Psychiatry & Psychotherapy Podcast - Transference Focused Psychotherapy, Borderline Personality Disorder, Narcissism, with Frank Yeomans, MD

Episode Date: February 22, 2025

In this episode, Dr. David Puder interviews Dr. Frank Yeomans, a leading expert in Transference-Focused Psychotherapy (TFP) and personality disorders, to explore the treatment of Borderline Personality Disorder (BPD) and Narcissistic Personality Disorder (NPD). They discuss object relations theory, identity diffusion, splitting, and the therapeutic relationship in TFP. Dr. Yeomans shares clinical insights on working with paranoid, devaluing, and omnipotent transferences, highlighting how therapists can navigate idealization, devaluation, and therapeutic neutrality. They also compare TFP with other psychodynamic approaches and discuss the role of aggression in mentalization and personality integration. Learn how TFP helps patients develop a stable identity Understand the differences between BPD and NPD treatment Explore the role of transference in psychotherapy Tune in for a deep dive into psychodynamic therapy with one of the field's top experts! By listening to this episode, you can earn 2.0 Psychiatry CME Credits. Link to blog Link to YouTube video

All right, welcome back to the podcast. I am joined today with Dr. Frank Yomans. He is an MD, PhD, prominent psychiatrist, psychotherapist specializing in personality disorders. We'll be talking about borderline personality disorder, transference focus therapy. He had his undergraduate at Harvard, graduate at Yale, residency at New York Presbyterian. He has had a number of professional roles. I'm just going to highlight the most pertinent to this discussion. He's the president of the International Society of Transferenced Focused Psychotherapy. He wrote two books that I want to emphasize, Transverse-focused Psychotherapy for Borderline Personality Disorder, A Clinical Guide in 2015, and a primer on Transfer's Focus Psychotherapy for Borderline

Patients, co-authored with Kernberg. I think both of these were, right? Yeah. Am I correct about that? Okay. Yeah, so you should also give credit to Clark and co-authored with Kernberg and John Clark. Very good. Thank you. So today we wanted to talk about borderline precise order.

We've talked about it from the perspective of mentalization-based therapy. Prior on this podcast, we've talked about it. We've talked about transfers focus therapy a number of times. So it's great to have you on here to kind of hear it from you directly. So thanks for coming on. The pleasure. Thank you for inviting me. And so I thought we'd start and talk about like what is maybe for those who are

are less familiar. And we're really speaking to an audience here of mental health professionals, people in training. They probably have heard about transfer focus therapy. I imagine they all know what transference is, but I'm hoping to really in this discussion pull out some of the nuance of the uniqueness of the approach on the podcast we talked about

reflective function and how Transfer's Focus Therapy uniquely improves reflective function. So I'm wondering if you could just kind of introduce broadly Transfers Focus Therapy and where it is, today in terms of research. Certainly, I'd be happy to try to do that. It might turn into a lengthy answer.

But when you said, going back to your statement, most people are familiar with transference. That's probably true. But there's also a common misperception, misunderstanding of transference, which is that it's the past being repeated in the present. That leaves out the mind, because what is actually being activated in the present when transference occurs isn't an accurate

version of what happened in the past. It consists of the activation of mental images, internal representations of people, experiences, relationships that are laid down as memory traces in the mind, but often become modified and sometimes exaggerated by the processes of the mind and unconscious processes that we think about when we think about a psychoanalytic approach. So there are fears, there are desires, there are anxieties, there are wishes. All these have an impact on the way the memory traces are laid down into the internal representations. So when I talk about transference in general, I'm going to refer to the title of one of Kernberg's early works, which is internal world and external reality. The idea that is that

in the course of the development of any individual, they internalize images, as I said, representations of themselves interacting with others. These become paradigms or templates or later experiences. So transference is, first of all, it's a universal phenomenon. we all transfer onto each other. Anytime I meet somebody new, my first encounter with you, there are traits, aspects of you that will activate in me memories of, and this is largely unconscious, but, you know, I'll think of, you know, he kind of reminds me of X, Y, or Z,

so I'll project onto you characteristics that may or may not really fit who you are. The challenge in adapting to reality, is taking in who the other is, so you get a precise, an exact sense of them that might be different from your initial reaction based on some kind of images that are activated in you. So it might help at this point to give, I think, what I think is a fairly dramatic example. And it's actually the clinical experience that convinced me to work with this approach. I had just finished my training as a psychiatrist and was working at a hospital, but also started a private practice. One of my first patients was a man with a combination of borderline and narcissistic personality disorders.

We can talk about each of those later, if you'd like. But in any case, like a lot of patients with narcissistic personality disorders, he had kind of an angry, aggressive, devaluing stance toward me a lot of the time. He was kind of a tough cookie to put it in plain English. In any case, in one session, this guy who was usually angry and critical, told me a story that's something that happened to him when he was a kid, five, six years old. It was a very sad story, and it brought tears to my eyes, which is not what usually happens when I'm in a therapy session, but it can happen.

Anyway, so he noticed that, and he said, you have tears in your eyes, and I simply said, yes, I didn't know what else to say. Then he looked at me very closely. He kind of scrutinized me and said, in all seriousness, he said, you're mocking me. So that is an example of transference where the internal representation, the other who was mocking you, so prevailed over what seemed like kind of clear evidence to most people that I was sympathizing with him. that his transference onto me was what we call a paranoid transference. The other person doesn't like me, is critical of me, is mocking me. And if your transferences are so strong that they prevent you from getting an accurate take on reality, then it makes it hard to adjust to life and to have success and satisfaction in life. And our patients tend to have those kind of distorted transferences for the internal image prevails over the external data that they're taking in. So in a more typical case, it's the patient who just assumes when, say, you look at the clock, does no one to end the session, that you hate

them and want to get rid of them, and that's a transference triggered by a minor external event, but leading to a massive projection. Can I ask you about this, so this comment, he said, you're mocking me. He's seeing you're feeling emotionally distraught. So he's unable to empathize with your true experiences. His reflective abilities about you and what you're really doing are off, very off, right? Was the paranoid transference there?

