Psychiatry & Psychotherapy Podcast - The Hero's Journey for the Mental Health Professional

Episode Date: April 3, 2021

In the last episode, we talked about the first two stages of the hero's journey. In this episode, I will focus on the path of the hero as it specifically applies to mental health professionals. I will discuss exactly what those are and how these are areas in our core being that simply cannot be faked. The areas we will be discussing require the hero (us) to develop and mature at the core of our being, to embody these things, and to be fundamentally transformed. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. All right, welcome back to the podcast. I am your host, Dr. Puder, and today I am going to be going through the hero's journey, specifically the second part initiation, in which we enter into this other world where there's trials.

And specifically today I'm going to be talking to therapists, psychiatrists, mental health professionals, and talking about our unique journey, our unique trials. In the last episode on this, I talk about departure, which is the call to the adventure, this belly of the whale moment, including coming up against our unconscious, the darker side of our personality, the shadow, where we might have aggression, jealousy, resentment. And I recently have had a client who has found this. who says, you know, I could easily be comfortable. I could easily avoid even looking at this part of myself.

But there it is. There's a hesitation to even go there to even look at that part, right? And then the second part is initiation. The third part is return of the hero's journey. The second part in initiation, we come up against trials, temptations that get us off track. and we talked about the importance of guides, multiple guides in our journey, the importance of being receptive to feedback, being a central theme, the necessity of guides. We talked about trials mostly in negative terms.

We talked about, you know, the things that get us off track, the things that get us away from our journey, maybe the trials that are more of the refinement. As mental health professionals, I see three things in the areas of continual growth that I'm going to be talking about in this episode. Empathy, Therapeutic Alliance, countertransference. And I'm going to be talking about how in our journey it is a necessity to grow in these at our core, not in a way that would be faking or pretending or, you know, a social veneer of sorts. And what I mean by this is that unlike knowledge that you can learn and therefore know, these require the hero, you, to develop and mature at the core of your being, to embody them,

to fundamentally be transformed. I had someone recently sign up for my resource library, and I read every little remark that people send to me, and I usually respond to it. And this person specifically said, I want to lie better. They were listening to my podcast so that they could lie more convincingly. And this struck me with a shock and made me a little bit sad.

Can we just learn how to lie better? Is that what makes us better therapists, psychiatrists? That would be knowledge without inner transformation. The thing about lies is that at some mere neuron level, other people are going to register it as not truth. Recently in a forum, a psychiatrist posted, a patient told me today, the way you're showing me empathy is making me irritable.

Now, this could say more about the patient than the provider, but imagine that the provider's empathy came with a lie. They were trying to say the right words, but didn't really feel into the person's experience. While listening, they had some other inner dialogue going on, maybe thinking about the kids, their spouse, how debt felt against their shoulders, the patient that had threatened a lawsuit, their teenage daughter, who was out the night before. You know, many things can go through our mind and distract us from listening from empathy.

Many other thoughts were going through their head, and maybe the patient felt the empathy was a lie. I wrote, I imagine the patient. feels distrust and unheard, because they are letting you know that something about the empathy does not allow them to feel felt. They don't feel you are with them. Something about the empathy seems robotic and distant. Secondly, I would say, thank you for letting me know. This for me is a true statement. them correcting me, allowing me to reset and pay attention to what is going on between us is a gift. It lets me know something is going on. I first look inside myself.

It takes two to have a relationship. On a side note, one of my biggest pet peeves is when a therapist blames the other person not in the room and gives the patient a psychological out. I myself believe at the core. Conflicts in marriage always are between two people. Work with the person in the room because that is the only person you can change. So I look at myself, was I distant, not listening, missing something? My gratitude for this chance to recalibrate is a chance to connect, and I truly want to connect. So that is where my gratitude comes from.

This is a chance to connect. In a culture where ghosting is more and more the norm, having a chance to actually hear a piece of interpersonal feedback that could lead to increased knowing is precious. Like true interpersonal feedback, right? How often are people really truthful with each other? Well, I would say most of the breakups I've heard about, it's like such a wrong non-truth statement. I just want to be friends. I'm not ready for a relationship.

Yet one day later, they're dating someone else. You know, often these things are said to not hurt the other person. But in therapy, we can really look at the truth. We can look at what's really going on, and that's kind of a unique place. So when this person said, the way you're showing empathy is making me irritable, we can be grateful that there's a real chance for reconnection, a real chance for communication on an honest level. Let's say that this is the first time this person has ever said anything like this and you've been seeing this person for a while. that could be very helpful because maybe they're moving from idealizing you to the other side, having some critical thoughts, be able to float out of their unconscious.

It's not that they haven't had those thoughts. Maybe they've just stuffed them away, split, all good or all bad, and now maybe their representation of you is more of a mix of the good and bad. That's a big psychological development, by the way. be able to hold together the good and the bad at the same time, that's like a huge, huge improvement psychologically. Okay, so first, gratitude, right?

The second thing is, help me understand what bothers you in particular. And this inquiry is out of a true desire to know what is going on. I don't want to project my own estimation of what happened. I want to know. At times, patients will feel like you are not a real person. You are playing a part. And I want to get away from playing any part.

