations.    By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog Link to YouTube video

Welcome back to the psychiatry and psychotherapy podcast. I'm your host, Dr. David Puter. Today, I am happy to announce that I have Nancy McWilliams back for a second time. She authored several of my favorite books, psychoanalytic diagnosis, psychoanalytic psychotherapy, and most recently psychodynamic diagnostic manual, third edition. We originally recorded this as part of the psychotherapy cohort that I lead every year. This year, Dr. Raga, Dr. Stokes, also led cohorts, and they were a part of this interview as well. None of the contributors have any conflicts of interest to report for continued medical education that is apprehended through my website, Psychiatrypodcast.com. In this episode with Dr. Nancy McWilliams, we covered things like

shame, personality styles, and countertransference, like how different personality types of schizoid, depressive, hysterical, narcissistic, how they uniquely have countertransference with patients. We talked about projective identification and how to handle intense, sometimes overwhelming countertransference. We also talked about stalking and about boundary violations and how to maintain a therapeutic frame. So let's get into the conversation with Nancy McWilliams. So we've been going through your book, psychoanalytic psychotherapy, and then psychoanalytic diagnosis will be like the second half.

So people are pretty familiar with you and your thoughts, and we have some kind of general questions. We'll start, and then I think we'll have time for people to ask, jump in and ask questions as well. Okay, that sounds easy. I don't have to prep. No prep. Ali, do you want to jump in and ask the shame question?

Sure. There's so many places to begin, but I think with the chapter that we read most recently and what we've been talking about a lot is, you know, there's a quote that really stood out the idea that self-knowledge is one goal of psychoanalytic treatment, but a more profound goal is self-executive. acceptance and how challenging this is when a patient is deeply ashamed.

I mean, of course, we all have parts we're ashamed of, but particularly a patient that is driven by so much shame. And how, this is a multi-part question and we can take it in any direction you see fit. And so I'll say it, and then we can take it from there. How do you help patients talk about shameful aspects of themselves? And how does exploring and sharing the shameful parts lead to a positive outcome, particularly how do you do this when a patient does not believe there can be any acceptance of the shameful parts? like it's really disbelieving of that.

And maybe provide an example of how you frame this, this rationale to a patient who doesn't buy in or can't fathom ever, you know, really talking about it or accepting it. Well, you know, I suspect I'm going to say this in response to a lot of the questions today. It often depends on your knowledge of the individual patient, and I would probably do it differently from one patient to another. But to try to generalize, I do several things. One is that I sometimes say very explicitly, you know, in one way I'm an old-fashioned Freudian. I think this process doesn't work unless you're trying to say everything, even if it's

socially inappropriate, even if it's hostile, even if it's critical of me, even if it's something you're ashamed of. If you find it hard to say something, you don't have to push yourself to say it, but you could at least flag it to me that you're having trouble bringing something up and we can look at why. And that often gives an opportunity to go into who shamed them. How did they learn that this idea was shameful? Some patients need you to explicitly make a distinction between feelings and impulses on the one hand and actions on the other. If they were brought up by parents that shamed them for feelings, or even in a religious community that said there were good thoughts and bad or impure thoughts,

I will sort of take that on directly and say, that's not my understanding of what you should judge yourself for, because everybody's got very bad thoughts. The question is whether you act on them. If you're trying to cleanse yourself of bad thoughts, you are in for a lifetime of disappointment in yourself because we are mammals, we have aggression, we even have sadism,

we have all kinds of very unpleasant aspects of ourselves. Envy, resentment, disgust, contempt, Those are normal feelings. And it sounds like something in your background made you feel like it wasn't okay to have those. I don't mean to enact them and to treat people with hostility, but even to have hostility. So I sometimes do a certain amount of that to try to really reframe how they're thinking about whatever part of themselves is so shameful. their mind. But I also will use humor sometimes or just, I haven't seen much positive come from simply trying to tell somebody that they shouldn't be ashamed, you know, that really constantly

talking about how, well, everybody isn't that normal, everybody has that. I might say that kind of in passing, but I find that reassurance never works. And instead, I'll attack the self-shaming part of them. Like, where did you get the idea that you're uniquely bad somehow? What makes you so much worse than all the rest of us, you know? Because they can take that in. Oddly enough, when you attack the self-attacking part, they kind of, feel they can listen to that because they get that you're attacking something about them and they

feel they deserve that, but you're attacking their self-attack. So I do a fair amount of that. Oh, I forgot you're too shameful to even join the human race. You know, one of these days you might want to rethink that, that kind of thing often moves it along. Just naming it helps. sometimes. Am I picking up that you're ashamed of what you're telling me? Sometimes people tell you behaviors that they've done that they should be ashamed of. I mean, shame is not entirely a crazy emotion. It's one of the ways that tribal cultures and larger cultures help people not to act out destructive parts of themselves. They shame them for behaving in certain ways. They can overshame them, and that's a problem, but you don't want a

shameless culture. You don't want people to behave shamelessly. So sometimes I differentiate between, well, it seems to me that it's reasonable to feel ashamed of you're doing that, although I hope over time you can forgive yourself for that because you're not the first person who's done that, as you well know. Shame is harder actually to get rid of than guilt because with guilt you can, guilt is very difficult for other reasons, but with guilt you can you can do something to compensate. You can apologize, you know, but since shame involves being seen in all your ugliness, you just want to crawl into a hole in the ground. It's not something you want to call attention to and try to undo. It's like, oh, God, the ugliness of who I am has been on display for everybody to see.

So it's a particularly toxic affect. And sometimes people don't even want to name it because they can't bear to feel that exposed. There are some patients, especially people in the psychotic range, where I am more self-disclosing, more conversational. And I will say something that I think they're ashamed. For example, an example would be one of my patients who was very paranoid and which had been humiliated about all kinds of things in his life. He confessed to me in a shame-faced way that he had struggled with irritable bowel syndrome. And I said to him, oh, that's such a difficult thing.

I had a long siege of that when I was in my 20s, and fortunately it was one of the things that my analysis changed. And he said, you admit that you had that? That's such an ugly condition. And I said, yeah, but a lot of people have it. And to just acknowledge something that is without the shame that I think the patient is ashamed about. Yeah, I see we have a break coming up. And actually, I hate separation, so I always get anxious around separation. So we'll have to pay some attention to that.

Just to model that stuff that somebody else might feel ashamed of is all in the human condition helps people. But ultimately, I think that any kind of therapy, and perhaps especially psychodynamic therapy is it's exposure therapy. It really is exposure on a grand scale. The person tries really hard to tell you everything and finds themselves with all kinds of feelings about that and you accept them.

You don't make a big deal out of, well, you know that's okay, don't you? you just say, yeah, so you wanted to kill so-and-so. Can understand why. And try to make it just a natural thing. But I don't think people are surprised when therapists are nice to them if they've seen mostly cooperative, pleasant parts of the person. But they're very moved when they've shown you their ugliest parts

including their hostile parts toward you, and you're still welcoming them. That actually makes a difference. Does that cover the general territory of what you're... Absolutely. Yeah. Yes. I think with that, I was thinking about a type of transference I've seen lately

where it's like they can almost fragilize the therapist and imagine that they would really hurt the therapist's feelings if they said something mean. or if that's any negative transference, how do you, how does that relate, or how do you sort of address that or notice it maybe even? Sometimes I don't see it.

