Psychiatry & Psychotherapy Podcast - Obsessive-compulsive Personality and the Personality Continuum with Dr. Shedler

Episode Date: January 23, 2023

For over a century, psychoanalytic psychology has recognized certain types of personality configurations that we see repeatedly. A clinician who understands these familiar patterns has a map of the patient's interior terrain to help navigate treatment. In today's episode of the podcast, we are joined by Dr. Jonathan Shedler to discuss obsessive-compulsive personality and the continuum on which personalities operate. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined once again with Jonathan Shedler. He was on a previous podcast, and it is a joy to have him back. And I was reading one of his book chapters called The Personality Syndromes. It is in a primer on personality disorders. Feinstein, who has been on previous podcast, organized it, wrote some chapters as well. And in this chapter, he talks about different personality types and bases it off of his own research and its clinical practice and years of reading and supervision and probably individual therapy. So you get true expertise when you combine all of those things together. So I want to jump right in and talk about obsessive, compulsive personality disorder, you know,

OCPD, but in this case, you're just calling it obsessive, compulsive personality, which is... Well, and there's a reason for that. Okay. If you want to start there. Yeah, let's go. So there's a whole tradition that originates in psychoanalytic psychology and, you know, really goes back more than a century. And the tradition is recognizing that there's certain kinds of personality patterns or

configurations that we see over and over again. And a clinician, a psychotherapist who understands these sort of familiar, recognizable patterns, you know, really has a kind of a map of the patient's interior terrain and the terrain that they're going to navigate in treatment. And the reason my chapter says, for example, obsessive-compulsive personality, or narcissistic personality and not personality disorder, is because in the clinical tradition from which these understanding of these personality patterns arose, these were not inherently pathological, not disorders.

We're talking about people's personality, meaning not what disorder do you have, but rather, who are you? as a person. So really the starting point for a discussion is recognizing every human being in the world has a personality and a personality style. And how can a personality be a disorder? So the idea is, well, there's no clear dividing line

between what we call a personality style and what somebody looking at it through a clinical lens would call up a disorder. The word disorder is really just a kind of a linguistic convenience, a shorthand for clinicians. And when they say personality disorder, you know, what it really means is there's something about this personality, a person's personality style that's so rigid, so extreme, you know, so limiting causes dysfunction or suffering, you know, that is a kind of convenience. We use the term disorder, but we're really superimposing, you know, a medical term disorder on something, you know, on something that every human has and that really falls

along a continuum or a spectrum. So people have narcissistic personality styles or obsessive-compulsive personality styles that are not disorders. And I'm talking a lot, but this is a really important point to make. You know, DSM kind of fucked things up in terms of, in terms of, the clinician's understanding and the public's understanding of personality, because what they did is they took, in order to shoehorn these personality styles into a manual of quote-unquote disorders. What they did is take personality styles that were familiar in the clinical literature,

you know, describe them in their most extreme and pathological form, in some cases to the point of caricature. you know, and appended the word disorder to them. And the reason I say it fucked things up is as a result of DSM, they've completely disconnected, you know, the concept of personality from the clinical understanding that it originated in. It artificially turned everything into a disorder. And now what has happened as a result is we have clinicians, you know, psychiatrists, psychologists, other kinds of, other kinds of, you know, mental health professionals. who think that personality can just be ignored entirely unless the person, you know, has a diagnosable

DSM personality disorder. So the effect of, you know, sort of ratcheting up the severity of all of the personality styles and labeling the disorders. I mean, the effect is they've just dropped off of their personality itself has dropped off of the radar screen for a lot of clinicians. and also any mention of personality at all is automatically assumed to be something pathological. And that's really being a devolution rather than an evolution of understanding of personality in the field. So that's kind of my preamble. Yeah, it kind of creates some rigidity around the, and rather than seeing the spectrum, and you have to, you know, you could have someone with different defenses that maybe it's not

hurting their life, you know. But see, everybody has defenses. There's no such thing as a human functioning in the world without defenses. It's not a question of, do you have defenses? It's a question of, you know, which defenses and how flexible and adaptable they can be, you know, versus how extreme and how rigid they can be. So we're always talking about matters of degree and we're talking about continuous. not categories.

So it's very different for, you know, especially for people, you know, listeners who might have been, you know, who might have been trained on the DSM. It's really a very different way of thinking about people. We're talking about, you know, types of people, not categories of disorders. Yeah. Yeah, that's helpful. And I think the other thing that the DSM that you noted was it took away the

underlying causes and the treatments, really, and just kind of gave, like, here's some symptoms that... Yeah, well, it turned it into something that's clinically useless. You know, if somebody, nowadays, if somebody diagnoses a personality disorder, you know, all it, you know, really means is this person has significant limitations and they probably pissed off the clinician. Otherwise, the clinician doesn't diagnose a personality disorder. It tells you nothing relevant to treatment.