I have a role to be there for them. I'm a real person. I'm present with my intent to listen, to help. Just our presence can be of help. Sometimes we feel like we need to do something spectacular. but just our presence and our attention and our willingness to listen can be of help. Perhaps they won't feel as alone in distressing memories. If they can feel connected with you, if they can feel heard and understood,

if they can feel less alone in those distressing memories, that will be powerful. Perhaps they will have new ways of looking at traumatic things that happened. if they integrate someone that is carrying into a memory that is distressing, the memory fundamentally changes. On a side note, because it fundamentally changes, the next time they tell it, it will be different. They may not be as dissociated. They may have more sorrow, more sadness, they may have more anger. So I see it as like stages of transforming a memory.

The first time it's very dissociative. Then maybe there's more anger. anger, then maybe there is more sadness. So what we're talking about today is at the inner level, at the inner level of our being, becoming empathic, connected, and able to sort of navigate very conflictual internal feelings that we might feel that might come up. our countertransference. So empathy.

Being empathic through mindfully practicing deep listening, attuning our affective empathy, reading, body language. You know, in my episode on empathy,

I talk about how there's different levels of empathy. One level is just seeing an emotion flash on the face. That's like reading a word from the book of their life. You can attune to just a word. And then there's like the sentence, the context of the emotion, which we may or may not understand by just seeing the flash of emotion on their face.

And then there's the chapter and then, of course, the book itself. So the chapter may be like, this is a series of events in their life. The book may be the context of what's going on in this chapter to the whole of their life. so we need to grow in our ability to have empathy true empathy truly understanding attuning moment to moment what is the emotion going on in this person the second thing is therapeutic alliance i have a series on this if you haven't listened to it it's um it's something that i find very very important to go back to and remind myself of. The value of teaching this every year is to remind myself of this

and hopefully be more able to connect with people. And at the core of our being, what does it look like to grow in our ability to have a therapeutic alliance with people? Well, enjoying, desiring deep, meaningful connections with others. And I would say enjoy. because there is a certain amount of pleasure that I get from connecting with people. And some people, there's less pleasure with connecting with them early on maybe in my career.

And I think I've been able to grow over time in enjoying connecting with a larger variety of people very different than myself. I might add here that I've had to give up doing things like watching the news at times. because, you know, the news almost like the affect of the people in the news talking about what they were talking about led me to have emotional reactions towards people who were different sides of the aisle. And so I think like growing in this is sometimes it's a sacrifice of not doing some things, right? Growing in the ability to connect with people is really interrelated. to empathy, and it's also interrelated to the third aspect that I'm going to talk about,

countertransference. Countertransference is something that we can grow in over time by more deeply understanding the difficulties others have working through our own traumas and difficulties, so that our reaction to people is minimal or none. it's unlikely that we will never get to none. It's absolutely ridiculous to think that. So we will have some reaction, but if we have a very large reaction, then I think that points to some work that's needed to be done in our own life.

This entails learning our own responses, identifying narratives that tie previous narratives to their narrative. untangling that and learning to have compassion for those with severe attachment and personality issues. I would not be surprised if some of you listening to me over time develop a narrative about me and potentially that narrative is intertangled to past narratives. Now, if you're overwhelmingly, you have positive feelings towards me, maybe I'm connected to positive people in your past. if you have like a negative reaction to me it's possible that's some of my own stuff but it's also possible that there's an entanglement of some of the past people in your life that you had negative

reactions to and maybe I remind you in some small way of them and so you kind of like intertangle the narratives and so this is stuff that can be processed and in your own work right in your own work of seeing clients when you have a strong reaction of being curious. Being curious about what's going on, learning to listen to the associations that come up. Associations as in like, as I'm thinking about this, I also have this person come to my mind or this situation come to my mind. if you learned how to tolerate a certain family member growing up, you may not have as large of a countertransference to that type of person.

So for example, if your mother was borderline and you served the role of a peacemaker, you may be great with borderlines now. What you may need to learn is boundaries. So you may need to learn how, as you work through your conflicts with your mother and stuff like that, and there's a great book called Understanding Your Borderline Mother, if you haven't read that, check that one out. As you learn how to have boundaries and not be 100% their therapist, that will actually help you in your roles with your clients as well.

And I see many exhausted clinicians. I mean, not many, but I've heard these stories over time, who basically have really strong difficulties having boundaries of patients. spent two, three hours with a given patient. And the more I listen to it, it's like it's a re-manifestation of their dynamic with their mother or their father and the lack of boundaries. So as they grow in their ability to have the boundaries with their patient, they'll also grow in their abilities to have boundaries with their parent.

Something to think about. Okay. So to get to a place where these things are who you are, is the therapist hero journey in my mind. And it is tragic that psychotherapy is largely taught through mostly giving head knowledge, manualized approaches, which have little to do with what I'm talking about.

Some have partially integrated some of these aspects. And little true mentorship or relationship. Like, it's easier to have a group of people in a class and to teach them content. than to have a one-on-one relationship. You know, one of the critiques of, like, the more traditional therapy schools like psychoanalysis is it's very time-intensive and it's very expensive.