It's one of those transferences that actually makes me angry because in my personality, I'm invested in, bring it on. I can tolerate it. And if you're trying to be nice to me because I would fall apart, I feel insulted, you know.

I remember once years ago, one of my patients, she was in analysis with me, and she was, there was a book party for me when one of my books came out. And I think it was a book party, but at any rate, she wasn't on the list of invitees because she was in treatment with me, but she heard about it. But she didn't know whether it was a surprise event for me or not, and she didn't ask anybody. But she got it in her head, and this fit with her transference toward me as somebody that, like her depressive mother, she had to take care of, she began seeming very blocked in treatment. And I'm, you know, turning myself into a pretzel trying to figure out what's going on. She's not talking about this. She was hurt

that she wasn't invited. She was envious of the people who were invited, and she didn't want to talk about it because maybe it was a surprise, and she'd be blowing the surprise. And when I found out, which I finally said to her, I give up. There's something that's bothering you, and I don't know what it is. What is going on? And she finally confessed. And it was a, interesting enactment because she could have asked somebody, is this a surprise party for Nancy? She kind of grabbed on to the opportunity to feel like she was taking care of me, because that was familiar to her. She knew how to relate to a mother figure that way. But my irritation with her was quite obvious to her when she finally confessed what would have been going on. Because I felt,

you've been making me work like a dog to try to figure out what's going on. You haven't been following the basic rule of just re-associating and talking about everything. I've sometimes had a patient tell me, oh, I want to talk about this novel I've read. Have you read it? And if I say no, oh, then I don't want to spoil it for you. And that irritates me. Listen, I'm your analyst. You're supposed to talk about everything.

I don't. I'm not, so you spoil it for me. big deal. That's not as important to me is that you keep talking about the things you're interested in. So I think I have a particularly reactive countertransference when people are taking care of me. When my husband died about 20 years ago, it was the news went around my grapevine with like a flash. And I called everybody the day after he died and said I had had a death in the family. and I was going to take three weeks off, and then we would resume in such a time.

And I had a lot of patients who would come in, and they'd go, oh, how can I talk to you about my trifling problems when you're going through this bereavement? And I pretty much had to say to them, listen, I really appreciate that you want to take care of me at a bad time for me. But if you really want to take care of me, let me do my job.

Yeah. So I react badly to patients who think I'm fragile and they have to leave certain things about themselves undisclosed with the rationalization that I couldn't bear them. And I'm curious, you know, what is it about maybe you as an individual that has that countertransference response? Is it something that's happening situationally in your life? Is it more of your personality style? No, it's a personality thing.

I lost my mother when I was nine, and when latency-age kids lose a parent, their role in the family tends to, I mean, teenagers will act out, younger kids will regress, latency-age kids will tend to try to show, I'm okay, who needs a mother? I'm going to be self-reliant.

And I was actually, when my mother was, dying, I was told your mother is dying. You're going to have to be more self-reliant than a lot of kids your age are. It's not going to be easy, but we trust you to do that. So that became part of my self-esteem, that I'm tough. You don't have to take care of me. So my poor husband, my current husband, complains about this a lot because he will do something for me. And I'll say, did I ask you to do that? Is it because I immediately think, he thinks I need that? Rather, I've gotten better over time.

But he's also gotten good at saying, I have an idea that I think might be helpful for you. Do you want to hear it? So every like four months, right, email you and ask you to come back on the podcast, you're not offended by that, by that continual question. No, I'm flattered by it, but if you said, oh, Nancy, I know you're so busy, but, you know, could you possibly, I'd rather you'd be very direct and say, we'd love to have you on the podcast again. Here's what I have in mind, and I can either tell you whether I can or I can't do it. There's some way in which for me, as a person who was an ambitious female, really before the feminist movement appeared in the 1970s, There's some way in which I'm, I easily feel that, especially men, are telling me, they're there, don't bother your little head with this, because in the 50s, that was the way men actually

behaved toward women. So, you know, speaking to, like, your ability to sort of rely on your own, you know, self-knowledge of your personality, but your countertransference to sort of pick up on. what might be going on based on your personality. I wonder, can you speak to sort of like strengths and vulnerabilities of different personalities of therapists? Yeah. Should we start with one in particular, maybe?

Sure. What would you like to start with? Maybe schizoid? All right. Ski-oid people tend to be quite. quite good therapist, or at least good at psychodynamic therapy. They're extremely sensitive people. And if your main defense is withdrawal into your mind, or maybe withdrawal into a fantasy world,

you don't have to distort. So schizoid people don't tend to use defenses like repression, reaction formation, the more distorting defenses, they see a lot of stuff that other people are defended against. So they naturally get the unconscious. The psychoanalytic therapy makes sense to them. And they have a conflict about closeness and distance,

how close to get to other people. They often appear to be very distanced and aloof, but if you get to know them, there's a longing for closeness that coexist with that. And being a therapist is, a nice resolution of that conflict because you get closer to your patients than anybody's ever been. And yet you don't have to take your hair down all the time. And, you know, you're protected by the fact that the session ends.

You know, they're very clear boundaries. And so you get a lot of your needs for intimacy met without the feeling of risk that goes with most social situations where you get easily over-stimulated and impinged on. So there are a lot of people with schizoid psychoanalytic work. I think Winnicot had this psychology. He's always described as shy and quirky and not very sexual. And even his concepts, you know, like the third or the space, transitional space,

going on being, impingement is something that he emphasized a lot, which is a very schizoid kind of experience of often a depressed parent who is impinging on you too overstimulating. So the downside of being a schizoid person and a therapist would be sometimes you can get overstimulated. And it's a, you need. need time to refuel. Often, my schizoid colleagues tell me that at the end of the day, they want an hour to

themselves. They don't want to see anybody. They don't have to talk to anybody. People with my psychology, which is more hysterical, are also extremely sensitive people. And I think we're good in the role if we can get past some of the hysterical defenses like a kind of performative style. And as you, I've already said here, we are reactive to gender issues, and we have to keep paying attention to that.

But those two psychologies are very tuned-in kinds of psychologies to other people, even though they look very different. Depressive psychologies are the most common psychologists for therapists. to have. At least that's what a study in Australia found out. And that's been my experience of, I have a big streak of that, and most of my colleagues, I would say, are pretty depressively organized, meaning that they tend to be self-critical. They use interjection rather than projection. If somebody criticizes them, their first assumption is, oh, there must be something right about that. They don't tend to do the paranoid thing, but that's your fault,

you know, if their patients get better, they credit their patients hard work. If their patients don't get better, it's their fault. And they like being close to people. They feel it's a very attached kind of psychology with sensitivity to attachment and separation, sensitivity to other people's pain and a feeling of some pleasure when they relieve pain. They tend to be people who are trying to help the depressed part of themselves by helping the depressed other, even though you can have a depressive psychology and I've never had a clinical depression.