And one of the reasons for that is what you said. So personality is not about just signs and symptoms and external behavior. Personality is about underlying psychological themes. It's about how we look at the world ourselves, how we attach to other people or fail to attach to other people, our habitual and characteristic ways of coping, our motivation, our unconscious themes and preoccupations. All of this is about internal experience, not just observable behavior. And what DSM did is, you know, they tried to focus exclusively on observable behavior and, you know, signs and symptoms. And left out all of the things that have to do with, you know, internal experience and internal psychological processes that actually, you know, that actually, you know, that actually.

are at the core of the personality styles. They basically hollowed them out. And then, of course, if you take that out, there's no information that's left that's relevant to, that's relevant to treatment. So, you know, knowing somebody has, say, I don't know, a DSM diagnosis of a dependent personality disorder, say, or avoidant personality disorder,

what does that mean for how you're going to treat the person differently. What does it mean for what you might do in psychotherapy? And you're shaking your head, correct? Because it doesn't mean anything at all. So we've just got these labels that we attach to people, but the labels don't give the clinician any guidance about how to work with the person in a way that can help them, which is ultimately the function of diagnosis. If the diagnosis doesn't help, then it's useless. Yeah. Yeah. I... I think then it becomes like, well, okay, so how do we come back to what is important with making a clear kind of diagnosis and then maybe giving some examples of how as a clinician you might use that constructively. So let's jump into obsessive-compulsive personality because I'm like really interested in this.

So you talk about how it's conscientious, meticulous, regimented, cerebral individuals. Those are the outward signs. Those are the externals. Those are the externals. Not in touch with their feelings, only thinking, living machines. Yeah, the real tell is if you ask a person with an obsessive compulsive personality style, whether it's dysfunctional and in the range that somebody might call a disorder, or whether it's the functional and healthy version of it, if you ask somebody with this,

personality style, what do they feel? They'll tell you what they think. So it's the use of the use of thinking and reason and logic as a defense against emotional life. But isn't reason like the thing that should be in control of the other things according to Plato, right? In control of the no, because absolutely, absolutely not. Because because, Because a person with, you know, all reason, all head and no heart is a very incomplete, limited human being. You know, we, you know, the goal of mature functioning and the goal of meaningful psychotherapy is kind of an integration of head and heart, of, you know, mind, you know, mind, emotion,

body. It's about, it's about, you know, sort of finding harmony and becoming more whole. And, you know, the thing is, you can't selectively put the lid on certain emotions and not others. You know, so, for example, I've been treating a patient for a while who is very, very successful, extraordinarily successful. And he's one of his central organizing principles. is he's really very defended against and afraid of his own anger. And so he's tried to construct his life in a way where he can squelch, not only expression of anger, but awareness of anger. The problem is you can't selectively squelch one thing.

What happens is all feeling gets squelched. So along with the unwanted and frightening, his capacity for anger and rage and aggression, you know, along with that, squelching that, is his capacity for joy and spontaneity and exuberance and excitement and, you know, desire, you know, emotional connection to other people that all get squelched. So, no, this is a platonic ideal of, you know, reason is the master, reason is control of everything. that is not written for humans. That's written for some other species.

Okay, so here's a quote. Under the conscious surface, the person with obsessive-compulsive personality is waging epic emotional battles. So are you talking about how there's a lot of defenses that keep these emotions underneath the surface, right? And it's like there's,

but underneath the surface, there's a lot going on. Yeah, so every one of the personality styles, despite what it says in DSM, every one of the personality styles is really defined by certain predominant unconscious themes and preoccupations. And this is true for every human being. It's not a matter of healthy versus pathological or this only applies to patients. This applies to everyone. So when we talk about an obsessive compulsive style, preoccupation, the unconscious preoccupation is around control,

is around controlling or being controlled. And the person is caught in a dilemma. There's an internal conflict. And the conflict is that exceeding to somebody else's control, to following the rules, you know, following the rules, you know. Obedience, obeying. Obedience to, thank you.

Deference for authority. Authority. Yeah. All of those things feel like shameful, humiliating submissions that leave the person ashamed, unconsciously. Unconsciously. Enraged. Humiliated.

It's intolerable. Those feelings are intolerable. The other side of the conflict, right? So one side of the conflict is about submission and how that's intolerable. The other side of the conflict is about taking control and being defiant. And that's experienced unconsciously as an act of destructive aggression that's going to be met with punishment or retaliation. So you think of a conflict, you know, two sides of it. The person is emotionally between a rock and the hard place.

On the one hand is submission to rules and authority, which leads to shame and humiliation and rage. On the other side is defiance, which leads to terrifying fears of punishment and retribution. Both of those options are equally frightening and unacceptable. And then the entire personality gets constructed around how do I, you know, how do I squelch all of the emotions on both sides of the conflict? And then that's where the more observable, you know, features of obsessive, compulsive personality come into play. You know, well, one way you do that is you live in the realm of thoughts and ideas and reason and not in the realm of feeling, right? So that's why when you ask someone

with obsessive compulsive personality, you know, what do you feel about something? And they tell you what they think, that's a defense operating. It's a moving away from emotional life. Yeah. And I think there's a lack of playfulness that ensues because it's hard to be not in touch with your emotional world and playful at the same time. It's like, can you be purely intellectual and playful? You can't be, right? Because playful is drawing on other parts of the personality and those other parts of the personality are being squelched. Now let me say, this way of adapting and defending, this way of being in the world, you know, also, you know, it also has some benefits. Every one of these personality styles, you know, you can think of, you know,

is every one of these personality styles is really two sides of a coin, right, where there's some significant cost and some significant benefits. Somebody with an obsessive higher functioning version of an obsessive compulsive personality is going to excel in fields and areas of life, you know, where reasoning and careful thought and precision is prized. Well, they might be a medical researcher. They might be an engineer. They might be somebody who can... An accountant, a medical biller, a You know? Well, all of the above. Philosopher.