Was the fear that you're mocking him? Was that tied into the actual trauma of what happened to him when he was five years old? was in that five-year-old instance of him going through that conflict, was there some aggression maybe that was disavowed, or was there some that now was pointed at you, his therapist? I think that's very likely the case, but it's a good point to bring up because a lot of therapies, and this is one way in which Transference Focus Psychotherapy

differs from more classical psychoanalytic psychotherapies, A lot of therapies would jump to the past and say, oh, in that experience, did you feel your parents, who were the people involved in the interaction, as I recall, you know, were criticizing you unfairly putting you down, mocking you, you know, then let's try to distinguish then from now. In transfer psychotherapy, we would consider that focus on the past to be an avoidance, of what's happening in the here and now, because we think it's more effective therapeutically to work with what the patient is feeling in relation to you

rather than say, hey, let's look at the past 30 years ago. So you can, let's put it this way, to say, okay, you know, you took in these ideas that people who are supposed to care for you or mocking you because your parents seem to have done that. this man is going through life on a daily basis misperceiving others. So we do not try to correct the distortion. If it would work, I'd be happy to correct the distortion.

I'd be happy to say to him, no, please trust me. I'm sympathizing with you. I'm not mocking you. But it doesn't work to say to somebody who's incapable of trust to say to them, please trust me. They're not going to. Right. So you have to enter into the projection.

You have to be able to carry the projection so that you and the patient can look at it together. So instead of saying, no, please understand, I'm not mocking you. My response, I mean, this was ages ago, would have been something along the lines of, that sounds like a terrible experience to come to therapy for help and to wind up with a therapist who's mocking you. Let's think about that together. I'd like to hear more about that. First of all, your willingness to entertain the negative projection, the negative transferance usually is an implicit sign. Maybe you're not so bad because anybody who's really

negatively inclined to would have said, oh, no, no, let's not go there. So my willingness to say, if I'm mocking you, let's think about it, opens up reflection. Okay. So, so like, let's, how do you feel if I pretended to, to be this patient and we kind of go into this scenario right there and see what happens. We can give it a try. Let's give it a try. Okay. So you had just said to me that statement, so I'm going to go from there.

Okay. Well, yeah, I'm here. I'm paying money to be here. And like, I'm telling you this awful, awful event that happened to me when I was five and all of a sudden, like, you're like mocking me. And I'm just like, what the heck? Well, I guess it's not just at age five, but right now your life is full of really awful events, including what's happening between us.

And I can understand your depression when a helper or a so-called helper seems to be the opposite. it must be awfully frustrating to seek help and to encounter the opposite mockery. Well, I feel like, I feel like, you know, somehow you're doing this kind of psychotherapy gymnastics around me right now, but I can't believe I caught you. Yeah. Mocking me.

So I'm trying to weasel out of what, in fact, I think of you really, which is kind of a negative critical mocking stance. I'm trying to put the veil over that and retreat to my pretend position of, you know, sort of being a concerned caretaker. That's what's going on? Yeah, exactly. Like how, you know, I tried to call you, and then it took like three days to hear back just the other week. and this is just another example of this.

It's like if you really cared, you would have called me back that day. I was an absolute crisis. Well, just parenthetically, I wouldn't let three days go by, so I'll have to find a way to adapt to your comment here. Sure, sure. So it's important that this is coming out so clearly now.

I guess you felt this for a while, but didn't bring it up. And again, I want to try to sort this out because it's a pretty sad situation in life when even the person who's supposed to health turns us back on you, doesn't care enough to call back. And now it seems like a kind of mockery you see in me has broken through. One thing that's implicit in all of this is the view that I'm dishonest. Maybe we should think about that because you seem to feel that I'm pretending to be one thing and I'm really another. And let's open that up, please. Yeah.

I mean, there's part of me that's like, I know a couple weeks ago I would have, I think, I don't think it, I thought I saw you that way at all. I thought you were the greatest, you know, doctor ever. But somehow, all of a sudden, it seems like you're just like all the other shitheads in my life. that have preceded you. Yeah, I can see that that's confusing, and I do remember my new team to think I was a good guy. So therapy is about trying to figure out things that are confusing. Maybe you've figured out or decided once and for all

that the good guy thing was nonsense, and that, you know, I'm a, like everybody else, I don't like you, reject you, internally mock you. But on the other hand, this seems to be a little bit of that first part, which, by the way,

might not be the whole story either because that seemed to be a little too good to be true. But in any case, I think you're struggling with something. It's not totally out in the open what you're struggling with because I think it's not, fully in your awareness.

But at the same time that you have this negative feeling toward me, you're still coming here. So that's kind of contradictory, and we should work to figure out how to sort out that confusion. You know, I haven't told you a dream that I had this week about you, and I think it might relate. I had a dream that we had ended a session, and I had left,

but the door was cracked, and I overheard a phone call with you and some colleague on the phone, and you were laughing about me with this colleague. And then when I woke up, I felt like it was so true like it actually had happened, but then I felt just absolutely betrayed. And that was the end of the dream.

When did you have the dream? Last night. Oh, just last night. Yeah. Okay. Well, it seems like it's the same thing as what we're talking about. Yeah, you feel as materialized here. That in spite of my, what you see as facade of interest in you and wanting to help you,

that in my mind the honest reaction I have is to think you're kind of a pathetic human being. and, you know, like I say, talk more about that. I might go into, you know... Should we pause here and kind of reflect on what's going on. Because what I'd like to do is, I'm trying to understand what in your mind would lead to my thinking you're a pathetic human being. Oh.