Narcissistic therapists have to work harder, I think, to try to try. to really get inside their patients' experience, but they can be quite good therapists over time. Sometimes their perfectionism works on their behalf. I guess one of their vulnerabilities would be a vulnerability to thinking when people have an idealizing transference toward them that they are enjoying it too much. this is how they should be treated. So it's harder for them to find the devaluing side of the patient's feelings. Psychopathic people should not be therapists

because they don't see others as subjects. They see them as objects to manipulate. There have been only a few psychopathic therapists that I know about in psychoanalysis, at least from my inferences about what their psychology was. Interestingly, Ernest Jones was pretty psychopathic. He was very close to Freud, but Freud privately called him the liar from Wales. He was such a maher.

Masochism is, in one way it's a plus if you have a kind of masochistic tendency, because you'll roll with a lot of stuff. but where you run into trouble as a therapist is setting limits on people and modeling not being masochistic because it's not really helpful for masochistic patients if you're being self-sacrificing and being more and more giving with the idea that at some point they'll see how good you are and they'll be able to take in that you're better than the people that have persecuted them in their life and that's always a loser. It's much better.

For example, if your patient runs into trouble with money, just say, I can really understand why you would want a lower fee, but I've gone as low as I can go with my fee. That's how I make my living and let them get angry at you. That's much more therapeutic than saying, oh, you poor thing, I'll reduce my fee, and then you end up resentful, especially when they drive up in a BMW after you do that,

or when you can see that you're reinforcing their masochistic pattern. What they learn is, you know, the worse off I am, the more I'm going to get stuff from other people, and you don't want to set that tone. Paranoid people, I haven't known too many therapists who are essentially paranoid. Edgar Levinson used to say that he felt he was essentially more paranoid. He was a very big influence to the interpersonal tradition in psychoanalysis.

But usually if people feel they're paranoid, they don't announce it. But paranoid people, even though they suffer a lot internally, they are also very sensitive. The risk they take is that sometimes what they think is understanding a patient is projection of what it would mean if that were them saying the same thing. Who am I leaving out? Obsessive? Hypomatic dissociation. Okay.

And obsessive. An obsessive. Obsessive people can be very good therapist because they have such integrity. I mean, they're trying very hard to be the best kind of therapist they can be. That's important to their self-esteem. But they do tend to join the patient in intellectual. So I periodically have to talk back to my own obsessive side when I'm explaining something rather than exploring something. Hypomanic, the only person I know who's a therapist who's called himself hypomanic, actually he called himself hypomanic with obsessional defenses, is Samanahtar.

and I think he's quite a good therapist, but I think he also probably over-extends himself easily. I don't know too many examples of that, though. Usually, hypomanic people have trouble with the sustained relatedness that is required for psychotherapy. It wouldn't be their first choice of profession. And it does involve using a lot of denial. And if you're using denial, you've got an additional obstacle to understanding people. If you're brilliant, like Salmon, that doesn't get in the way. But for most of us, it would get in the way.

Dissociative, there are a lot of dissociative therapists. A lot of therapists are trauma victims, and they get easily triggered. And I think the important thing for them is to try to. to figure out what triggers them and not work with patients like that. So if, for example, you have a sexual abuse history, you don't want to try to treat pedophiles. You may have to during your training, but once you have control over who you see, you just don't want to retramatize yourself. It's hard enough being a therapist. But they certainly have a feeling for how trauma can take you over.

Some of the best people in the movement to try to understand dissociative patients have significant trauma in their own background, and that was what partly made it possible for them to see this group of people that the rest of us weren't seeing yet.

I'm thinking of people like, I don't know his personal history, but I would say Richard Clough, Cornelia Wilbur, Frank Putnam, Ira Brenner, Christine Courtois, a lot of people that originally put dissociation on the map in the 1980s were people who knew something about it. Judith Herman, I think, was not traumatized herself,

but she identified, it was important to get women talking about this. In the 80s, we saw this perfect storm of the festivals, feminist movement where we were listening to women's experience. The Vietnam vets were starting to talk about their trauma finally 20 years after it happened. And people began realizing how much trauma there was out there. But Judith Herman's book was a groundbreaking where she basically said suffering sexual abuse does the same thing to your psychology that combat trauma does. And it's a Jennifer Fried later called it betrayal trauma. So she's the one that reframed it.

I remember a time when people would talk about incest as if it were like this forbidden satisfaction of some edible desire, rather than the drastic exploitation of a child's helpless dependency by a predatory or clueless parent. how do you, and we don't necessarily have to jump here, but how do you work with, you know, someone who really uses dissociation as a defense or has like a dissociative transference? I don't know if there's such a thing as a dissociative transference exactly. I think in different self-states. Let me describe the dissociative transference as kind of like what we're thinking, because we've talked about this.

Okay. Prior as a question. It's like when you may be making an interpretation or something towards them, it's like they space out during that. Oh, okay. So it's like their brain doesn't even register what you, the therapist, said maybe during something, you know. Yeah.

Well, that does happen a lot when you're working with dissociative patients, and I will just try to name it. Are you still here? You know, I feel like you zoned out. Did I go somewhere that you're not ready to hear? And I do a lot of basic grounding. Can you look like you've gone into another place. If they're outright DID, I say, am I talking to somebody other than who I was talking to before?

And sometimes they'll say, yeah, why are you trying to help her? She doesn't deserve it. this split going on. And the literature on working with dissociative patients is pretty clear. You always act as if all of the parts of the person are in the room, and they're all hearing you whether or not they're identifying as the person talking to you at the moment. So, for example, when a hostile alter personality emerges, they're often angry and even a little threatening. He said, listen, I know you are trying to help Marie. And I think she's scared of you, but I understand you're trying to help her and you're

afraid that I'm trying to hurt her. So I get it, but you're not allowed to threaten me. So with frankly D-I-D people, I do accept the premise that their experience is that they're different people at different times. With more ordinary dissociation like people zoning out on me, I sometimes miss it for a long time because people learn to pass. They learn to cover. One woman that was a Frank D-D-D-Patient that I worked with for several years told me when she stopped treatment. that she was somewhat disappointed that she wasn't as gloriously integrated as she had hoped originally that she would become. But she said, it's such a relief not to have to dissimulate and lie anymore.

You know, I used to spend all my time. People would confront me with stuff I'd done in another state of mind, and I didn't remember it, and I would try to develop a cover story. Oh, yeah, I guess I was angry that day. Sorry. And now I can just say, you know, sometimes when I'm under a lot of stress, I dissociate and I don't remember what I did. What did I do? I'm really sorry I did. And it took a tremendous weight off her that she wasn't having to constantly pretend not to have this tendency. So again, it depends upon the patient, but I often begin to know that there's a dissociative process going on when I zone out. When I think I'm listening and then I realize I've been thinking about what to buy at the grocery store instead of really hearing what they're talking about. I bring myself back and I will say something like, wow, I think I was just zoning out a bit. Are you fully here?