A philosopher. The kind of philosopher who would subordinate emotional life to logic and reason. They might even become a therapist, the kind of therapist who would subordinate emotional life to have logic and reason and builds an entire theory of psychotherapy purely around cognitions, which is basically to say conscious thoughts. There's a denial of, you know, the sort of richness and complexity and layers of emotional life. We can deal only in the realm of consciousness.

But, you know, somebody who's building a bridge or coding software is maybe very much in their element. It has costs in other areas of their life. So it's not that this is one more reason why I really want to strip the word disorder from all of these personality styles because every one of these has costs and benefits, a bright side and a dark side.

Yeah. Yeah, I appreciate that. So, and I think it is a superpower to a lot of people to have that meticulousness and that intellectualization or the rationalization in many domains of their life, but often in their personal life with their life, their kids. A lot of academics have obsessive, compulsive personality style. hopefully the higher functioning versions of obsessive-compulsive personality styles,

and they excel in certain areas, which lost, as you said, joy, spontaneity, creativity, play, emotional intimacy, those are the costs. What I found from working with a couple people over time is they say they can feel the yearning to intellectualize and rationalize, but they can start to notice the emotion underneath, and they can choose not. to. Yeah. And so it's like they have some flexibility there. And that's really the goal of treatment. You know, we don't, you know, even in the best psychotherapy, we don't turn people into somebody else other than who they are. What we do is try to help them become the most, you know, try to help them become a better version of themselves, a more mature, flexible version of themselves. So it's really nice to have the capacity.

Can I, you know, I mean, if I were on, if I were, you know, a patient on a surgery table, you know, I don't want my surgeon acting out of, you know, out of emotions in the heat of the moment. I want him to be thinking, you know, clearly, rationally, logically, you know, systematically. So, but the flexible version of that is that that may be your kind of, you know, that may be where you default to. It's nice to have that as a capacity, something within your repertoire of what you can do. It's not nice for the person to not have a choice about it, where that way of being is obligatory and driven, and there's no options. So the goal at work in therapy is to kind of loosen up defenses and create more freedom for the person. Okay, so let's say you're someone who's a professional, and you're like, oh, my gosh, you're speaking exactly to me. What I need to do is I need to read more about this so that I can master it and I can totally understand the ideas around it.

And that will be my cure. Well, that would be very appealing to somebody with an obsessive, compulsive personality. And it would absolutely miss the point. And when you think about it, you know, I said the core conflict or the core preoccupation underlying this is about control. You know, well, if you are reading it, oh, you're processing it on your own terms. You know, you're in control. You're taking it out of a relational context. It's not in therapy anymore.

Now it's between you and yourself. There's really not much role for another person, certainly a psychotherapist. You know, it's basically saying, I've got this. I'm going to do it in a way that doesn't allow for. anything to emerge that might be spontaneous and unplanned. So we'd go about it in this very, you know, planful, systematic way that, you know, coincidentally eliminates the possibility for something unknown, unforeseen, which is what play is about, right?

Emerging, you know, in a freer and more creative way. One of the other thing that happens in therapy with people with obsessive compulsive personality disorder, you'll make an observation or point something out as the therapist. You know, perhaps, you know, perhaps you respond this way or feel this way because, right, that's the kind of observation I'm talking about, right, with the intent of illuminating something or, you know, or bringing about some insight about something. And a person with an obsessive, compulsive personality style will very commonly say, you know, oh, that makes sense. And the clinician thinks they're on the same page. Oh, it makes sense. They took it in.

They're not on the same page at all. And, you know, so one way I respond to the patient who says, you know, that makes sense. You know, are you saying that it just makes sense intellectually? Like, you know, you get it, you understand how that, you know, how that would work. Versus is that something you feel and recognize in yourself that you feel to be true? Right. Because those are different things. It makes sense versus.

I see and feel this in myself, in a way that's real, are really quite two different things. And it makes sense is really a defense against engaging with it. And the person, you know, somebody with, you know, a real obsessive-compulsive personality, it's not that they're dismissing and saying, no, this doesn't apply to me, nor are they saying it does apply to me,

you know, they're sort of operating, you know, intellectually in the clouds. It's like it's not even a question. It's not even an issue for them. Does it or does it or does it not fit how they experience things? So when we say, you know, that makes sense. When we say it makes sense intellectually or you feel it in yourself, what we're actually doing is calling attention to the discrepancy between thinking about something in a, you know, sort of abstractly intellectual way.

way versus thinking about something in a more intimately personal way. Yeah. It's like moving back into the body. I think this is where like some of the somatic schools of psychotherapy, what they taught me is to sort of retune to like bodily sensations, which is actually really helpful. Yeah, I'm actually not, I agree, but I'm not going there yet. Okay.

But there's first there's the question of, why do we need to tune to bodily sensations? If we did that with somebody with his personality style, we're skipping over something. And the something we'd be skipping over is the recognition that something is disconnected there, that something is missing. So the person says, well, I don't know if it applies to me or not.

That's the first important insight. So you're accustomed to thinking about things, you know, in a way where you're missing the internal cues. Okay. That tell you whether something is right or wrong for you. It tell you how it feels for you. It tells you whether it's what you want or don't want. First comes the recognition the person is missing internal cues.