I mean, I think it's like a deep fear, you know, I mean, and you know, you know, when I was some of the early situations that I had, where I felt some level of betrayal. And I think it's a fear that I have. Being betrayed and being pathetic are not exactly the same thing. I can understand you're feeling betrayed, but what I see now is a kind of feeling pathetic where you, you know, we've seen so many instances where you disqualify yourself, attack yourself, put down an effort you've made. And I think kind of what's happening between us, as you see it, goes on in your mind within you. In other words, you against you,

the way you see me against you right now. Yeah, and so I think I'm confused because it seems like you're not against me in this moment. You're curious about how I'm observing you. Do you think, okay, let's pause. Let me just finish. I say another possibility. It's very important to figure out which of the two possibilities seems more real. but anyway, okay, that's enough, yeah, okay.

Well, I think I'm curious, because you've done this a lot, like, what would the patient say at this point? Would they softened, you know, and their kind of observations, would they get more reflective? Would they dig in? I would say more often than not, no, because defenses are very strong.

When I say defenses, I mean, especially when we're talking about people with borderline level personality disorders, splitting defenses, which we should discuss at some point, the person can't get in touch with their own aggressive feelings and see all the aggression in the other, as this man is seeing all the aggression in me. I'm trying to get him to see there's some aggression in him, which in fact he turns against himself. But to answer your question about what patients usually do, usually they say, oh, you're just, you know, what will they say?

You know, you're just running circles around me. You're just trying to use the psycho babble to cover up what I know is true. So you can't expect every intervention to lead to increased insight, but you just have to continue with it to stay committed. and assume instances like this will happen again and again, and that when you're lucky and you've accumulated enough mutual experience, one of those moments will lead to the person thinking about what you're saying and beginning to reflect and take it in.

We have some research along those lines. One of our colleagues, Yoga Ev Kavidi and his other researchers, published a paper about what leads to change and to the reflective functioning you mentioned. And it is what in his paper he calls bids for reflection. In the traditional TFP literature, we call it confrontation. A lot of people say that's not a good word. It applies a hostile confrontation.

But it really means doing what I tried to do with you in the clinical vignette. Say, we've got this and we've got that and they don't seem to fit together. how can we reflect on them? So short answer to the questions, most usually the patient continues with their defensive projection, but if you keep going, eventually they begin to reflect.

Yeah. Oh yeah, I think it's, I think there's a couple things that I was trying to embody, the idealization early on in treatment, and then this kind of became into the devaluation, right? So I think this is a lot of what clinicians have seen. It's like initially, the patient is like, you know, you're this all good, perfectly nurturing, you know, figure who really gets me.

You truly understand me. Finally, I have a clinician that has enough expertise to help me. You know, you hear like a bunch of these string together and you start to get a little bit worried as an experienced clinician, like, oh, okay, there's something deeper going on here, right? And then the devaluation, right? So this is, he's currently in the devaluation where it's now you're, malevolent, incompetent, cold, rejecting. And this is partly what you consider like borderline level of functioning, right? So not neurotic level of functioning, not psychotic, but borderline

level of functioning. There's a lot of this idealization devaluation. Yeah, but let's talk about the basic theory, because to understand what's behind idealization devaluation, I think we have to take a little review of object relations theory. Is that okay? Sure. Okay. So object relations theory is a branch of psychoanalytic theory that emphasizes the self in relation to the other. Early Freud-posited neurotic conflicts based on an internal struggle between an impulse, a drive, and a prohibition against the drive. So, you know, somebody wants to have sex, but they think it's bad, and they get a symptom, and, you know, I'm simplifying. But in any case, some later analysts came along, and the one I'm thinking of in particular is mentally kind, and said, well, people do have drives. They have sexual drives. They have libidinal drives. And libidinal means more than sexual. It means affiliate of, you know, attachment related, you know, wanting to have or satisfying relations with others. So there are libidinal drives in the broad sense, and they're aggressive to drives, anger, wanting to strike out.

wanting to combination of assert oneself and defend oneself not all aggression is bad it can involve competitiveness and assertion and competition and creativity anyway the idea is that if you have those drives libidinal ones and aggressive ones

you don't just feel a drive you feel a drive in relation to the object of the drive if you're feeling you want to connect to somebody you have the idea of with whom you want to to connect or if you want to, you know, have some kind of competition with somebody, there's an object of that. So given that emphasis on the connection of the drive to the object of the drive, we can then look at infant development. And the newborn takes in a lot of experiences and it's complicated because of neurobiology and the myelanization of the brain and so on and so forth. But,

And, you know, there's still a gap between the analytic theory and neurobiology. All the gap is narrowing. So in this theory, in the early year or year and a half of life, as it is positive, experiences with the caretakers are by the infant seen as either perfectly satisfying or totally depriving. because there's no concept of object constancy. If you're being, you know, caressed and fed and kept warm and cozy, you're in heaven. But if you're uncomfortable, you're cold, you're hungry, you're soiled, and the caretaker isn't there, you don't have this feeling, oh, I know she'll, mom will come around, you know, just give her a little time. You don't have that object constancy. You're in pain, you're suffering, and you perceive the opposite.

other as the source of the suffering. So you're either in heaven or in hell. The other is totally caring for you in an ideal way, which doesn't correspond to reality, by the way, or the other is persecuting you, not just unavailable, but persecuting you. So in object relations theory, the early makeup of the mind is divided between the segment of the mind that's about positive, ideal experiences and negative persecutory experiences. Interestingly, this corresponds to some neurobiology because it seems like the brain areas where positive affect is located and the brain areas of negative affect are different brain areas that require clortical intervention to bring them together. And we think therapy can help with that. So in any case, if you go through life where things are

either perfect or terrible, you don't adapt well to the complexity of life because life isn't that way. So to go back to your concepts of idealization and devaluing, patients often come in projecting, I finally found the ideal therapist. This guy knows everything, everything's going to be perfect. Now, that positive side of the split internal world is just as pathological. it's the negative side that's all about paranoia and rejection and harm because the positive side doesn't correspond to reality. You never find the perfect caretaker. No matter how much you're in love with your partner, they're not going to be perfect. So you have to accept that, but people with splitting, when we talk about splitting, we mean splitting between the all good and the all bad.