Somehow you and I think we're both up in the clouds. So, again, it depends on the person. Yeah, we have a group member. Ariel has a question specifically about transplants. Ariel, why don't you go ahead and ask Dr. McWilliams directly? Hi. Thank you so much for being here today. I actually have a question that came up at a time when I was,

going through some countertransference, some really, really difficult projective identification issues to the point of becoming physically ill, seeking medical help. I would just share really quickly that reading your psychodynamic diagnosis book, there was a very specific passage which actually really helped me in my processing of this. And that led me to asking a question. that is, I'm curious to learn about your most intense experience or experiences with projective identification and countertransference. More specifically, how did it feel for you? What about it affected you so deeply? And what is your most effective strategy or tool that helped you process and work through it? Oh, well, I'll just go with what came to mind. I mean, I've worked with a number of

patients who are so intense that they activated me a lot. But one that is particularly memorable to me was I had a somewhat paranoid patient who was very sensitive to any indication of rejection. And he had very rejecting parents. And he was one of these people who scans you all the time. And it's exhausting because you keep feeling like if your face twitches in a way that he thinks is negative, he's going to go right into, what are you thinking? You were critical of me. I know it. You may not know that you're rejecting toward me, but I know you are. I mean, he was poised to project into me his whole internalized drama that he's going to be rejected. And one day, he came to the office and the door was locked. My husband had thought I was finished for the day, and I had an office with a separate entrance. Then there was a stairway, and it went up to a second floor office. And my husband was just securing the doors at night and thought my day was over and locked it.

But I didn't know that. and I hear the patient at the door, and I went down, I said, I'm so sorry, I don't know how that got locked, you know. And he said, okay. And I thought, with his whole rejection thing, I better investigate this. So he sat down and started talking about something else, and I said, you must have had a reaction to coming to the door and finding it locked. And all of a sudden, he looked terrified. And he later explained to me that, and this is the way you can get sort of screwed up in your own mind when you're working with a person for whom some virtually psychotic reality feels like the reality. He said, when you brought it up, I couldn't think of any reason for you to bring that up except if you knew it was true.

that you were rejecting me, right? So, and, and he gradually let in the idea that somehow, there were professional reasons for my checking with him about that. It didn't have to be that that was the actual feeling that I had toward him, that I didn't want him in my, in my office, that I basically hated him. And this interaction happened several times over the course of a long treatment, where he was sure he knew better than I did that I hated him. And through projective identification, I wouldn't say that I felt exactly hateful toward him.

What I mostly felt was the terror that was behind his hatred. I was terrified that I was going to lose him as a patient, that I was going to hurt him, that I was going to do more harm than good. And one time when we went around on this, he was so certain that I was being naive and self-deluded, and he knew what I really felt, that I started to cry. And that's what broke it. I didn't do it in a deliberate way. I just, I said to him, I don't know how your conviction is so complete that I somehow hate you. I feel helpless because everything becomes evidence of that. And he later told me that the fact that I actually cried about it made him believe that maybe I wasn't just rationalizing.

So, you know, there's nothing in our textbook that tells us if you're out of all other things to do burst into tears. But, you know, sometimes the things that actually get to patients are not the things that are in the rule books. but that was a particularly challenging case. I really loved this guy. He was a very tender-hearted person, but his conviction was pretty psychotic, and he saw it everywhere. I had another patient that I got out of it

with a similarly outside the book experience. I had this patient who had this patient who was pretty narcissistic, who had had a depressed mother, and he came down every morning to see her sitting at the kitchen table with a cigarette in one hand and a coffee cup in the other hand, staring into space. And, you know, she was almost never fully alive. And in the transference, he used to come in and say something like,

oh, you look really tired today. And I would, wanting to analyze it as a transference, I would say something like, gee, I'm not aware of feeling tired. Is there some reason why you might want to tend to see me that way? And he'd say, oh, you know, I'm a very sensitive person. You may not know you're tired, but I can see that you're tired. So he would always sort of one-up me by he was a sensitive person. He would walk in and he'd say, oh, you look depressed today. And I would say, gee, I'm not aware of that.

What's going on with your perception of me is depressed? He's, oh, I know you're depressed. You just kid yourself. You're depressed. So what actually moved that treatment along was I was pregnant, and he hadn't noticed. And I got into my sixth month. for this super perceptive guy, notice, and I had to call it to his attention.

We went through the usual thing. I know you want to look at this as a transference, but it's about you. It's not about me. And I finally said to him, if you're so fucking sensitive, how come you haven't noticed? I'm six months pregnant. And he stared at my belly. And he said, oh, my God, you really are. And that was the first time he rethought the possibility that maybe his conceit that he always knew better than I did, what my state was, might be affected by his own psychology and not just mine.

So a couple of times I get rescued by some reality because it's so hard for people to believe that what they are projecting on you might be their stuff and not yours. I'm going to pull in Dr. LaTal here. I wanted to know your thoughts on the relationship between love and trust within the therapeutic relationship, both from the therapist point of view and from the patients. Well, I think one of the things that drives people crazy is not only not being loved, but not having their love except. it. If you're a child whose parents seem indifferent to you, who don't light up, who don't respond to your love of them, you're going to get damaged by that. And to the extent that the therapy relationship is curative just because it's a different relationship than what you've had previously with authorities.

You have to be welcoming to all of the patient's feelings about you, including their love without breaking any boundaries, and they have to have evidence that you care about them, that you're really interested in them. I don't typically tell patients that I love them, but they can tell that there's love in the relationship just by my commitment to them. trust usually takes a bit longer. Patients will find it easier to love you than to trust you if they've been betrayed in their history or horrifically neglected. So epistemic trust is the core to any kind of secure attachment, and it takes a while to build.

there's empirical evidence that if you're if you're if you're if you've got one of the insecure attachment styles it's pretty robust I mean if you're three years old and you're in the strange situation paradigm and you test as having avoidant attachment when you're 33 years old you'll probably test as avoidant attachment on the adult attachment inventory but there at least Philip Shaver's empirical work has demonstrated that if you are in a loving relationship, like a good marriage or partnership, if you have a really close other in your life, for at least five years, you start to test more securely attached. if you have intensive therapy, that can happen over two years.

So at the end of the second year, you actually do see shifts in attachment style toward a more secure attachment, and that's basically the evolution of trust. When patients know that they don't trust me, often they do know that at the beam, I say to them, I'm aware that there's nothing that I can say. say that is going to make me more trustworthy in your eyes because from what I hear of your history, nothing has given you any foundation for feeling that other people are trustworthy. But I am hoping that I can be trustworthy enough that over time you'll actually take it in that I can be trusted. But you don't have to trust me now. In fact, you can't choose to trust me now. I'm

quite aware of that. I think it answers about 80% of my question. The other piece is like, do you feel like you need to have some sort of trust for your patients, or how does that work for you in a long-term relationship? If your patients aren't trustable, you certainly have to set conditions in which they can't act out in ways that are problematic. For example, I've had colleagues whose patients were fascinated with them and befriended their, children on Facebook and tried to get interesting information about their therapist from the kids. One patient of one of my colleagues joined AA because she learned that the therapist's son was in AA and she became his sponsor and then came into treatment announcing that she was the sponsor

of the therapist's son. Oh my gosh. Yeah. I have another colleague whose patient joined her swim club because she wanted to hide in one of the cubicles and look through the slats to watch her therapist undress. Therapists, and I don't think we get good training in this at all. We get a lot of training about how to be empathic, but most therapists are naturally empathic. That's why we went into this field. We don't need a lot of training in how to care about people.