Then maybe they get curious about, well, what do you mean? What kind of internal cues? Then it makes sense to say, well, you know, Let's notice what's going on, you know, let's notice what's going on physically. You know, let's notice, let's start with noticing what's going on in your body. Because typically that gets shut out along with emotional life. Yeah. But we don't want to, the goal isn't to try to, you know, if the patient is building a wall,

in this case, a wall between them and emotional life, the goal isn't to get around the wall or over the wall or through the wall. The goal is to call attention to the fact that there's a wall being built in the first place and to get very curious about why this particular wall, why in this particular spot, not somewhere else, how is it being constructed, why is it being constructed, what purpose does it serve? So before we get in the business of what's behind the wall, let's really understand and feel the presence of the wall.

Okay, so one thing that I often will say, and it's always helpful to kind of start off with what I imagine might be the most helpful thing, and then to get a different opinion, is I'll say something like, it makes sense that you, you know, it's adaptive. It's been adaptive throughout your life to, you know, intellectualize or put this more into thoughts than feelings.

You know, from what you've told me, feelings have been not allowed. You weren't allowed to be angry when you were young. And so you had to, to survive, put this into more of, to thoughts and push your feelings away. So I may say something like that, you know, and it's like maybe kind of empathizing with the defense and show the adaptive nature of the defense. I would say that's not exactly empathizing with the defense because you're describing the defense in a very abstract form. Whereas, in fact, what's going on in the session is something very immediate and personal in the here and now between you. So, you know, emotions have been difficult and this is, you know, and, you know, pushing them aside and working in the realm of thought is how you adapted. That may be true.

I mean, it is true, but it's also a bit experienced distant. So, you know, let's make it concrete. you, for whatever reason, you're a few minutes late for your session. The patient is waiting for you. And, you know, you come in and, you know, say, perhaps you had some feelings about being left waiting. And the patient might say, no, no, I understand, you know, you have a life and, you know, perhaps your other session ran late or something came up.

I mean, the patient is very logically understanding about it. and making it more immediate would be saying something like, you know, all of that is true. You know, those are one set of thoughts that you have about it, you know, but I noticed that it doesn't really leave room for any other thoughts and feelings that came up. Well, there were no other thoughts and feelings. Right, right, right. Like it makes perfect sense. You know, you would start working with that. rather than looking for more sort of abstract explanations.

Okay. You know, maybe you get to say at some point, you know, it must not have felt very good. Yeah. They were waiting for me, not knowing where I was. And the patient says, well, yes, but, you know, I understand. But you're really busy. You're very important.

Exactly. The patient says all of that. And I might say, but the but in that, you know, everything you said is true. It's not right or wrong. You're entirely correct. Yeah. The but in that sense.

Okay. You know, yeah, it didn't feel good, but the butt shuts the door. Okay, well, let's bring this more, let's bring it more into the here and now of our, of our time together. You were a couple minutes late. I was. I don't, I, I don't have any conscious representation of frustration towards that. now there may be some there but I'm just, I have no access to that, you know?

And I've... Well, I don't know that it's there either. I mean, it was a hypothetical, you know, example. But you would be... I guess I'm just curious, like, would you... Like, if I were to say to you that, like, well, I don't really know if I felt anything negative about you being late,

I have no access to it. Would you wait for it to slip out like a slip, like a butt? Well, the butt is already, I mean, the butt is already information, you know. Right. Yeah, you know, I had other thoughts, but, and, you know, and I would make that transparent. I would just, you know, I would say pretty explicitly, you know, when you say the but, you know, we get to hear the other thoughts, you know, the butt is, the, the butt in that

sentence is shutting the door. I'm hearing about, you know, hearing about the thoughts, right? The sentence was going somewhere, you know, yeah, I had other thoughts about it. But, and the but is a change of topic. We don't get to hear the original thoughts. And then the person might want to tell you the original thoughts. And I don't want to go there just yet. I don't say, there must be a reason. What if they felt shame in sharing those other thoughts with you, the other emotions they may feel? Yeah, and that's what we'd like to come out and be able to explore and talk about in words, because if the person can say, if the person can say, you know, I was angry or I was resentful or I was planning a revenge fantasy, which actually wouldn't be uncommon for someone of the obsessive,

compulsive personality. They live in this world of, you know, of being, you know, perpetually between a rock and a hard place, of being controlled by somebody else in a shameful way, or, you know, wanting to be angry and controlling of the other person, you know, in a way that has its own problem. So, you know, the person might have a little fleeting, you know, passing fantasy of turning the tables or, you know, settling the, score. So we want the person, there's a world of difference between saying, you know, well, you know, I was pissed off and I imagined blah, blah, blah, but it's really uncomfortable to talk about. It's shameful to talk about. There's a difference between saying that something is shameful

versus not having it in words, not having it in thoughts, and being controlled by that. Okay. Okay. So I think this kind of is a nice bridge into, One thing that I've noticed with a lot of local therapists is when I talk about things like transference, it's like they don't even have a vocabulary for it. Or they've heard about it like in some class, but they don't ever work in the transference. That's for sure. Or the interpersonal. Like the interpersonal maybe a little bit, but like the work that I have been enjoying works a lot in the interpersonal. It's like maybe it's half of the session or more.

It's like that what is going on between us? like that what you're talking about right now of like little things like the little fantasies that come up or the or the um the moments of shame that may come up you know it's like why do you think that working in the interpersonal is so helpful for personality stuff yeah well i would say it's so helpful for psychological difficulties in general not just for everything is you know this is this is when i was talking before about you know how you know how DSM, you know, created some real problems and a devolution and understanding. Everything that we're dealing with in psychotherapy is in the context of the person's personality.