Well, it's like that one-on-one, it's like the relational aspect is so important. And by the way, I don't see this only in the psychotherapy world. Many spiritual people go to some sort of school, like a seminary, which is very, very heavy in head knowledge and very little relational space. And, you know, another side of this is some people are seeking spiritual growth through psychedelics, which is kind of like this very quick reaction, hoping to get some spiritual growth. Whereas the work of relationally going there, week and week out, is actually difficult.

So we have this desire to grow in this way, but often the cost is too much. Many feel that doing this work is too time intensive to expensive, but at the same time, you know, you pay $40,000 for a car, $40,000 for one year of school. By the way, $40,000 would get you two to four years of the highest end therapy or supervision. and I often will get an email from like a nurse practitioner or something and they're fresh out of school and they're supervised by a non-md and I will say like pursue a relationship with someone who you respect and you could actually grow from and pay them and if you pay someone you know appropriately they will give you their attention and teach you.

And it is probably one of the most important things you could do the first, you know, 10 years of your practice, I would say. And I'm not just speaking to NPs. Like this is something I've practiced. Like when I got out of residency, I went into a two-year therapy. It was cool. It was lots of supervision. I saw my own supervisor, own therapist.

And I've continued with that process. And I just budget it. I budget a couple thousand dollars a month. you know so and i have a lot of debt so it's not that i don't have debt so you know you just live you you plan on living under your means if you get a physician supervisor you know find someone you respect find someone who is well respected in your community or in your state right because um if if you have a supervisor you need them in your state okay so it is expensive to do this type of one-on-one mentorship, but it's worth it.

And there's a statement, beware of unearned wisdom, which comes from Carl Jung. It might be a summary of his thoughts on LSD Mesklin, but I like this statement. Beware of unearned wisdom. And it's like this idea that knowledge without transformation, a wisdom that's not a knowledge that's not embodied. knowledge but without a moral or spiritual fundamental transformation this is why i'm talking about this as a journey the other world the world where we look at ourselves and hopefully come out more fundamentally empathic connectable and tolerant of others prickly the prickliness of other people right we

hopefully were more tolerant or um able to to bring that into consciousness and and and and utilize it actually to help the other person. So here's an example of knowledge without inner transformation. Let's say you knew, you listened to my episode on forgiveness, you look at the handout, you have looked at the research, you understand that forgiveness can decrease chronic stress, maybe you even teach others about its value. But yourself, deep down inside, feel resentment and bitterness

towards something in your past, maybe 60% of your emotional energy each day is consumed by your anger towards your ex, your parent, a person who hurt you. And so your ability to help and guide someone through the act of forgiveness would be thwarted on several fronts. The first of which is that when you're in relationship with this person and you're trying to help them forgive, they can feel to some degree that you have not been able to do the thing that you are calling them to do.

I think this is communicated through mirror neurons. You haven't found the ability to find peace in your core. And people can feel if you have, like, resentment and bitterness. I know when I meet someone new, I can feel that. It's like when you meet a used car salesman and you immediately get this yucky feeling, it's like, is this person for me or are they for themselves? not that all used car salesmen are like that. I've met a couple good ones,

but I've also met some that I just like cannot. It's like, okay, I'm just going to get through this. This is like an ordeal. This is a trial. Buy a car. I never want to do this again. So potentially, you will, on some unconscious level,

be registering your resentment in their experience of. you. And you may also have countertransference towards them if they remind you of this person that you have unworked through conflict. And so that may actually just leak out, right? We unconsciously leak out our resentments. So to make this more personal, I've been in this place. I used to go into the juvenile hall and actually give talks. And one of the talks I would give was on, forgiveness and the value of it. And years later, I was in a place where I was full of bitterness and angered towards something. And I wrestled with this for a good couple weeks where I was like,

I could not forgive. And so I prayed for the ability, the gift, the grace to be able to forgive, praying mindfulness, whatever. You know, it's a spiritual practice. And, um, it took about four days of being very, very continuous in my desire to gain this gift of forgiveness. I think it's almost like a spiritual gift in my mind. And something shook up in me at one point where it just like, okay, I forgive. And my critical mind, my obsessive anger was not just pushed further into my unconscious, but it was it was truly gone and it never bothered me again

this thing so it is through trials pain suffering good guides healthy spirituality that one transcends and it is through learning from our own life it is from struggling mindfully in our own journey and it takes a full reorienting of our mind

at times and knowledge may proceed it. Like you could binge on a ton of podcasts on something. You could have that knowledge. And then it may take months to years to fully embody it. And you may need to be reminded over and over and over again. You might think, but is not being excellent, just practice, just doing something. And I used to kind of think, yeah, it's just practice.