But we need training in how to set limits that ensure that we have the conditions of labor under which we can practice. So you have to set limits with your patients. Look, you are not allowed to befriend my kids on Facebook. You are going to have to tell my son that you can't be his sponsor anymore. If you want to continue, we'll have to stop the treatment. I don't want my life to be overlapping with yours. gets in the way of my doing my job. And we have to stick with that. We don't have to absorb everything that some desperate patient inflicts on us. I've had a couple of colleagues who were

stalked, and they put up with it too long. And in one case, the person's office was burned down by the stalker. So if you have a patient who starts to stalk you, it's a serious thing. And you've got to immediately set boundaries on it or refer the patient to a higher level of care, because that's a dangerous psychology. So maybe you could define, like, what is stalking behavior if there's any others that clinicians should be concerned about? And then maybe if there's any nightmare stories that I know people have reached out to more than the, maybe you're, you've probably heard more of these stories than the average

clinician. Any stories come to mind in particular? The stalking stories are usually by the time they get to me. They've elaborated in ways that are really hard for the therapist to get out from under. So it is a good thing to know something about the psychology behind that. I don't know why they didn't put it in the DSM because it's a well-known syndrome. Erotomania is what it's typically been called. And it's really an obsessional preoccupation with another person that includes attraction and hostility.

The hostility is often unconscious. But it's a paranoid syndrome. In erotomania, I believe that you really want me. That's the projective identification of my own craving, but it's paranoid in that it's denied in the self and it's seen as coming from the other person. If you weren't so wonderful, I wouldn't feel this way. And it can be so powerful that even people

who've brought stalkers up on charges, like if they've gotten a legal prevention on the person coming in their orbit and the person disobeys the ordinance, And it gets to court. Reed Malloy, who's an expert on this, told me that the stalker so firmly believes that they were encouraged, that this was really what the stockee wanted, that they can often persuade a judge and a jury. Because you can see how it would happen. The therapist, therapists are nice people.

And when you realize somebody's impinging on you much too much, you might, this happens to non-therapist. too. A kind thing to do would be to say, listen, you're a very nice person, but I don't want to have that kind of relationship with you. And then their defense attorney gets on the stand, gets you on the stand and says, didn't you say, you're a very nice person? And the stalker is sitting there going, I was encouraged, you know, I was seduced. And it's really a powerful paranoid. condition. It was first, interestingly enough, it was identified in women who would have these reactions to men of higher status. It was thought to be a female disease originally because people would get preoccupied with the local Duke or Earl, you know, back in the 1700s, and they would

follow him and make his life miserable. And celebrities, of course, often have at least one stalker. That's our contemporary version of that. But therapists become important to patient, and if they have that dynamic, you can be in real trouble. So you have to sense it early and then set limits on it really clearly and have consequences for the limits. You know, I told you not to befriend my kids on Facebook. It's come to my attention that you have a, under a different name, under a different social media handle. You've done it again. I'm sorry, we have to stop, and you leave it there.

The self-protection that we have to pay attention to his therapist has been pretty much minimized in our training, I think. Do any questions on this specific topic from anyone, anyone have any concerning people, they can just jump in the chat and I'll bring them in or raise your hand? Or maybe even tendencies. that are concerning. So maybe if they don't necessarily fit this full psychological profile, maybe there are certain behaviors that have been exhibited throughout treatment that are concerning. Give me an example, and where would you start getting nervous with a patient? What would be some of the

behaviors? I would say if there's overt behaviors that start to infringe the frame, where I've established parameters, I've established boundaries, Yeah, exactly what you said, violations of the frame, if they start calling you in the middle of the night, if they happen to have been in your neighborhood. And I think we are reluctant to set limits very early because we want to understand them first. There's a book by a woman, I think it came out about 15 years ago. It's called You Know You Really Love Me. It's her description. of having you been stalked by a patient.

Ian McEwen wrote a novel about being stalked by a gay guy that became obsessed with him or with the character in the book. So that was interesting because it was the same gender. Often it's a heterosexual phenomenon, but it can be a gay phenomenon too. I think we're seeing more of this in recent decades. There are a lot of desperate people out there

that want to glom. And cannibalism. Can you explain cannibalism from a transference perspective just so the group understands? Because I don't know if everyone understands that. I just mean that you feel consumed by a patient like this. Completely consumed. They put the emphasis on the dependency and the erotic attraction, the love. And it's not that that's not there, but it's all merged with,

a lot of aggression. You know, you're good enough to eat, so I'll destroy you. And it's so hard to put into words of how that feels to be on the other end of that. So Nancy, obviously there's been an uptick on autism diagnoses in the last several years. And I think, you know, from a psychoanalytic perspective, what are some of the ways that you distinguish autism from schizoid personality, perhaps the overlapping features, because I know, you know, as a clinician and then working with a lot of other clinicians, particularly who will come to me for consultation, and I'm not directly working with the patient. A lot of times they'll present the patient as an autistic patient, but then it sounds and feels more like a schizoid personality

structure. So if you could just share with the group, if there's any process that you have to distinguish the two, that would be great. Yeah, they look a lot alike superficially. Both groups are highly sensitive to stimulation from outside. They may have certain rituals that deal with the stimulation. The main difference is in two areas. I think they may have a sort of similar neurological pathways that are operating, But two things.

A schizoid person may withdraw from other people a lot, but it's not because they don't understand what's going on in the other person. They read social cues. They just don't want to comply with them because of their conflict about it. So a schizoid person may have trouble, like, hugging his child because that feels like a lot. but they know children need to be hugged. They get it. An autistic person, you may have to tell them, you know, it's good for children if you hug them once in a while. And they'll go, oh, okay, and they can do the behavior.

That's one thing. How much do they really read social cues and how much is they're not reading it versus how much are they reading but finding it too hard to play their role? The second thing is schizoid people live in this world of imagination that's very rich. And autistic people, and, you know, I do think there are some overlaps. And as we learn more about neurodiversity, I think we're going to learn a lot more about all the different ways you can, all the different brains you can have. But my grandson is on the autistic spectrum. and he had trouble with other children. That's how we first sort of noticed it

because other kids had an imagination. And so when he was three, some other kid would come up to him and say, I'm a lion. And my grandson would say, you are not a lion, you are a kid. And his mother had to teach him about imagination. The kid is imagining him.

being a lion. And now, now that he's older, he will say to his mother, oh, is that that imagination thing? So, again, he's a, he's a loving kid, he's a warm kid, but he doesn't get those processes. Schizoid people, again, can have extraordinary imaginative lives. And they're quite clear what the difference between that and reality is. They can play. in a way. So those are the main difference that I've noticed. But, you know, I think our diagnoses are, all of our diagnoses are problematic

because the DSM and ICD have gone in the direction of trying to define everything based on what's externally observable. And sometimes what's most important to people is the internal experience, which they don't always share right away. Wonderful. Thank you. Why don't we open it up to some of the group members?