You can't separate out, you know, their obsessive-compulsive symptoms or their depression or their anxiety or their avoidance and their personality. It's all, you know, I mean, our symptoms and our difficulties are woven into the fabric of who we are as people. If we're working effectively, we're always working with personalities. When I say it's woven into the fabric of who someone is as a person and woven into the fabric of their lives, that's another way of same personality. Okay, so just with the clarification that when we're working with something psychological, that's enduring, that's recurring, that's repetitive, that's been enough of an issue, that it comes into psychotherapy, we are in the realm of personality,

not necessarily personality disorder, but the realm of personality. So with that said, our lives and our minds are organized around certain recurring patterns or themes that we tend to live out over and over again. We form certain relational patterns or templates for what happens in our relationships. we form them through our earliest attachments or attachment relationships. And in one way or another, for better or worse, we relive those patterns. Unless something intervenes to change it, we relive those patterns for the rest of our lives. It's not good or bad.

It's just the way it is. And, you know, if the patterns allow for connection, intimacy, productivity, spontaneity, joy, meaning, well, all is well. If the patterns get in the way of those things or cause limitations, you know, then all is not well. So the key to understanding transference is, you know, we're really, we're forged in the context of our early attachments. We see the world and we see our other relationships with other people through the lenses created by those early attachments. That's the human condition. here's where it comes into therapy. So we replay these relationship patterns.

Psychotherapy is also a relationship. There are two human beings in the room or having a relationship. And the patient will bring their lenses or their patterns into the therapy relationship. It's not a matter of choice. It's not you plan to or you intend to or you don't. It just is. You will, in one way or another, start to recreate your relational patterns. in the therapy relationship, because there's really no choice to do anything other than that.

Right. Yeah. And that's what we call transference. The therapist is a new person. They're not, you know, they're not a continuation of some past relationship. They're a new person that the patient doesn't necessarily know a lot about. And yet the patient attributes all kinds of, you know, motives, intentions, thoughts. feelings to the person, which reflect the lenses that they bring with them, certainly as much as the reality of who the therapist is. So we count on the patient to bring these patterns into the therapy relationship. That's what we call transference. We want them in the therapy

relationship because that's where it becomes possible to, first, to recognize them, not in a intellectualized kind of way. I mean, in a lived way, you know, to recognize them by living them with the patient. That's where it becomes possible to recognize them, understand them. And if the work of the therapy is going well, you know, to hopefully find ways to be able to rework them. So the patient isn't, you know, sort of trapped, you know, isn't doomed to keep repeating the same, you know, the same self-limiting or painful patterns, you know, for the rest of their lives. It's in therapy where this can change. And it's infinitely more powerful than somebody

telling you about things that are going wrong elsewhere in their lives, you know, something talking about there and then. Now we're talking about here and now. Yeah. the what's going on between us. Yeah. Yeah. It's, I, and I think like, I think part of why I want to bring you on is to hopefully convert some therapists or psychiatrists who are on the cusps or kind of thinking, like, how do I want to practice psychotherapy? To kind of rethink, think, hopefully not just think, right?

hopefully like feel and and participate in your co-participate with a person that you're with. Let me broaden that. Okay. Even if it's, right, because a lot of psychiatrists now don't practice psychotherapy at all. I mean, you know, they do medication management practices. You think transference and countertransference aren't in the room at every moment when you're, if you're practicing psychopharmacology, do you think the meaning of a pill to a patient is just a pill? It's not. It's not, right? The pill becomes, you know, the pill takes on the meanings that the patient is experiencing in the relationship. So that, you know, a doctor prescribes the very same pill, you know, to two different patients. For one patient, you know, the pill is like, represents the doctor's, you know, care, you know, concern, goodness. It's like a piece of the doctor's care. And so like a piece of the doctor's care.

and goodness to take in and make part of oneself. Another patient may be someone with a more hostile or paranoid orientation, suspicious orientation, you know, sees it as, you know, an effort by a, you know, persecutory or malevolent doctor to, you know, to control them from the inside, right? Right. So for one patient, it's help. For another patient, it's a means of, you know, coercive control,

but it's exactly the same medication in both cases. And I would say that somebody who's, you know, just, with a purely psychopharm practice, somebody who doesn't recognize this is going to be a lot less effective, even as a psychopharmacologist, than somebody who does understand it. I still teach the residents at Lomboleine University, like two to three hours a week,

and I teach mostly psychotherapy. And one thing I tell them is that you are practicing psychotherapy if you like it or not. It's either good psychotherapy or it's not so good. And there's this one study, I don't know if you've seen this, but it's like the best study to look at psychiatrist effect. So they're looking at the effectiveness of amypramine versus placebo. And for those of you are on YouTube, you can see this little graph here. But psychiatrist one here, his placebo is better than psychiatrist eight and nine's amypramine.

And so, you know, what they found was that there was a huge variability within, the psychiatrist. So there's actually something called a psychiatrist effect, and the psychiatrist effect was actually stronger than the difference between the placebo and amypremine. And this is an old find, this is a newer paper. I'm actually not familiar with this particular paper, but I know of two other papers that basically report the same finding,

and that the most effective psychiatrists are more effective with the placebo than the least effective psychiatrists are with the active medication. And I mean, you could argue, like, and I would believe, like, it would be different for schizophrenia and bipolar, like, I really do. Or maybe ADHD or OCD. This is depression. So I think there could be a little bit of a difference, and they could argue that. Or, like, other people will say, like, well, amipramids an old man. But I think the big takeaway is that psychotherapy is happening. And some of these therapists, psychiatrists, were more effective with their placidates. then other one's active medication. So irrespective, like, how the patient feels about you gets internalized into how they take that pill. Of course it does.