Well, this, you know, practices in like, okay, I'm going to break this down and as an athlete would break this down. And I read this book early on, talents is overrated, which kind of deconstructed this myth that world-class performers are largely talent-based. They talked about how that was a myth. And most of these people had discipline practice for years and years and years. And there's this guy Erickson who authored many. seminal papers on discipline practice. I'm going to do an episode on that in the future. Shout out to Kat Wu, who's a resident who's going to be helping me on that. And so it can inform our understanding of how to become an expert. It's a part of it. And we can think

about this, how this applies to what we're talking about. I once had a coach, Steve Gladstone, one of the best college rowing coaches of all time. And I said, him, I guess I just need to spend more time rowing. And you say, no, no, no, no, no, no. You need to spend more time mindfully rowing, focusing, and being fully present with every stroke, time where you are getting feedback. And this is struck, this is always kind of stuck with me, right? And after reading research, it meant even more.

and it was, I think, why he was such a good coach. He was very astute at what people were doing wrong. He could give you small corrections. But he was also always reminding us to show up, be present with what we were doing, our intentions, focusing on every stroke, every stroke. And so what is discipline practice? Individualized learning objectives. is number one

individualized learning objectives so the best performers direct their time, attention, and energy to the steps required for reaching their goal. Better results are achieved with higher levels of involvement and motivation. So you have these learning objectives, things that you want to improve.

So for this, if you align with what I'm saying here, your learning objectives would be like, okay, I want to grow in my ability for empathy, therapeutic alliance, connectedness, you know, and countertransference. Okay, so you have that learning objective. And then you need to get ongoing feedback regarding your performance and learning. So checking in with people is one really good way of doing that every session.

Hey, was there anything you felt like it didn't quite understand or you wanted me to understand a little bit differently? Is there anything I'm missing? That's a good way towards the end of your session to check in. with someone. Ongoing feedback also for me is monitoring expressions of anger when I do give empathy. So when I'm looking at someone's face, I can see a micro expression of anger. And then if I see that flash of emotion, it's like, oh, maybe I missed something. Maybe I said something that was wrong. I'm going to check in with them. Okay? So ongoing feedback. Sometimes there's like post-session

evals that you can do. I did an episode with Miller, and he talked about how he has an ongoing assessment that he hasn't filled out afterwards. That can be one way of doing that. Number three is involvement of a coach. This is someone who maybe is viewing your actual sessions. This is someone who is listening, who is guiding you, who is seeing what your weaknesses are, who is hopefully embodying the very things that I'm talking about,

connectedness, empathy, a bit, you know, this countertransference, which is like you don't feel any shame from this person for being you. And then number four is successive refinement. So slowly, progressively refining what you're doing. So Miller at all found that just doing the activity had a point two correlation with success. So without the feedback, without coaching yourself, without the plan, right? And the correlation between success and deliberate practice was found at 0.4, which comparatively is much higher. So 0.4 is the correlation between success and deliberate practice. So obviously there's more than deliberate

practice going on. That is difficult to measure, right? But deliberate practice is one of the key things. And when you multiply a correlation against itself, it gives you the between person performance variance. This means that deliberate practice accounted for 16% whereas just doing the activity accounted for only 4% of between person performance variance. So that shows you how much more powerful it is than just doing the activity. So getting the feedback, growing through your process of seeing people. So the four aspects of deliberate practice, once again, individualized learning objectives, ongoing feedback,

involvement of a coach, successive refinement. You know, to kind of draw this back to Hunger Games, Katniss Everdeen, her father was an illegal hunter who took her into the woods beyond District 12 to teach her how to hunt. She spent countless hours practicing shooting her bow in real life hunting situations. So you can see how that played out with her in the games. I think about the Daniel and karate kid who was trained by Mr. Miyagi and often was cleaning Mr. Miyagi's house, doing the movements necessary to do karate well over and over and over again.

So sometimes therapist played the role early on as peacemakers in their family. If you look back at your family, your practice, you're practicing this thing of connection, empathy, countertransference may have started when you were very, very young. Like, I have a picture of my brother being hurt and I'm next to him. And I have this, like, pain expression. on my face, it was adaptive for me to be empathic in the peacemaker in my family. And if you think about your own family, you could think about what role you played.

And maybe your training started way before you even thought it did. If you're a therapist, you may ask yourself, why practice things like alliance, empathy, like why is this? What's important? And I would say there's this one. graph from the book the Great Psychotherapy Debate, which talks about factors affecting outcome and the effect size of the factors. And it shows that the factors that affect outcome include collaboration, empathy,

alliance, positive regard, congruence, whereas the factors that don't make much of a change include treatment differences, adherence to protocol, specific ingredients, So, you know, everywhere I look at where they have these trainings, it's a group thing, mostly teaching, very little relationship forming. You're learning new techniques, highly theoretical. And I don't know if you listen to my CBT, ACT episode, or the ACT episode. But acceptance commitment therapy, very in vogue. But when you compare ACT to CBT, it's like equal outcomes for depression. maybe ACT is a little bit better than CBT for addiction, for complex anxiety stuff. But overall, they're very, very similar outcomes. And this is where if you look at the therapists within these studies, some therapists are doing better and some are doing worse. So what are the therapists doing that are the best therapists? Well, they have empathy, their ability to form therapeutic alliances better.

and so on and so forth. So to grow our authentic empathy, ability to form alliance, positive regard, we cannot just learn knowledge from a textbook. We need to actually be practicing, receiving feedback, and walking our own journey. And I teach empathy to residents, so I know that there's a certain amount that can be taught. We watch videos of others doing therapy. we look at micro-expression, small moments of connection, disconnection. When we watch videos of someone doing a session,

we can see when a patient doesn't feel heard. We can look at what was said before, what was said after, was the psychiatry resident able to reconnect with them? Often they are. You know, what's the connection look like? And we look at this and we study it. And this really does help us understand and see things that maybe we wouldn't otherwise see.