People who splitting expect perfection and for a while they might continue. with you with the illusion that they found that. But inevitably, there'll be disappointment, and then it flips into the devaluing. So let's talk about what happens in successful psychological development. In success, oh, by the way, that split organization is called the paranoid schizzoid organization. It's called schizoid because it's split. Why is it called paranoid? Because in that mental organization where aggression and libido, fondness, and aggression are totally divided. The person experiencing aggression is not comfortable seeing himself or herself as the source of the aggression. They tend to project the aggression and see it as coming from

outside. So as soon as you begin to get close to somebody, you're nervous because you think something bad is going to happen, rejection, harm, so on. So in successful psychological development, we move from the paranoid schizoid position that project the radical separation of positive and negative and the projection of anything aggressive on others to what interestingly Melanie Klein called the depressive organization, which doesn't sound great who wants to be depressed, but it's more specific than that. If you integrate those two radical polarized extremes, two things happen. One is you have to give up. and you have to mourn your belief that you can ever find the ideal other,

or that you can ever be the perfect ideal self. You have to give up on thinking anybody can be ideal. And that's kind of a sad awareness. The second thing that happens when you begin to integrate your positive and negative emotions is that you begin to have awareness and take some responsibility and consciousness. For the aggressive feelings, you always saw as outside of you. So it's a painful trajectory from splitting and projection

to integration and mourning the ideal object and accepting that one has one's own aggression. I'd like to give you a clinical example in a minute, but does this help understand why patients come in with the idealization and then inevitably switch to devaluing when you don't meet their perfect expectation? Yeah, I think the thing that I would love to hear, hear from you kind of like how it fits into this is the idea of identity diffusion.

Yeah. Can you integrate that into how you, does that fit somewhere into this? It's perfect. In fact, it's good you bring that up because in our model of the mind, of personality, and of personality disorders and its treatment, identity is the core concept, whether the identity is integrated or fragmented and diffuse. It's important when we talk about identity to think about how we mean it.

Because a lot of people, when they think about identity, think about identifications. You know, what's my gender, what's my sexual orientation, what's my ethnic affiliation, what's my nationality, what's my sports team, what are my interests.

So there are all kinds of elements of identity. And when we talk about identity, that's not exactly the level at which we're talking. We're talking about identity as the ability to be in touch with grasp and manage the full range of your internal emotional states. In other words, does your identity allow you to assume and connect, with the full range of who you are as an emotional being. That's a different level of identity. It's a very core sense of identity. Do I have an integrated identity means have I gone beyond the paranoid schizoid position where everything was polarized and fragmented so that I could not have a stable emotional existence? I was buffeted back and forth. I was buffeted back and forth.

between idealization and devaluation. I don't have that core sense of emotional stability where I get it. I can be loving. I can be angry. I can adore somebody. I can be rageful with somebody. So our sense of identity integration is to be integrated emotionally, not to rejects, but often project parts of your emotional self. Okay. So I've been, I've been, been reading thinking about identity diffusion i was reading about this guy solomon octars yeah six characteristics and is it this is this is this what we're talking about the same thing or is that slightly different his six characteristics were temporal discontinuity of the self a lack of authenticity feelings of emptiness emptiness is kind of different than loneliness because there's a

hollowness. Yeah. Just feeling like just like a shell, a lack of identity around gender, a lack of identity around sexuality. So just kind of like a diffusion beyond just like, who am I? What am I doing in the world? Is this kind of what we're talking about? Or is it building up?

Yeah, is a really brilliant guy. And I haven't read exactly what you're talking about. I would agree with the first part. I wouldn't talk as much about the second part. The emptiness, can you mention the first three things you said? One was emptiness versus loneliness, so I want to talk more about that. Like the discontinuity in the self. Yeah, and it did continuity in time, yeah.

So it's like a quote it from him is like, the past, the present, the future are not integrated into smooth continuum of remembered, felt, expected existence for these patients. Yeah. So that's one of them, temporal discontinuity, discontinuity of the self, like a chronology of how they see their life, a lack of authenticity. Here's a quote, act as someone else they know would act, not in a manner that genuinely is their own. So they kind of like put on different faces, so to speak. Feelings of emptiness is like this like hollow, shell-like.

lacks capacity to fantasize for a person or experience in the midst of like a lonely person may fantasize for connectedness with someone like they don't have that fantasy for that other person. Yeah. Let me, yeah, I want to say I think that's a nice delineation of what we call identity diffusion. And it has to do with the development of a core. sense of self. If you remain split and you're flipping back and forth, I love this person, I hate this person, which by the way has internal correlates, which is I love myself, I hate myself, as I was trying to point out in our patient role play that he was very rejecting of himself,

at the same time he saw me as rejecting. You don't have that ballast, that core, that integrated foundation on which to build. You're just flipping back. and forth between two states that never come together. That leads to emptiness. That leads to a sense of not development over time, but just time passing without development. Dr. Kermberg has an interesting article about what he calls the destruction of time, because if we consider time from the subjective point, of you. What is our experience of going through life and the passage of time? Kermberg's idea is that we sense time as we build and grow as a self, as we enrich who we are, we add to our sense of who we are, we become more complex, and we add to what we've done and what we plan to do. If you haven't

yet achieved emotional integration, you can't develop because you're don't know whether you're loving or hating, you can't combine the two, and if you're always jumping back and forth between two things, you don't have that foundation upon which to build. A lot of my patients say to me, you know, the worst part of having borderline personality disorder is not the acting out when I'm maybe hurting myself or having a rage attack or something like that. And we should get back to the experience of aggression in the borderline patient. The acting out isn't the worst part. The worst part are those moments when I'm sitting alone by myself and I feel totally empty. We have to, as therapists, try to empathize with what that is

like. It's pretty horrifying, pretty scary. And a lot of the acting out is to escape from that core feeling of emptiness. And if you do have that feeling of emptiness, and on clarity about who you are, then you are going to mimic other people. You know, I'll do what this one does, I'll do what that one does. So I agree a lot with what Actar says. I want to invoke another title of one of Kernberg's book.