And how the patient feels about you gets packaged and internalized with absolutely any, quote, unquote, intervention that you make, right, which is, you know, which is the fallacy at the heart of manualized, manualized therapies, you know, so-called evidence-based. therapies, but the defining characteristic of evidence-based therapies is they're manualized. They're conducted according to an instruction manual, which lists specific techniques, specific interventions that the therapist is going to use. And the fallacy at the heart of all of this is there is no such thing as a therapy intervention or a pharmacological intervention psychiatry, where the meaning of the intervention from the patient to the patient can somehow

be separated from their feelings about the therapist or the doctor and about the relationship. It's always, right, so the same intervention for two different patients or delivered by two different therapists, the same patient, it's not the same intervention. And that's the fallacy at the core of so-called evidence-based therapy. You cannot isolate the effects of interventions from the relational context in which they're offered. Right, right, which is why, you know, you could have better outcomes with one therapist compared to another therapist that are practicing the same modality. You know, and that's why I think the interpersonal. It's never the same modality, this idea that there's such a thing as CB.

or psychodynamic therapy or IPT, interpersonal therapy. The idea that there's such a thing as a therapy model that you can isolate from who the patient is, who the therapist is, and the relational context, the rhythms and patterns and meanings of their interactions. The idea that you can do that just doesn't fit. Okay, I want to jump back to transference and countertransference,

specifically for like someone with more of the OCP. I'm not, I'm leaving out the D. Obsessive compulsive personality, right? More of the obsessive-compulsive personality. Like what are the common transferences that a therapist will have? Let's start there. You know, it depends because the core conflict underlying the personality style is what it is, but the way it manifests in the treatment can be quite different.

I mean, you know, there's this kind of a naive idea that there's somehow a simple one-to-one correspondence, you know, this underlying conflict leads to this, you know, specific pattern of behavior. Well, you know, not so. So somebody with an underlying conflict around, you know, control versus being controlled might be very submissive in the therapy. You know, very cooperative, a very quote-unquote good patient, you know, very deferential to the therapist authority, although their anger and aggression. and resentment about it will leak out indirectly, or they might be quite openly, you know, oppositional, you know, and argue with the therapist and debate the therapist. The therapist says, you know, could it be that so-and-so is so?

And, you know, the patient treats it as like a, you know, kind of academic argument to, you know, to dissect and, you know, and counter, you know, point by point, you know, generally missing the entire point of what the therapist is saying. So, you know, so, you know, one countertransference is if the patient is overtly, you know, controlling and, you know, an oppositional and kind of one-uping the therapist, you know, one-uping the therapist. You know, one counter-transferences, the therapist gets very, you know, frustrated and irritated. I mean, they feel like they're trying to connect with this person and they, you know, they keep walking into a stone wall. and there's a kind of a subtle coercive put down around it, right?

And they start feeling pretty retaliatory, whether they acted on it or not, which interestingly is exactly the patient's fear. If they're defiant, they'll be punished and they'll be retaliation. You know, if the patient is, you know, particularly submissive and, you know, and deferential. the therapist might initially feel good about it. They might end up feeling that they're being, they might start second-guessing themselves,

or are they being controlling and sadistic? Why is the patient not here as a full person? Why are they just sort of deferentially going along with anything I say versus bringing in their own will and their own wants? And then maybe as time goes on, the therapist starts to realize, you know, we're having all these discussions, and the patient is, you know, accepting,

of everything I say and takes it in, agrees, and says all the right things, and nothing ever changes. The therapist starts to feel frustrated. In one way or another, the therapist is going to be a participant in a conflict around control or being controlled. Yeah. And so how does having that knowledge as the therapist help you? Well, if you try to set aside your countertransference, you're depriving yourself of what is probably the most important channel of communication happening in the therapy. There's three channels of communication and therapy through as the patient communicates. There's the content of what they say, their actual words.

There's their nonverbal communication, body language, facial expression, tone, and so on. And there's the countertransference. What do they elicit in you? And, you know, we ignore that last chance. That's the one that people are least often trained to pay attention to. It's probably the most important one. It's the one we ignore at our peril. So I would say the most common, you know, reaction of therapists is with an obsessive,

compulsive personality style is you feel like you're sort of involved in some kind of chess match. You know, every move gets, you know, there's like a, counter move and you're not going anywhere and you start feeling irritated about it. And somebody who's not trained to think in terms of countertransference is to set that aside and be a good doctor or a good therapist and offer their, you know, their interventions. But the most important thing that's going on is that, you know, there's a quality of a contest or a power struggle in the room. And instead of trying to offer more or different or better interventions are more of the same, right?