I had a resident once who was treating a very difficult client that I had seen for years before I referred them to the resident. And the therapy ended after several months. I was in the room, you know, once a week watching this. And sadly, at the core of the residence being, they did not have empathy or love or kindness for this person. They were often saying the right words, but didn't really have the love. They did not look forward to the sessions. It was painful because it reminded this resident, I think, of someone from their past. And I take responsibility in part for this, not being a guide in a way that could have allowed the resident to grow in what was going on.

transcend. These are the moments that kind of like wake us up to, hey, what's going on in us? Right? How can we grow? How can we work through our own stuff so that we can be fully present for this client so we can enjoy the work? The core of our work is relational. So we have to do relational work. There's a There's this verse that says, you will know them by their fruit. When you look at people, you want to follow leaders. There's ancient wisdom that says you will know them by their fruit. And the fruit being love, peace, joy, kindness, self-control.

If you are looking to find a good supervisor, look for those attributes, does this person embody these things with me, with other people, it's this fruit that comes from growth, real growth, right? Not like knowledge. You can only grow in peace by kind of like a practice, a discipline of doing your own work, right? So it's interesting, there's this kind of new fad of like doing joy work and positive psychology only and, you know,

Negative emotions are seen as monster emotions. And some of the leaders kicked out one of my friends from the group and told my friend that they were a narcissist and went all bad on this person. And in my mind, I'm listening to this. And it's very cruel that they did this, right? They are the leaders of this joy group. And yet they did this. And in my mind, I'm thinking to myself, isn't that interesting that they're embodying, their

theoretical model is joy and positive psychology, but interpersonally, they're very prickly. It's like the negative side is unconscious and then it lashes out all at once, right? And I don't see the fruit that I would want to see in someone I would want to be my mentor. So something to think about. The implicit sort of reactions that we have are not just cognitive. Countertransference is often very early stuff, very deeply ingrained. It's not just like something that can quickly be transformed. It takes time.

It's kind of like I saw this picture the other day of like this overweight person and it took 20 years to get this heavy. And then the next picture was, wants to get a six-pack in six weeks. And it's like this, it's this kind of fantasy that we have, right, that we can undo 30 years of damage in like six weeks. I'm going through that right now.

I'm trying to get in more shape. I'm posting pictures on my Instagram of my progress. And it's something that I'm going to have. to have patience for, you know, being a dad, having a lot of stress, taking me away from being in the type of shape I want to be long term. So it takes work, it take, you know, and it's not going to be something that happens over six weeks. It's going to be something that happens over years. And I have been working years on this. I've been lifting for about three years now. but um you know the covid 20 happened to me and um we're working on that so be patient with yourself

in this process is what i'm trying to express like it's it's okay if this if this isn't something that happens quickly like it's okay if you have strong reactions to some clients and um it's something that you can continually kind of work through So when I studied supervision research-wise, I'm trying to get this paper published on it, I really found that there were four domains in connection. Empathy, psychological safety, education alliance, and feedback. We've talked about all the importance of all four of these, but we haven't really talked about psychological safety.

And that's the ability to give your supervisor feedback and for them to, accept it and to catabolize maybe it or make sense of it curiosity and without lashing back or shaming you and it's so important to have the psychological safety for the people we train for our clients you know for them to feel psychological safety and expressing negative thoughts and so when you're looking for a supervisor, also look for someone who embodies these four things. Because what we found was that if you have a highly connected supervisor,

it actually decreases your burnout, like 0.7 points out of 7, which is kind of a big shift. So there's actually therapeutic value to this for your job too. So having someone who's empathic, who's a supervisor, is important as well because I think to some degree you catch these things. They get integrated in you. I'm indebted to one of my supervisor, Dr. Tar, who's worked with me for years. I sent him the outline to this episode.

And I want to read to you what he wrote back to give you an example of just how precious this man is. This is what he said. excellent excellent excellent comprehensive stimulating practical and focusing on ways to implement successful practices in psychotherapy a huge amount of dedication and work and talented expression by you of what facilitates or may detract from the journey's progress and successes very helpful in facilitating therapist maturation and consolidating their identities and benefiting from their own inner lives while simultaneously helping others. Thank you for the privilege of reading and digesting

and vicariously participating in your feelings and thoughts, ongoing wishes for the widespread dissemination of your insights to benefit therapists and through them collective, assisting the universe of those who are needing, disparaging, trapped in their outmoded patterns, disregulated, devoid of hope and confidence, lonely and misunderstood. wonderful help for the helpers and thereby benefiting the world of suffering and distraught.

Reading this additionally adds to my respect for your potential and influencing in widespread ways. I share this not to just to give you an example of like how important encouragement is from those who are your supervisors. Emails like that are very encouraging, you know, and when you're trying to do creative pursuits, it's like you need. you need encouragement. So I hope that you feel that from people that you get supervision from. And sometimes, you know, supervision can be tough because we can get critical remarks and shameful remarks. And, you know, our supervisors are not perfect people.