He has a title called The Inseparable Nature of Love and Aggression, and I think that relates to this concept of integration. A lot of my patients who are stuck in that kind of naive belief that you can find the ideal, say, I know I'm getting better because I'm going out with this guy and, you know, we were having a really good time. But then, you know, I don't think I can sustain it or, you know, I ruined it all because I got angry at him. I felt angry at him. And I say, well, yeah, but let's look at that. Do you feel you can really know somebody in depth, have a lot of shared experience, and it's all going to be positive?

if that's your goal, you're not going to have any deep relationships because in intimacy, deep connectedness is going to include negative feelings as well as positive ones. That's a more concrete example of integration. In one of your YouTube's, I forgot which one, but you said something like the strongest identities are based off of religion, philosophy, or art. Did you say that?

No, I didn't, but I'd be happy to talk about it. Wait, who, I swear I was, who said that? Who said that? Okay, was that? I don't know who said that. I think you might have, here's what I said about religion, philosophy, and art, which is that that's where you can idealize.

Oh. Yeah, I said, you know, when I just went over the object relations theory, where you go from the split organization, paranoid schizzoid, to the integrated, more complex, organization where you give up the idea of perfection and finding the ideal in another person. I want to emphasize that I'm not totally cynical. I don't think you're not allowed to have ideal beliefs, ideal values. They might be embodied in a spiritual system, an ethical system, an artistic pursuit,

an aesthetic pursuit. So I think ideals are laudable, but look for them where. they might exist and not in another person or oneself. Okay. Thank you. Thank you for that clarification. So, okay, so it's like, is someone inevitably always going to be in the depressive position? Is that where they stay forever? Well, first of all, when somebody advances to the depressive position, that really enriches life. As I said, you lose the idealization and you have to take responsibility for your aggressive feelings, but then you're in much closer contact with reality. You can really engage

with others more fully. You can engage with your work, your projects more fully. So when patients make that shift to the integrated depressive physician, we help them work through the sad feelings about mourning the ideal object, and usually the guilt feelings about having their own aggression, and we try to help them see they can, what we call sublimate or direct or manage their aggression so that it can have positive applications, not negative ones. But when you mention the transition

from the paranoid-schizoid split position to the integrated depressive one, unfortunately, that's not a development that necessarily takes place once and for all. People like you, I assume, and me, I hope, who are in the integrated depressive level. Under certain circumstances, we can regress back to splitting if we're under enough stress or if we just want the pleasure and simplicity of splitting, because splitting allows you not to think as much. Spilling is simple, but in a way it's reassuring. When your mind functions according to splitting, you know what's good and you know what's bad. There's no ambiguity.

So if, for example, you go to up here in the Northeast, it would be a Red Sox Yankees game, for two hours, you can allow yourself to regress, to forget about all the complexity of the world. You know your team are the good ones, the other team are the evil ones, and you can enjoy that for two hours. The problem is that political leaders can appeal to splitting. When they say, we're all good, the only problems are outside of our group. Everything bad is outside. That's just like the borderline patient who says, everything bad is in the other. I am, I don't have any bad traits.

So I think there's a seductive splitting. You don't have to think as much, and you're told what's right and what's wrong. And I think there's a, I mean, if you look at both sides of political spectrums, it's very common that the person will adopt all of the policies of one side, right? It's very rare to find someone who's nuanced and parses out different policies and can see good and bad.

So I think we all, do we all kind of enjoy and revel in at times this splitting as well within our sort of tribe, right? And is that a natural process? We can until the system breaks down because in that tribe mentality, people are not taking responsibility for themselves, but only blaming the other. And then when you get enough of that going on, somebody's going to get into. violence and it's going to fall apart. Okay, so I think this is like a really good aspect I like about depth therapy is you get the person to a place of taking some responsibility rather than just blaming purely all of their situations they found themselves in. But do you find that also like there's this kind of

over-exaggeration of like all of life's issues that you have are because of the trauma. us that you've faced, right? And does this kind of like push against transfer's focus therapy, which is kind of like, hey, we're taking responsibility for? No, you're bringing up a very big issue in a controversial one, an area in which we sometimes get accused of being insensitive and unempathic. So let me give you a clinical example first, and then I'll get back to that trauma question. Because when we talk about, taking responsibility for one's own aggression, we should speak for a moment about the concept of acting out. Everybody talks about acting out, but the true meaning of the term has been

lost. At this point, when clinicians say, oh, he or she acted out, it usually kind of means they misbehaved. But the definition of acting out is to put into a an action and emotion one cannot consciously stay with, that one cannot tolerate in oneself. So you discharge the emotion through action instead of feeling it and thinking about it. So here's my example. Patient of mine came to therapy saying that even though she made a suicide attempt, she wanted me to understand she didn't have a psychiatric illness, that all of her problems were caused by her monster husband who made her life so miserable that any woman married to him

would sometimes rather be dead. And unfortunately, that can be the case. At the beginning of therapy, I had to consider that that might be an accurate description of her life. Anyway, a couple of months into therapy, she comes into a session and says, I told you how awful my husband is, can you believe he forgot our wedding anniversary he knows how much that means to him he's awful he's callous he's cruel in the meantime before that session i had received a phone message from the husband who said doctor i don't know what to do i forgot our anniversary and i know that's bad and i know that you know it's something my wife cares a lot about but she got so angry at me that she picked up the TV and threw it across the room at me.