What do you think? Let's do it. Carrie Pond, I'll bring you in here. So one of the things that I would love to hear your thoughts on is I think this kind of, this question came from a little bit working with couples, but then also kind of in the therapist-patient diet. I'm curious if what your thoughts are about, like, combinations of particular personality styles or like how they might interact. Yeah, kind of reading through psychoanalytic diagnosis

and kind of understanding kind of styles within individuals and the defenses that come up, I'm just kind of wondering if you have any any thoughts about particular combinations or ways in which things might combine and certain styles might pull on certain, like, aspects of our own kind of psychology if we're hybrid or just kind of anything in the interactive kind of dynamic between people realm, if that makes sense. Yeah, most of us have elements of more than one personality style.

And, you know, if you really want to get to know somebody, you end up learning what their specific story is. What is their narrative? How do they understand the world? What is the theme of their life? And it can often involve combinations. My own personality, as I said, is someone who's somewhat depressive. It's very common to have a combination of schizoid and obsessional. The kind of person that Jeremiah was talking about, who combines paranoid with psychopathic is altogether too common. And our legal system doesn't help us with that either,

because the legal system insists that you be one or the other. You're like, you can't be, if you're psychopathic, you're not crazy. Those are mutually exclusive diagnoses, but plenty of people are both. The psychotic and psychopathic, paranoid to a psychotic degree and psychopathic. Depressive and masochistic tend to go together a lot. Would you say those combinations find each other in different people? Like, do you see, I don't know if you've ever, if you ever work with couples, or just kind of in your experience, like, do certain styles tend to find one another and have

more hostile or more equanimity in terms of their combination? Or, like, with your personality, do you have certain styles and patience where you're like, this seems to work really well on others that you're like, wow, this sucks. This is not a good combination. Something like that, kind of between people? The only combination that I've noticed over time as a, a, a common combination is schizoid and hysterical. They have certain things in common, like their level of sensitivity.

So in some ways, they're similar. But let's say it's a schizoid man and a hysterical woman. They are drawn to each other like magnets sometimes, because the schizoid man admires her comfort with other people and her expressiveness. And she admires his capacity to stand alone. and reflect. And then they get together, and in couples therapy, you get these pursuer-distance dynamics because her way of solving a problem is to move closer to him and his is just get out of there.

And that's actually something that you can interpret and they can see and that they can, she can learn to give him space. He can learn to move toward her when she's upset instead of avoiding her when she's upset. So that's a pretty common one. But I've seen all kinds of combinations. And I think for me, I've enjoyed working with all different kinds of patients. I think the ones I have the hardest time with are people who are profoundly narcissistic. Because they don't really love.

And I don't mean ordinarily narcissistic. We all have narcissism. But, you know, you're malignant narcissist. are very, very hard to reach. There's a reason Freud thought they were untreatable, and it wasn't until the 1980s that we had literature that allowed us to conceptualize ways that they might be helpful to move more toward the capacity

to have I-Vow relationships rather than show off or idealize or devalue relationships. Awesome. Thank you so much, Carly. I think Grant had his hand up a long time. Okay, we'll do Grant next. Hello, nice to meet you. Thank you so much for coming. I'm a large fan, so I'll probably just get that out of the way.

I don't know how to really word this question so that it's the most, maybe like socially appropriate, but hearing, I've never been analysis with you, obviously, or any of your, like, the leading minds of psychoanalysis. but there's something about the way that you speak and the way that you write that I find different from the other leading minds and a pleasant one I find. So I was more curious if that was something that you experience as well, maybe that you feel differently, some like theoretical differences that you feel. And what would those be?

I don't think it's theoretical differences. I think it's a combination of personality and feminism. I wanted to represent my own voice and not to try to sound like a mansplaining expert. But I think I'm just very lucky. I have absolutely no memories of ever having been shamed. I have some painful experiences in my history, but I was never shamed. I was always supported in my confidence.

So I always hated it when I felt people were using obfuscating jargon and not talking like real people. Interestingly, Freud was a very good writer and stylist, and he was very down to earth. That's one of the reasons that he became so popular in the Haiti of psychoanalysis was that he was very direct. And Theodore Reich, who influenced me a lot, also was, and very self-disclosing. And from the time I was adolescent, people used to say to me things like,

you're so sincere, sort of. So I think that comes from never having been shamed. I think I'm just incredibly lucky that way. It's very interesting to me with my diagnosis book, frequently people will tell me what I really like about the book is the stories, you know, when you give a vignette about something. And there's one story I really love in that book. It's always the same story, right? I bet some of you are associating to it right now. It's that I, in the flush of a rescue fantasy, I loaned my car to a psychotic patient, and he drove it into a treat. And I think people are so pleased to hear that I could be that stupid.

But I think that's what we need is mentors who talk about how hard the work is, what kind of mistakes they make, how easy it is to make those mistakes. So as a writer, I haven't been particularly self-protective to protect a certain image. And I think people are grateful for that. Yeah, I agree. There's something about the way that you model that brings down the authority that analysis has where you give this interpretation and you're this professional. But yet, at the same time, you're supposed to be creating a space where we're both human.

And sometimes I find that when I read, I feel like the, you know, the doctor, whoever's writing have kind of lost sight of that in a way. Yeah. And I find when I lose track of that and I'm fighting that because I'm new, I look back at your writings and I just, yeah. So that's why that's, that was the stem of my question. So thank you for answering and thank you for setting a good model. Thank you. Yeah, there's such inherent authenticity, which is.

you know, so true to your character, I think, you know, I think that that sounds like it comes quite naturally that authenticity in your writing, but the use of self-disclosure as well allows so many to just feel seen and takes away some of the shame. I think that, you know, or fear. Good. Because it's hard enough learning to be a therapist without alienating jargon. Yeah. Do you want to go next? Yeah, I actually had two questions, but I thought one may be a better segue from the last one. So I'll ask that one first and then maybe throw in the other one if you want to answer that one too. But the one thing I wanted to ask is like what skills as like a psychoanalyst or like a psychodynamic therapist do you think can be learned through training or just through your career?

And then like what skills do you think are kind of like inherent to who you are? So it becomes almost like you know, you kind of are born with like a superpower and, you know, because of that, that is what makes you. a good therapist or a good psychoanalyst. Well, I think an awful lot of what makes people a good therapist or a good analyst is just natural human qualities that haven't been snuffed out, like curiosity about other people, respect for other people. We haven't theorized respect a lot, but I think that's even more important than empathy, you know, for people to feel you're approaching them with the attitude that you're interested

in learning from them, you know. And many therapists have that naturally. If you don't have that naturally, you can learn a lot of things. But it's always going to be a little bit of, I don't know, a performance. Yeah. I've had a couple of supervisees over my time that they just don't have the intuition that I think most good therapists naturally have. So, you know, I will say something like, well, did you ask this guy about what is substance use is? Because he's mentioning all these addictive things in his family.

Oh, no, I probably should have done that, you know. Whereas it wouldn't be a matter of my going through a checklist of what I should ask. It would have been a matter of my just hearing intuitively that, you know, I should ask about this. Some people don't have that. Now, he's got, he's, the guy I'm particularly thinking about, he's done okay as a therapist. I don't think he's had quite as many successful experiences as some of us. But he's not doing harm to people. But I can't imagine his patients don't feel like there's something missing.

Yeah. Now, that's a great way because I think about it, even from like a clinical or like a medical standpoint of there's a difference between a doctor and a caregiver. Yeah. You know, and the doctor is like the technical, like I'm again going off a checklist of diagnoses and then the caregiver is actually bringing humanity back to the relationship. And so I think that's kind of a beautiful way to put it is just like, you know, understanding that there's a human at the end of it, not a diagnosis, not.