I always tell my residents, if their supervisors are not as warm and empathic as Dr. Tarr, see what you can get from them. like in terms of like what are the things the gifts that they have to give you know some supervisors will be experts in psychopharmacology utilize that some will be experts in one type of therapy try to learn what you have to learn from each person you know i think i've been very blessed to have dr tar in my life so dr tar if you're listening to this thank you and i appreciate you and i hope you don't mind that I share that. So one of the questions that I'm left with is what is the nature of the work that we're

doing here. And some of it is looking at parts of ourselves that we would rather hide. I would rather project an image of success. I've been trying to be honest with my struggles more in this podcast, like the David Burns when I went into some of my. anxieties, fears. And we would rather project an image of success, right? All of us.

And I think, of course we would, right? I don't know how we can be more kind to ourselves, more truthful, until we know that the truth is okay to hear. One famous book comes to my mind, St. Augustine's The Confessions, it was a new genre of books. So, irrespective. of your spiritual tradition, you might find this book very interesting because in this book, he does something that no author has ever done before. He expresses all of his inner, horrible,

dark thoughts. And it was his conception of grace or redemption, spiritual journey that allowed him the boldness to put out his truth. And this was the first book of its kind. And there are a lot of books that have come out since then. But I think it's like this idea that when you're with a supervisor, when you're with a therapist, that has the ability to see you, appreciate you, value you, even if there's darker sides and to not be afraid of that, to not shy away from it, to meet your darker sides honestly with like, wow, thank you for sharing me. I mean, this like helps me feel more connected with you. And when you get that response, it's surprising.

It is utterly surprising. I can remember through some of my mentors, it's like sometimes I would share something I would feel so shameful about. And it shocked me that they didn't have that same level of, the same level of criticalness that I had towards myself, my own level of self-criticalness. And self-criticalness is like very hard to live with. having lived with it for years, I feel less self-critical of myself at this point,

but at times I still have, you know, thoughts and have to work through them. But having lived with a more critical self than I am now for years, I could honestly say it was at times torture some. So can you find someone, a supervisor, a therapist, a spiritual leader, that embodies the opposite of shamingness, where we can start to know ourselves more. And I hope that each of you have those people in your life. I really do.

Often we have more in common with those that we treat than differences. And I think that it helps to know that we are, as young coined, wounded healers. there was a Greek myth of a centaur chiron who was conceived by rape half horse half human and what kind of overcame and gave back I said to be the founder of medicine a great teacher a great healer and this story of this in this Greek myth embodies this kind of idea that like it was through his woundedness that he was able to help other people. There's one study that showed that over 40% of social workers

reported experiencing mental health problems before their social work careers, and almost 42% indicated that they experienced mental health problems over the course of their social work careers, with 28% currently experiencing such problems. There's a poem by Rumi, which I have to include here. This is so beautiful. Trust your wound to a teacher's surgery.

Flies collect on a wound. They cover it, those flies of your self-protecting feelings. Your love for what you think is your own. yours. Let a teacher wave away the flies and put a plaster on the wound. Don't turn your head. Keep looking at the bandaged place. That's where the light enters you. And don't believe for a moment that you're healing yourself. So as we think about when we react to clients, countertransference, we should not feel bad that it is there. We should not run from those thoughts.

Ideally, we would be curious, not obsessive, but observe, see what it associates to, process it with a mentor. Sometimes we get clients we need the most. There was one point in my career when I looked around the room

in this IOP that I was treating and every person I saw was my mother, my father, my brother. You know, sometimes we get clients we need the most. Sometimes I feel like I should be paying my clients because of how much growth is occurring through their working with me. Great psychotherapists and psychiatrists have faced their own psychological problems with courage, exploring their own complicated inner realities,

finding a solution, and then giving that solution back to others. Marshall Lanham comes to my mind. She formed DBT. She struggled with suicidal thoughts, hospital admissions, and her journey. She talks about this. She's very open because she's worked through it. Victor Frankel sought meaning in concentration camps, formed Logo Therapy afterwards.

By the way, if you haven't read Man's Search for Meaning, please do that. We're going to have an episode in a couple weeks on that book. And it will be good if you have read the book before that episode comes out, so you can kind of reflect on it yourself. And if you do, if you underline something that's meaningful, if you write anything down, I'll post something on my Instagram and you can comment and we can all enjoy each other's thoughts on the book. I've read articles about which patients people find the most difficult.

For primary care doctors, there's one article that talked about how, if they had five or more somatic symptoms, they were found to be more difficult, if they had a lot of stress, depression, anxiety, greater severity of symptoms, worse functional capacity, and other mental disorders, they were found to be more difficult. I got a message from a primary care doctor upset about the tone that might have been used or the words that might have been said about primary care doctors. I want to just put it out there for the record.

I have a lot of respect for primary care doctors. I was almost a primary care doctor. That's actually the direction I was headed out first before things took a turn my senior year. And I have a lot of respect for primary care doctors. they're in the trenches, a lot of their patients have mental health issues, a lot, a lot, a lot. And they're doing a lot of it themselves. So if you're a primary care doctor, thank you for joining us in this journey of taking care of these clients. So when I have a difficult client, it brings up my own issues.