The value is actually in making explicit that there's a power struggle. You might say to the patient, you know, I'm noticing something, right? Because you're not going to notice this the first time. It's going to happen 10 times over or more before it sort of registers. With the therapist, what's helpful for the therapist to do,

they're feeling a certain way. Irritated, like irritated, like they're caught in a, we've caught in a power struggle of some kind, but it's very subtle. It's not, it's not explicit. I mean, it's not like the patient is saying, you know, screw you. You don't know what you're talking about. That's a different personality style. Someone with an obsessive-compulsive style wouldn't say that. They would fend you off in a more logical, intellectualized kind of way. Well, yes, I could see that. That might be so. But there's always the but. But, you know, here's another explanation also,

and it could be this also. Well, yeah, it could be this. It could be that. It could be a lot of things. but what's left out of the discourse is, you know, what connects to what the patient is experiencing inside in their emotional life and in their body. So the therapist is becoming increasingly irritated by this, you know, this chess match or this power struggle. We don't want to set that aside. We want to bring that front and center.

We want the therapist to pay attention to it. And then what we want the therapist to do after noticing that they're feeling a certain way is why am I feeling this way with this particular patient? What's going on here between us? What's happening in our relationship? I'm not feeling this way by accident. I'm feeling this way because I'm sort of in the gravitational pull of this particular relationship.

And what's more, whatever is going on in this relationship with me is a window into what's going on and what's going wrong in their other relationships with other people. So I, you know, I mean, I don't want to, you know, I don't want to close the window or, you know, cover over the window and not see what's in there. It's like, this is a window into the person's day-to-day life. So we're going to say in the therapy, when the therapist starts thinking along these lines and has thought at length, we don't want to just blurt out. You know, we don't want to just register the countertransference and blurt something out. We really want to understand where it's coming from. So the therapist is, huh, I'm feeling irritated.

I didn't know why at first. but now I see that basically everything that I say gets evaded or countered or deflected in some way. And it's pissing me off. Now we're starting to get some more information. What is the patient specifically doing that's countering or deflecting? And then at that point you're in a position to say to the patient, you know, I'm noticing something. You know, I've felt this before, but I haven't really been able to, you know, quite bring it into focus or putting it into words, but I'm noticing that, you know, there's a way that there's a way that

you fend off what I say so that it doesn't really touch you. And then you would name what's going on right here now, you know, for example, you know, I just said whatever, you know, and you said, you know, well, I could see that, that could be so, but, you know, this could be so also. Do you see how when you respond that way, it leaves us both in the dark about whether what I said is something that you recognize, that you feel it, that it applies to you? When I say something and you say, you know, it could be that, but it could be this. Do you see how that leaves both of us in doubt about what your experience is? And, you know, I'm saying this is a monologue with a real picture.

I like that. I like the monologue. It's good. It's helpful. A two-way dial. They shouldn't say, you know, there's something about that way of responding. I think keeps me off balance, you know, never really knowing if I'm offering something unhelpful or unhelpful.

I think there's also a way it keeps you not knowing, you know, as if it's more important to, you know, sort of fend off my idea. then it is whether it's right or wrong, to sort of take it on and chew on it and try it on for size and, you know, and see if it feels like it fits or not. Yeah. Yeah, so you're kind of like inviting them into a dialogue

of what might be going on between you guys. And then, of course, a lot could go on after you invite that dialogue. And if the patient is being really difficult, you know, most patients aren't this difficult, fortunately. You know, then the patient might then want to argue the point about that. It's like, well, no, I'm not really fending it off. I mean, you know, you're interpreting it that way, but you could interpret it this way and this way and this way and give you a whole, you know, a whole menu of things that could be.

Right. And the therapists would say, but, you know, they really need to stay there at that point. You know, a lot of therapists when the patient responds that way, they kind of get cowed and they, you know, leave the topic behind. And we don't want to leave the topic behind. We want to stay right there and say, well, you know, this, you know, the way you've responded to what I said is an example of what I was describing. You know, I described, you know, I commented that you respond in a way that fends off what I say that doesn't really take it in for consideration that leaves both of us in the dark about whether it applies to you or not. and your response to my saying that was, you know, to say something that leaves us both in the dark about whether that's so.

I mean, it's happening just here and now. And he says, well, maybe it is or maybe it's not. Well, what difference does it make? Now, here's where all the knowledge that I have from getting to know the patient and, you know, in depth over time comes in. It says, well, you know, it occurs to me that there's something about this that's quite similar to, you know, know, this interaction and that interaction and that interaction that you described with your wife that leaves you feeling, you know, distant and alienated from one another and feels crappy. Like, if what's going on here is similar to what's going on there, you know, there might be

some real value to you and thinking about it, taking a look at it. Yeah, that's good. So you're kind of from there bringing it into their more conscious awareness. that it goes on. So maybe they catch themselves when it does happen. And if it doesn't stir up too much sort of defenses against the idea of it, it might actually

get somewhere. If it doesn't stirrup, shame. I think that's where I would say something like, you know, I think that your ability to take this and to intellectually take ideas that are that are maybe thrown at you and come up with counter ideas

has actually really been advantageous to you in your past. But maybe in your interpersonal life, like with your wife, for example, maybe it creates some disconnection. And if it happens here, maybe we could look at what happens between us. I would want to go, yeah, I agree, and I would want to go there and bring that into the discussion.

But I want to keep it in the here and now as much as possible. Yeah. I don't want to get into the realm of abstraction yet. I want to say, you know, do you notice there is something about what we do that keeps me off balance. So I'm never really quite sure how to deal with you. It's really very similar to how you were described. And I'd be very specific. You know, what happens with this person in your life, you know, your wife, your son, your friend, your co-workers.