Yeah. You're treating your person with appendicitis. You're not treating an appendix. Exactly. You're treating a person with it. Some people have all the words and none of the music. You know, they just... Exactly.

No, that's great. Thank you. And I think I wanted to quickly circle back because we were talking about like stalking and harassing. And the question I had for that is, you know, are these patients, you know, coming in for like other reasons? And then, you know, through that, you know, those sessions that kind of like intense psychopathic transference happens where they exhibit then those stalking and harassing behaviors or are they actually coming in for that particular? They never come in saying, I worry that I'm a stalker. I've had a couple of people who were worried that they were a stalker, but they weren't stalkers. They were just obsessionally concerned that there was something wrong with them, and that that was what they grabbed.

No, they always come in for anxiety or depression. Wow, and then that is what would come out. Like, there would be like something that would happen from there? And then would you be able to, like, tie that through? Because, you know, when we talked about Shedler, he talked about patterns. And so would you be able to see in other instances, in their life, you know, as they're talking about it, where that behavior is common or coming up again and again. So it's not just... Well, that's one reason I think it's important to take a history.

You know, so what went wrong with each relationship that's been important to you? If they've been in therapy before, what ended the therapy? You know, because that's going to happen to you and whatever happened there. And you have to make it come out differently or figure out that maybe this person needs a higher level of care. I think we're seeing more in our outpatient clinics and private practices of this kind of behavior, partly because we don't hospitalize dangerous people anymore the way we used to be able to do. Gotcha. Thank you so much. Also a huge fan. Heidi, you had something. Hello. Hi. I'm newer in the field, but I wasn't trained very well in personalities. So your book on personality's diagnosis,

the one thing that was really helpful, and I just wanted to say thank you for this, was in working with a schizophrenic patient, you had talked about normalizing how scary their thoughts are. And I did that with my client and to see his, like, relief and the way he could move towards me and the way he opened up to share more with me, it was really valuable. So, so thank you. Oh, good. That population, the psychotic population, they have been so badly treated over the last 50 years. I mean, when we got the antipsychotic medications in the 50s and 60s, we were so impressed with how they could calm a person in a state of absolute terror and aggression and misery. they were so impressive that, you know, we started saying, you know, you're going to need to keep this medication going for life. And we started telling them that they had a condition

like diabetes where they just had to get on these medications. And we didn't, we stopped offering them therapy. And we started offering them groups to manage themselves that mainly were groups to keep them on their medications. And I'm not at all. anti-medication, especially for somebody with acute psychosis, but we've over-medicated them, and we haven't given them any therapy. And even if you're on antipsychotic medication, you have stuff you should be able to talk with somebody about. So we've made no progress with that group at all. And now they're learning that long-term excessive use of antipsychotics damages the brain as much as or more than untreated schizophrenia.

So we have to develop, we have to refine our effort to try to. These are people we all went to kindergarten with who lost their minds in a particular way. Freud says that the mind is like a crystal, you know, if it gets whacked, if it undergoes certain kinds of stress, it will fracture along the lines that are, you know, inherent to that crystal. And I think that's a beautiful metaphor with some of us under stress dissociate. Some of us become neurotic. Some of us become borderline. Some of us become psychotic. But we're all human and we all need relationship. So that that group is particularly underserved and mistreated, I think. They're told that they've, you know, they have schizophrenia as if it's an alien

condition that infected them, that they just have to medicate forever. as opposed to they've had a hard life and they lost their mind. Yeah, it really helped me dispel my misunderstanding of what schizophrenia was and how it had and look at where that came from, you know, to your point, it was the monsters that they had been created out to be years ago with institutionalization and so forth. So, yeah, thank you. Hello, I'm a huge fan too, but there has been a,

a search in the use of gender affirming care, and I wanted to hear your views on it. Well, I mean, I'm not even sure I like the term gender affirming care, because very often patients' problems are they don't know exactly what to affirm. They are very conflicted about who they are. Some people know that they're a man trapped in a woman's body or vice versa, and they've always felt that way. And they're very conflicted. pretty easy to help. They just need somebody who will witness their effort to put their physical body into parallel with who they know themselves to be. An awful lot of other people are harder to help because they worry that they're trans, they don't know if they're trans, maybe they're

gay, maybe they're trans. They need to have a place to talk about all that without a thing. having an agenda for them. And I worry about the immediate agenda that you should get surgery and hormones, as much as I worry about the agenda that you shouldn't. You should, you know, you should make your peace with the gender that you were assigned at birth. I think we have to open space for people. For so many years, we were pathologizing homosexuality, and it was just a matter of majority people thinking that anybody who was different from us

heterosexuals, must be pathological. And that was very, very damaging. And I think it's more complicated with trans people. For example, in dissociative identity disorders, sometimes people have, often they have alter personalities of another gender. And so they're trauma victims, and you need to figure out what each personality is doing in the system with them before you make any global decisions about who they should decide that they are in terms of their gender. So it's very complicated, but you have to give the patient space to tell you their story. I've known people whose lives got immensely better once they transitioned,

and I've known some that transitioned and were very disappointed about it because they believe that it would solve all their problems to make the transition, and they discover that life still hurts. So I just don't think we should get enthusiastic that we know more than a patient does about what they need. Great. Gotcha. Thank you. Okay. One of my questions for you is like with the transfer of idealization, when is it too and or when is it like a nice amount of idealization that's like kind of a non-threatening like okay I'm going to let this just I'm not going to analyze this verse when is it like too much

where it's like you have to kind of address it and then how do you address that? Again this really depends on the patient and the combination of the patient and the therapist But there was a big conflict about this in the 80s, in the general discussion about how you treat narcissistic patients. When they idealize you, there were really two different viewpoints. Heinz Kohut said idealization is a normal part of development. If the patient's idealizing you, you just accept it. They slowly have to go through a developmental process that they weren't able to go through. They either had a parent who wasn't good enough to idealize in the first place the way children need to idealize their parent at around age three or so where they think you hung the moon.

Or they had a parent who was very defensive about being de-idealized when the kid got to an age where they realized that their kindergarten teacher knew more about asteroid. than their mother and starts, you know, putting you in perspective. If they were able to go through that, they're not going to turn out narcissistic. If they got stuck, they need to go through idealization and then de-idealization with you. And you don't have to interpret it. It just happens during the therapy. That was COVID's position. Kernberg's position was not that idealization is, you know, I mean, I think he would say

some kinds of idealization are normal and people go through that, but he felt if you were diagnosable as a narcissistic personality, you'd gotten off track. And you were using idealization to defend against, let's say, envy.

And so he would interpret that. He would say something like, I think you want to believe that everything I do is right. Because if you saw me as sort of struggling to understand you, you would be terribly disappointed in me. Or if you feel like I'm idealizable, then you're struggling with envy toward me.

Do you notice that every time I talk, you interrupt me or you tell me you already knew that? I think that's, you know. Interestingly, Kernberg worked with more of the devalue. narcissists and cohort more with the idealizing narcissists because they were in different settings. But I've had patients that make cohort look good and patients that make Kernberg look good. There are some patients that you can't analyze their idealization as a defense. You simply have to put up with it.