So in the session, I said to my patient, I said, well, I can understand your hurt feelings and how bad it was that your husband forgot your anniversary. But he left me a message that you threw the TV at him. You know, I said that calmly not condemning her in any way, staying neutral. And she said, what else could I do? I was upset. It's different to say I was upset than to say I was rageful and angry. She felt a discomfort that I believe was rooted in her rage and anger, but she didn't want to feel I'm rageful and angry. I want to get rid of this emotion. So I'll throw the TV and then I'll sort of get it

out of my system. So if we see acting out as the discharge of something one cannot think about, Our job as therapists is first and foremost to get people to think about what's in them that is too difficult for them to think about on their own. Now, how does that tie into trauma? Wait, can I ask sort of a side question on this? How do you feel when the family member calls you and gives you information like that? Because sometimes it can put us like in a difficult position, right? Sometimes I'll get like an email from a mother or father, you know,

and it's like, you know, sometimes it is a little bit, like, okay, what is reality here, right? Oh, very much so. But I'm glad you asked that in TFP, we're, even though we're based on psychrelated concepts and techniques, we are more open to contact with other persons in the patient's life. you know, classic analysis is the analyst or the therapist and the patient, that's like totally hermetically sealed. But with patients with severe personality disorders, in the initial evaluation, we emphasize you have to evaluate a person and discuss that the nature of the treatment will be and what the conditions of the treatment will be. You have to have all of that in place before you begin the therapy. So anyway, part of that assessment in our.

practice increasingly involves bringing in the parents if it's a young person who's very dependent on the parents or the partner if it's somebody who's living with somebody or very close to something. And why do we do that? We do that because first of all, most people don't understand personality disorders. Most people, and I think this is a problem with American psychiatry, most people think about, yeah, most people just think about symptom disorders. It's a depression. It's an anxiety disorder. So there's got to be a medication for it. Well, you can be depressed because of the way your mind works, not because your neurons aren't firing right. So if we, one of our steps of beginning treatment is after our assessment to have an open discussion with the patient about

our diagnostic impression, if it is personality disorder, we say that, we explain it in simple English. We emphasize the new understanding of personality and personality disorders, that it centers around difficulties in the way one thinks about and feels about oneself and about others. That's in the alternative model of the DSM-5. And then we bring in the family with the patient president. We have the same discussion. Why do we do that? So first of all, they won't have unrealistic expectations that there's just a medication that hasn't been tried yet, or ECT, or TMS, or something like that. And secondly, because there's a common misconception that you can't expect much from a person with a personality disorder. And we don't find that to be true. We think you can expect a lot,

but I don't mean to say this in the sense of putting a burden of the patient, but opening the patient up to their potential so they don't see themselves, as men as disabled for the rest of their lives. Yes. They can get better as many do. They can have a much more productive life. So anyway, having... I think that's so important

because especially, I think people think personality disorder, you have this for life. And I think that a lot of people with BPD or borderline level functioning, they take on illness as a narrative about themselves. And then, you know, what you're challenging, is that identity of illness. Yeah.

And like I am an ill person. I will always be an ill person. Yeah. Which is why I get, I've turned so many people from bipolar to unipolar and personality disorder because it's like, it's like, no, like there is hope, right? You're not, you don't need to be on medication your whole life.

If you have a personality disorder, actually the new standard with the APA, American Psychiatric Association, the borderline personality disorder is not, medication isn't going to treat borderline persia disorder. It may treat some of the comorbid issues, but not actually borderline per sali disorder. That's the most important message from this whole discussion.

I hope your viewers have stayed with us long enough to hear what you just said. So, go on, go on. I'm like, we're on the same team here. That's very important. Anyway, after having had this initial contact with partner or parents, whoever it may be, with patient present, I said, you leave it open that if those parties think there's something important to communicate to you, they can provide you that information.

The patient usually says, you're violating my confidentiality. And I say, no, because I'm not telling them anything. I'm just letting them know if they have a concern. They think I should know about they can tell me. And that doesn't mean I'll necessarily believe them. You know, maybe, you know, they'll say something and, you know, you'll say, that's not accurate and maybe it'll be their issue and not yours or ours. So anyway, that I hope, is an answer to how we deal with information from a third party. Yeah, that's good. Okay, I think we were

now... The trauma. We're talking about trauma. Yeah. And the reason why I'm bringing this up, because I've been thinking a lot about complex PTSD, BPD, and the odds ratio when you go into like adverse childhood experiences. When you go into like when a child has four to five, the odds ratio of either one of those is like 20. It goes way up. And so I personally see it's like, it's like not enough to have a lot of aces to develop PPD, but it's like a part, it seems to be a part of that process. Yeah. Well, it gets complicated. So first of all, let's think about what Freud called the complementary series. It's a basic concept where he sees two main contributors to psychopathology. One is temperament and sort of emotional raw material. One is born with some

people of much more fiery and intense temperaments than others. So temperament could be the main factor in the development of the personality disorder. But the other part of the complementary series is developmental experience. And the adverse childhood experiences you're talking about can be a good example of that. So in Freud's model, he says, you know, any individual might have their own proportion of the temperamental contribution to the pathology and the developmental. But let's go back to what you said about complex trauma and moreline personality. Let's rewind to the 1990s. I was running, I was the unit chief on an inpatient unit where we had all patients with relatively severe borderline personality disorder. And we like to invite people who might contribute

to our knowledge to come and talk to us. And at that time, and it's kind of a resurgence of it now, there's a very strong emphasis on trauma. as maybe the most important factor in the development of personality disorders. So Judith Herman, who writes and researches, you know, trauma a great deal along with her colleague, Bessel van der Kolk, came and spoke to us. And her work is really good, but I think she and we are not on the same page about borderline personality disorder because she said, you know, you guys don't understand borderline personality disorder is a misconception. All of these patients you have are trauma patients, and you should see them and treat them as trauma patients.