They are my teachers. I bring that to supervision, which I'm still in, get feedback, try to explore what is my contribution, what are the aspects of my personality, my ego thwartedness, that are being stirred up. And I try to grow. I try to continually grow. And I will likely be in that process forever, as I will always need to grow more.

So there's a thought that we are gurus. And I'd like to say, we are not gurus giving advice from a place of superior wisdom, judgment, and authority. We're in the trenches as wounded healers, as people going through our own journeys. And it's interesting, I first got into my own therapy journey because the supervisor recommended it. And he said to me, do it because it will help you be a better therapist. And so I did it. And little did I know, you know, years and years later, how important it would be

just for myself. You know, it's like, it's like I didn't want to believe that I needed it, right? And then, you know, you find out that it's actually really, really needed. So sometimes it's hard to say that we needed ourselves. It's easier to say, oh, it's helpful. If it's easier to say it's helpful for you in your career and start it because of that, but you'll probably find out later that it's helpful for you. I want to say any ten and ten,

for narcissistic defenses of blaming the other need to be worked through, or you will gaslight them when you are at fault. And in every relationship, what I'm trying to say here is that our countertransference, part of that is our true reaction. And if they're picking up on that, and then we blame them for our negative reaction or something about ourselves, then essentially we're gaslighting them and we're teaching the patients to become the bad guy, to take on the bad from other relationships as well. If we can take on our own stuff and work through it and not blame them, then we are teaching our patients to know that there are,

perceptions are true at times and to be able to attune their perceptions to reality better. So this is some of the work of that counter-transference work that I'm talking about, why it's so important to do that work. In every relationship, we bring learned expectations from past encounters. We also react to what the patient is bringing to us their transference, right? and so we shouldn't be surprised when we have this and we should be conscious of it and when we're conscious of it if we're able to attach meaning to our reaction we are changing our reaction if our reaction if our reaction is distressing we bring that to supervision maybe we can feel not alone in our reaction by processing through a strong reaction we are changing the way not only we will react in

a similar situation, but for all future situations as well. And it can guide us to what areas we need to continue to work on. So I'm going to put in my handout here a list of the reactions that we can have. And it's sometimes helpful to look at this list after a session to see if you are feeling this at all. So for example, I break it into disgust. You may You have thoughts like I dislike him or her. I feel repulsed by him or her. Often this is just a part of us. There's part of us that enjoys it, part of us that feels some other emotions.

And those are pretty strong emotions. We need to work through some of that. You may have attraction. I feel compassion for this patient. That's a good thing. If this were not my patient, I would want to date him or her. I feel sexually attracted to him or her. I would want to be their friend.

I look forward to the sessions with great pleasure. So there can be attraction, right? And this can also be distressing to people I talk to, psychiatrists I talk to, so distressing that maybe they avoid connection with the client or they avoid the client. And so it's good to work through these things. It's good to put words to it. I'm still working on my episode on. sexual

transference, countertransference, you know, and the sort of the studies that are out there talking about how much goes on and what goes on,

we will get to that in the future. So let me know if you want to hear that. There's also sadness that we might feel. We can feel depression within the sessions, maybe guilty about feeling, we have towards clients, we can feel a strong disappointment in yourself. Maybe you don't feel like you're helping them enough.

Interestingly, sometimes that feeling of disappointment, that self-criticalness is the client's self-criticalness that you are feeling. So be curious about that. How much of what you're representing counter-transferentially is a mere neuron representation of their inner struggles? Okay, this is how we use. our countertransference to actually help them, because then we can give them empathy for that.

We can be curious, like, hey, as we're here together, do you ever feel critical of yourself? You know, if you have a patient that you feel most critical of yourself about, check in with them. Are they feeling critical of themselves? You can ask them, if they say no, then it's okay. Maybe it's your own thing, right? But if they are, then empathizing with them,

helping them work through that, that will probably make you feel less critical towards yourself because your mere neuron representation will decrease. At times, you may feel like an imposter. I recently had someone said, someone say to me, I'm not feeling like an imposter, I am an imposter. And yet they were incredibly competent, right? but it's like they weren't just even thinking that 10% of them felt like an imposter everything in them felt like no I'm not having a hint of this I am an imposter and this person

is so talented it's like it's painful right it's like when you empathize with it it's like it's so distressing to feel so inadequate especially with these couple patients or is with all patients. It's with all patients. Okay. Well, that's incredibly distressing. It's incredibly distressing to feel like an imposter despite all of your education, despite all of your studying, and, you know, exploring that, what other associations come from that, associations from their childhood, messages from maybe a critical attending, critical supervisor, I have this image that comes to my mind of a negative piece of feedback, and it's a piece of rice, and it's black. And this person is looking at this negative feedback, this piece of rice, in a magnifying lens,

and all they see in their vision is this blackness, and that's all they see about themselves. and yet if they were to look at the bucket of rice, what they would see is the bucket is all white rice with one little black piece of rice. And that is the situation that they're in where they're focusing with the magnifying lens on this one little piece of black rice, whereas most of the rice is white. All of the white is white except for this little black piece.