A pretty common evolution in therapy in my experience is that people start, start out with a very benign idealization. It's not bothering you that they idealize you. It seems to be actually helping the treatment that there's a kind of

a natural wish to do well for you. But there comes a point where suddenly it bothers you. And you can tell that the person doesn't want to feel certain other things and they're using it

as a defense. So it started out as a normal developmental thing, but now it's a defensive thing that doesn't feel good. And when that happens, I think it's always valuable to talk to a colleague about it, but I think you should trust your countertransference. It's telling you something. Maybe the person has moved on, has grown, and now is capable of not idealizing you, but they're hanging on to it because that they're used to it. So I don't think you can generalize about which way to go. Some people are too fragile to do anything other than be who they want to think you are. And other people, you do them a big disservice if you let them leave therapy thinking that, you know,

you're so brilliant. Because when somebody's idealizing you, inevitably then they're seeing themselves as, less than. You want them to end therapy, not thinking that they had the best therapist in the world, but that, you know, their therapist was good enough and a good process ensued, and the therapist didn't make too many mistakes, and they're moving on. Yeah, that's good. That's helpful. I didn't have a lot of idealizing patients when I started my practice. I had a lot more devaluing patients. You know, you look pretty young to be a therapist or, you know, where did you get your training? Or did you read that on page 52 of your manual? I mean, I get a lot of that kind of

low-grade devaluation. And I had to learn to, for patients who needed to do that and it wasn't analyzable yet, I had to learn to roll with it and say things like, yeah, I guess I guess I just I'm not a good enough therapist. You know, you are a genius at finding everything that I do wrong. It's really impressive. And modeling that, I'm not threatened by the fact that they're de-idealizing me or devaluing me. It detoxifies it some to be able to roll with it that way. Okay.

We have a question on frequency of events. visits. I think that Shedler kind of has a stance of like it has to be too, to get the, but I'm like, I'm a little bit more loose. Like, I see a lot of weekly patients. I have one twice a week patient. What's your take on this and has it changed over time, like frequency of visits? I used to do a lot of three or four times a week psychoanalysis, but that was back when insurance companies happily covered that. That's hard. for patients to do now. And so I think we've all adapted in the field.

And it's really different from one patient to another. Some people do quite deep work at once a week, and some people, you can see them four times a week, and they never get to the stuff that you think they need to deal with. So I don't think there are rules about that. We've wasted an awful lot of ink with the frequency wars in psychoanalysis. What is real psychoanalysis? Is it three times a week or four times a week? What's the minimum number of times you have to see to make a difference? I think it's fairly

common for people to say as a general rule, and perhaps this is what Jonathan actually said. As a general rule, it works better to see people twice a week because when you're seeing them twice a week, they're not spending half the session giving you the week in review before they get into their stuff. If you hurt their feelings on Tuesday, you know that on Thursday you can try to repair that. You don't have to worry that for a whole week they're dealing with you're having made a mistake or they're having brought something up at the last minute that you didn't handle well. So I prefer to see people twice a week, but I've had some patients that did well on once a week. I love seeing people three and four times a week. It really deep.

in the treatment. And I learned a lot about the depths of certain kinds of psychologies that way. You want to do one more? What do you think? Sure. Serena, go ahead. Bouncing off that topic, I was wondering if there are any ways you changed how you worked with patients to work better with the once-a-week structure that insurance companies are so hyped about. Probably. I don't know how much of it is the difference in frequency and how much of it is just relaxing into the role. I have a colleague who says we all start out as principalists. We're trying to put into practice certain principles and we're following certain rules that we've been taught as how you're supposed to be as a therapist. And as we mature, we become consequentialists. In other words, we judge what we do by. what we expect the consequences to be.

So we don't tend to have rules about you always self-disclose here, you never self-disclosed there, you kind of feel, if I were just disclosed such and such here, what would be the consequence? And so you make your decisions in a looser way based on accumulated experience with what you can expect the consequences to be. So I don't know how much of it is that I just have looked. loosened up. Also, when you get as old as I am, you tend to feel like, listen, life is short and you've got to get going. I think I move in on stuff a little faster than I once did.

So I don't know how to separate those things out, but I do think I'm more interactive at once a week, a little more self-disclosing, a little more likely, and I've been influenced by the relational movement to say more about, you know, what's going on between you and me, not how are you feeling about me? But do you think you and I are involved in something, in the reenactment of what you've been describing in this time? Because here, you're saying this, I'm doing that. It sure looks like, you know, the past has come into the present here. And so I own more of my own accountability for what's going on than I once did. Because at once a week, you can't be quite as anonymous because you don't know what they're doing with what you've let sit out there without engaging with it as much.

It's hard to describe, but I think I'm more active, more self-disclosing. Like, I'm finding myself anxious here. You know, you're telling me this without any anxiety. and I'm feeling anxious. What do you think is going on? It feels like I'm carrying your anxiety. I wasn't trained to do that, but that's often a less toxic way

from the patient's perspective of saying, you're defended against feeling your own anxiety. That would be a one-person way of saying it, a two-person way of saying it is, I'm feeling something that I don't think you're letting yourself feel. All right. One last question.

Amanda, you're up. Okay. I wrote mine in the chat. I wanted to know what general advice you have for working with child and adolescent patient. So, like, specifically like countertransference, transference, and even self-disclosure, like building trust with adolescents. And I found that I've been a lot more loose, but trying to keep that balance by, like, you know, being authentic, but also keeping within the frame. Yeah, I think I haven't worked with adolescence or children for a while. I did it early in my career for maybe 20 years.

Then I was, I had my own children and I was sitting on the floor playing with Sanker's toys enough. And also, it's harder work working with kids. kids and adolescents. My colleague Beverly Stout in Atlanta does as a whole practice of working with adolescents and kids. And she's a person of an incredible energy, more than me. But when you're working with kids and adolescents, you're inevitably working to some degree with the parents. Because whatever the role of the child is in the family system, as they start getting better with you and changing, the family system tends to, you know, fight back. They're used to them being the identified patient. And if you don't help the parents and the family to adapt to the change in the

patient, I've seen very often the patient gets yanked out of treatment. So it's twice the work, really. But you have to, they, the parents have to feel like you're not, blaming them, that you appreciate their genuine concern for their child, that you respect them, and they are going to be highly alert to any talking down that you might do to them. So being very conversational and flexible with them is important while keeping the regular boundaries about time, fee, email, all the other things that we set boundaries about. Thank you. You're welcome.

Thank you, Amanda. Okay. Well, thank you, Nancy, for your coming on and your time, and we really appreciate you. Really good. Yeah, this is really fun, and thank you for these thoughtful questions. Yeah.

Thank you so much. Thank you so much. My pleasure. I have to say, so we all have our own little cohorts, and my cohort was very, very excited about having you on. I don't think I could even put it into words. So we're very grateful for you showing up today.

Well, thanks. It's not too hard to do. I really like talking to other therapists. It's an isolating profession. Absolutely. We need each other. This is wonderful. Thank you so much for your time.

And yeah, we'll leave it there for today, guys.