What is the difference there? The difference is what you said about most trauma models. I'm not saying all because I'm not totally versed in trauma models, but they would not see any contribution of the patient's own aggressive feelings. They would see aggression in the patient, not as the patient's innate inherent stuff. but as the result of traumatic experiences which have been introduced into the patient's mind from outside. Mentalization-based therapy is sort of a good example of this. They talk about the alien self.

Their model of BPD is somewhat different from the TFP model. It's interesting because both are considered psychoanalytic models, but I think TFP goes deeper in terms of looking at the core, deep conflict in the mind between libidinal feelings and aggressive feelings, loving and hating. Whereas in MBT, they say what happens is that the Borline patient has had experiences of trauma growing up. So they have in their mind an internal image of aggression that has been introduced to their mind from the outside, and that is to use their word colonizing their mind, and as you help them to think and reflect more clearly, to mentalize their internal states and the internal states of others better, that alien

aggressive element just kind of goes away. I consider that a little naive. I think that everybody, you, me, and everybody I've ever encountered, you know, part of the human nature, part of human nature, is to have some aggression. We wouldn't have survived as a species otherwise. The problem is how in touch with that are you and how do you manage that? So I think what happens with BPD patients is, as we know, let me just give a little reference to research

and then I get back to the clinical example. Studies have shown that about 70% of patients with BPD have had experiences of trauma. But first of all, if you look more carefully, as Joel Paris up in Montreal did, the trauma isn't all major trauma. But I think more importantly is to reference a study that shows that if you start by looking at the general population, and you look at the subgroup of the general population who have experienced trauma, and you study that group of trauma experiencing individuals. The majority of them do not have psychiatric conditions.

So you can't say trauma equals the development of psychopathology. We think it has to do with the way trauma is processed. We're not saying that trauma doesn't have an impact, but let me reference a patient of mine who is actually a lovely young woman in her early 20s who was lovely except when she was making. serious and violent suicide attempts. In a session in my office, she banged her fist on the arm of the chair and said, I'd rather be dead than think I have anything in common with that awful abusive father of

mine. And I said, I think you just defined your problem beautifully. You'd rather be dead than think you have anything in common with him. Whereas, as a matter of fact, you almost undoubtedly have something in common with him, because we all have some angry, aggressive feelings, part of who we are. I think your problem is that when you feel the first emergence, the slightest inkling of an aggressive feeling in you, you can't think about it, accept it, and work with it.

The slightest inkling of an aggressive feeling in you activates the internal representation of a totally abusive father, and then you think you don't deserve to exist. So the problem is that, that the trauma introduces into the person's mind images of aggression that are excessive and not easy to tolerate. Yeah, I'm following you.

I have a couple of thoughts. One of the thoughts is I've studied micro-expression, so I look at like small moments of flashes on the face of people as they talk to me. And often, you know, anger is given a bad rap. People don't like to think that they are angry, people don't like to imagine that they're angry. And my conception of anger has shifted over the years as I've watched people.

Yeah. Because they not only flash micro expressions of anger when they're frustrated at their spouse or in an argument, but they flash it as well when they're talking about what they're passionate about, a book that they're writing, an artistic endeavor. It's a passion project. And so I've reconceptualized anger as it's the energy to overcome an obstacle. to move towards a goal. And so I agree with your conceptualization

that we have this drive, right? Which I would say is aggressive, this aggressive drive, a drive that's maybe competitive, maybe at its worst, it's envy to a place that it doesn't allow friendships. Maybe at its best, it's a drive that allows people to accomplish worthy things

that improves society, improves your family, improves yourself. So that's my first thought on what you said. The second thing is when I think about, we've talked about BPD on prior episodes and we talked about some early studies by Chess, Thomas, Rudder, Earth, 1963.

They did a study of 141 children that they followed, and it was this longitudinal study where they classified people as easy, slow, to warm up, and difficult. And 10% of the kids were difficult from a very young age, and the difficult ones they described as, quote, often irregular in feeding and sleeping are slow to accept new foods, take a long time to adjust to new routines or activities,

and tend to cry a great deal. And they followed these children, and the difficult children accounted for the largest proportion of kids that had behavioral problems later on. And so it was Dr. Cummings, who has been on my podcast, number of times. He was emphasizing that a lot of the kids that potentially develop BPD have this kind of like temperamental sensitivity, higher aggressiveness, right? And then if they don't go through traumas, maybe they don't develop BPD. But with the right, with a wrong environment, lack of empathy, lack of connectedness, maybe a disconnect between parenting styles, disconnect between

personalities maybe they develop something that looks more like BPD maybe they you know we know that attachment disorganization has something to do with it the beta is pretty small emotional dysregulation and in adolescence has much higher beta so i'm i'm i'm kind of like agreeing with you and kind of adding on this uh this layer so coming back to like this idea of aggression and the positive sense of like personal responsibility, taking ownership is sometimes disavowed and someone ends up in this kind of like victim, hero, persecutor. Yeah. The trauma therapy ends up in that place where the patient is always the victim. The therapist is always the hero. And the bad things in life is always the persecutor that happened earlier in life. And that's, it's a very seductive

placed to live, but it's also, it kind of leaves them in that illness narrative, which I think keeps them stuck. Yeah, there's so much going to. First of all, I really endorse this emphasis on micro-expressions. That's when a lot of what is split off and not in awareness comes through in facial expressions, non-verbal communication. Second, that was Stella Chilett. his work you're referring to? Yeah. I haven't thought about that in ages. I'm very glad to hear you refer to that

because it should be given more importance in the current days. Or maybe it's just me, but I haven't thought about that a long time. But getting back to what you just said about therapist, hero, patient victim, abuser, outside. That's where we sort of upset the Apple card, if you will. because we don't accept this hero role in TFP. And this is where the role of therapeutic neutrality comes in. We're often criticized these days for what you call neutrality.