That's called overgeneralization, the cognitive distortion of overgeneralizing from one bad piece of feedback on to all situations, one bad encounter to, this is who I am, this is my identity. And what we need to do is we need to look at the eyes and blur our eyes a little bit and see all the whiteness. All we would see is whiteness.

As this person, would you see whiteness if you squinted your eyes? And they said, no, I would see gray. I was like, okay, no, you would see whiteness. We could have, sometimes our countertransference is censorium issues, feeling tired, feeling exhausted. You know, we may feel just exhausted. I know in dealing with residents, there are times, a lot of the time, especially in the first two years, where the residents just feel really exhausted all the time.

And it's like, of course they do. It's like, that's because you're working all the time. And this is really hard. and that's part of the process, right? Working 80-hour weeks with the sickest of sickest clients, it's like that's exhausting. And trying to maintain empathy, trying to maintain these things,

that's really, really difficult. And so don't feel bad if at times you feel tired, you know. This is like probably a good indicator that, you know, sleep and get into nature, get some exercise. take care of yourself. Don't feel guilty about taking care of yourself. I'm trying to embody that more. I'm trying to go out rowing every morning. If you follow my Instagram, you might see some pictures. And I'm trying to take care of my body so that the next 20 years I'm better able to be present for my kids, for my wife, for my friends, for my patients, for you guys listening. another set of countertransference reactions I would put into anger

I feel dismissed, devalued, and effectual, impotent, patient is non-compliant, which by the way, if you're treating schizophrenic patients, that's like 30% of the population, according to the Katie. Dismissed, devalued, if you have a more narcissistically oriented client, that's very common. And I could tell you story after story. of little jabs that they've made towards me.

And maybe it's competitive. I feel competitive with him or her. I feel like this very successful person maybe is really good at certain things, and you may feel a little competitive. That's something else to explore. Maybe the feeling that you get is being manipulated. This person wants a certain medication. That can make us not feel very,

warm towards people, right? And so maybe thinking through like, okay, that this person's coping strategy has been Xanax for most of their life. It's what works for them. And so, yeah, they're pretty bent on getting Xanax. But maybe as I work through this with them, they can see that there's some other options. You may feel more, another category is dissociated or shut down, where maybe you feel confused, lightheaded, numb, nauseated, difficult to feel yourself in your chair. When you're working with strong trauma, you may feel this, or when you're working with someone who's generally depersonal,

you know, going through depersonalization, derealization, they're very dissociated. So grounding yourself, feeling your seat in your chair, becoming conscious of that this is going on, feeling your feet on the ground, rubbing your hands together. sometimes pushing, I like almost like pinch myself or push my nail into my nail bed, sort of reorient myself to the here and now.

If you struggle with a lot of imposter syndrome self-criticalness, you may be pushed into this state more and working through those things. The shame might help as well. So decreasing our internal shame helps us get out of that dissociative place. and finally fear and anxiety I fear being incompetent and adequate to help him or her that may be

a countertransferential mere neurone experience of their hopelessness that no treatment is going to help it may be I fear I'm failing to help him or her and that could also be

like part of the internal representation of the other person's hopelessness. So we want to consider how much is our stuff, how much is their stuff. So in summary, I think that the trials portion of our journey, as therapists, is refining our own internal inability to express empathy, maybe our strong reactions countertransferentially, or our difficulty of connecting. And going through and sort of going through the trials

of learning how to do this better, of growing in our ability to give empathy, of growing in our connectedness, our ability to tolerate or to digest our countertransference. You know, growing in those abilities. is essentially coming up against our own woundedness to some degree. It's, we become wounded healers. We face our own woundedness, just as our patients are facing theirs.

Our patients become our teachers. Our mentors become our guides. And we are growing in the process of delivering care. We're growing in our own journey. These things take knowledge to know that they are there. And I hope that this episode has given you some knowledge of that. But they really require us doing our own work. And my hope is that you, if you have never been in your own therapy, your own supervision,

you will value and be willing to invest time and treasure to obtain this. Treasure being financial treasure. you can get creative, you know, with this. If you are someone who does not have a lot of money, there are sometimes training places where you can get a discounted rate. If you are someone with resources, you can apply some of those resources to get the best possible, you know, person that fits your needs that can help guide you.

And I recently, there was a couple emails. I received recently where people said, hey, Dr. Peter, it's been one year since you've recommended that providers get therapy. And I just want to thank you so much for your recommendation. It has helped me immensely. I've gotten a couple of those emails lately. And I'm just, I'm, I'm kind of honored, honestly. If this can motivate you to getting your own help, I am honored that that has taken place. And so, you know, what a blessing that those people sent me that email. They let me know, like, hey, this actually made me get my own therapist, my own, you know, supervisor.

And it has really, really been a huge help. So if you have a supervisor you're paying for and you feel they're abusive to you, consider that they might not be the best fit. So please don't just uncritically choose who is going to be your guide. You know, be selective, especially if you're paying cash. You can be selective, and that's a good thing. So I hope this episode has been helpful for you in your journey. As always, these show notes are in my resource library.

If you put up a message, I read it. I respond to it. if you have any thoughts, reflections, feedback, I'm always willing to hear it. And I hope that this has helped you in your journey a little bit.