I mean, you know, you really want to embed it in specific details about their life. you know it seems like there's something going on between you and me right here right now that might shed some light on that yeah no but what i'm saying is that i think in the here and now i'd also try to show them how it's been helpful maybe to reduce the shame to get them to be able to to grasp it in a way that it's not something that they just push out of their uncomciful I don't think the patient has access yet in this example to shame. They're not feeling shame. They're just feeling like, well, it could be that. It could be this. Sure. Okay. Fair enough. So the next step would be, you know, first of all, you know, do you see how that keeps us both in doubt about what you're actually experiencing?

You know, the patient needs to register that. We need to be on the same page. You know, well, you know, I guess, yeah, I guess I could see. how that might leave you in the dark. I still wouldn't accept. I wouldn't settle for that. You guess casts it in doubt. You do see how it leaves me feeling like I'm in the dark, or no? Well, no, I do see it. The missing Lincoln there is perhaps there's a reason for that.

That, you know, that, you know, it serves a purpose, you know, to keep this in the realm of, you know, kind of academic theories for us to debate about, you know, rather than the realm of, you know, this is about you and your life and it matters. You know, perhaps there's a reason why you're wanting to keep it in arm's length. The patient says, you know, well, you know, I guess there might be. There might be, you know, let's find out what comes to mind. And maybe now you get a memory of, you know, something that happened in, you know, in the past, a time when they felt humiliated or ashamed, right?

They're going to go on a sort of an associative link. They're not going to just come out and say, I feel ashamed. They're going to, you know, if they're talking openly and freely, what we call free association, their thoughts go to another situation. They describe a situation where they came away feeling humiliated or ashamed. Then the therapist to make the connections. You know, your thoughts went there, right? On the heels of, you know, thinking about why you might want to offend this off, you know,

suggests that there's something in this that feels shameful to you. And the patient says, hey, well, I never thought about it like that. And say, tell me some more about it. So you're, you know, you're sort of opening doors and inviting the patient to come in and explore with you. You're not telling them what your, what their experience is. You're not saying, you know, well, this is because blah, blah, blah. You're not giving them a prepackaged, you know, interpretation of their experience.

We don't have access to their experience. what we're doing is saying, you know, here's a possibility. You know, let me invite you into thinking about this together. And the patient is the final arbiter. The patient gets to say, yeah, I do feel that. Yeah. It was a horrible feeling. Yeah.

Oh, yeah, I definitely agree. It's like we don't want to put our experience or put our ideas on them. That would be us intellectualizing on top of them. Well, that would be like old school, you know, bad analysis, psychoanalysis is at its worst. That's what everybody is afraid psychoanalysis is about. And of course, that's not at all what psychoanalysis is about. But that's people's stereotype of it. Yeah.

Yeah. Well, okay, I know we've gone beyond the time that we were planning. Anything else you want to kind of highlight as we kind of draw this to a close, since we've talked about, you know, obsessive-compulsive personality. We stayed on obsessive-compulsive. Yeah, we didn't get to the other ones. Every personality style has its preoccupations and will elicit countertransferences in the doctor or the therapist and the countertransferences are the gateway to understanding what's going on. So just to not leave listeners with, you know, if this applies only to assessive compulsive, I mean, you know, consider narcissistic personality, which is about the patient's internal struggle with, you know, if this applies only to assessive compulsive, I mean, you know, consider narcissistic personality, which is about the patient's internal struggle with.

feeling inadequate and unimportant versus feeling, you know, very important and grandiose and white special. There's this constant interplay between, you know, between these two different ways of experiencing oneself. And, you know, when the patient tries to sort of inflate themselves or puff themselves up and feel important by way of warding off, you know, feelings of emptiness or insignificance or inadequacy, so what does that look like in therapy? one of two things tends to happen. Either the patient idealizes the therapist and sees them as, you know, kind of larger than life and brilliant and special and important,

so they can feel more special by association. But they're turning the therapist into someone other than, you know, a real whole three-dimensional human being in the present, or they subtly or not so subtly devalued the therapist and put the therapist down. So there's two kinds of transferences that we characteristically see. If the patient is being idealized, there's a strong tend pull from the therapist to kind of join the patient in this mutual admiration society, which is not therapy. Or if the therapist is being devalued, either the therapist becomes irritated and resentful or the therapist starts to emotionally withdraw. from the relationship from the patient, right?

And that doesn't help either. So again, the gateway into how do we work with us in a way that's helpful is to recognize, notice, understand the countertransference, connect it to what's going on in the relationship with the patient that's eliciting these feelings in us, and then bring it into the session for discussion. So I just wanted to put another example on the table. Yeah, and I think maybe in our next time together,

we can i would like i would like to get the full you know shedler breakdown of narcissistic personality you did a great job in the paper looking at different subtypes and stuff and um i've actually thought a lot about the different subtypes as well like there seems to be that psychopathic subtype which doesn't have maybe some of the same um yes kind of that under underbelly devaluing underneath it you know like someone with pure psychopathy it doesn't seem like they have that as much, whereas, and I think you touch on that a little bit, kind of like that malignant narcissism, psychopathic version versus the, yeah, well, there's a spectrum, and this is really Otto Kernberg, is the theorist who's written the most and, you know,

the most, I think the most perceptively about this, but he puts narcissism and malignant narcissism and psychopathy on a spectrum, that they're all, they're, actually related, you know, related ways of organizing. You know, where on the spectrum are you? Hopefully not on the spectrum. I was sorry, I was just bringing that to the hearing now. Well, we will leave it there for today. And thank you so much for coming on.

I really appreciate it. Well, it's been a pleasure as always.