Can I talk about that for a minute? I noticed it in our back and forth. It's like you weren't overly reassuring, right? And you were like curious. And I was almost about to push you on it in the role play, but I decided not to shift gears and be like, I feel like you're really distant right now. You don't really care. It looks like you're almost bored. You could be quoting a session I had yesterday, but go ahead.

So go ahead. Tell me about that's the point. We stay neutral, and that doesn't mean indifferent. We care a great deal about our patients. We react emotionally to our patients. We tend to keep our emotional reactions inside and to reflect upon them, that gets to countertransference and how one can use that. But if you're not explicitly endorsing, and I'll use the word validating, because that's so important in DBT, the patient, often you're considered suspicious or negative, and then you just don't get this hero treatment that you would get. If you said, yeah, it must be terrible to have had that dad, who was so awful. I mean, I wouldn't say, I wouldn't necessarily not say that. I mean, it was terrible to have that dad, but then I might say, but if we only talk about him in the

past, I think we're missing something that goes on in your current life. And that's when you sort of stop from totally supporting a projective defense, and you begin to be open. And you begin to be open to a deeper look inside. And that's when you're not the hero anymore because you're saying something that connects with the patients doubt about themselves, but they had doubts about themselves before they came into your office. They just want you to reassure them. They shouldn't have any doubt. But instead of that, we're saying, what are your doubts about? What is there in you that you're concerned about. Maybe if we thought about it, you could sort of get to know yourself more fully. Okay, so what if, what if, like, okay, so like, what if I had said to you in that roleplay,

Dr. Oben, I feel like as you're responding to this to me, like, I sense there's so much dispassion, and I would expect you to at least react a little bit. to me saying that you were making fun of me, it seems like you're just kind of apathetic to that accusation. Uh-huh. Again, I'm channeling a session from this. It's a tough position because you're being, oh, I don't, let me say.

Go ahead, go ahead. So, yeah, so essentially you're experiencing me as a combination of indifferent and neglectful. Yeah, it's like for some reason, that feels more true than you being the abuser. You know, it feels like, it feels like you're, it's a form of abuse. Yeah.

So just neglect me and to be apathetic. So what you would like is for me to hardly endorse the position you're taking and just say, if we could just get you beyond what your parents did to you, you know, you'd sort of deal with life better, be able to have better relationships, feel better about yourself. Is that the model you have in mind? It's like I'm talking to a door.

And like I just want some, well, something other than this. I mean, it's just like, even, even the speed. at which you said that, it's like lolling me into some sort of like hypnosis or something. I don't know if that's like part of what you're trying to do. Well, I don't mean to be sarcastic, but the kind of thing you're asking me for, you've had a number of times over kind of long periods of therapy. So first of all... Yeah, and I know, and I know they were all like, I hate them all, you know, like, they're all. Like, they're all, well, some of them had some decent parts, but most of them were like all, you know, just quacks.

They were quacky. But let's get back to here. Okay. You know, I'm speaking slowly, so I'm a robot without any feeling about you. And I'm just kind of, that reflects my lack of interest. Am I getting it right? Yeah. Like, do you, I don't know, maybe.

maybe I'm just one of a hundred patients of yours and you're like, you know, it's just like, okay, here we go again, you know. That I get. What do you mean you get? What do you mean? What does that mean? You get it.

Now I get why it's so depressing your life. I mean, I don't think I'd say... Yeah, it's like you're the person who's supposed to care the most. And when I sense that you don't care at all, it's like, a dagger into my heart.

Well, I can understand if you feel that after coming here now for three months, twice a week, that I don't even see you, that you're, I kind of just have this boilerplate response to the person who came before you and the person who came after you, that would leave a person pretty sad and desperate, so there I do get it. Yes. Thank you for that. Yes, it leaves me sad. It leaves me desolate. It leaves me feeling like, what the heck am I doing here? Yeah. Like, did I choose wrongly? Am I crazy to think that you'll be able to help me? Well, that's the question. What are you doing here? Because, like I said,

before, in spite of all the dissatisfaction and, and I guess pain your experience here, you keep coming. so I just wonder if there's something else going on. Why? You're the person who's supposed to tell me what I'm doing here. Not me. Like, I'm not the professional. I have a hypothesis. So my hypothesis is that in spite of all surface appearances,

our repeated meetings have activated some feelings in you, negative, positive, both. But we're seeing the negative ones. We're not really seeing a whole lot of the positive ones. And yet you're coming here and continuing to do so. So just there's something positive, but it seems really scary to you. I'm embarrassed about how honest this conversation is right now. Like, this is very uncomfortable for me.

I usually am not this honest. Well, would you agree with me that honesty might be useful and helpful in therapy? And what are you? What would you usually hide? I don't think what you would usually hide would be your criticism of me and you're saying I'm a robot and don't care and mock you. I think what you might be hiding is that you kind of wish we, had a good connection, but that's scary to think about.

It's scary to think that you don't care. Well, you see, that's what... I desperately want to know that you care. Like, do you... Yeah. Yeah, but I don't think I could say anything that would convince you. I think we have to continue with what you're experiencing here.

And what's noticeable, I think you could agree or disagree, is that you feel safer with the negative feelings and with the positive ones. And when you said you were being a little more honest here, I think it had to do with maybe communicating something positive, but that's like really going on thin ice for you because that's not your general experience in life. I think if you were to give me a hug,

I think that would convince me that you appreciated me. Well, I disagree. Because you've had that kind of thing, therapy before. And I think to ask for that is to short circuit what you're feeling right now, to short circuit the tug of war in you right now. Can I trust him? I'd like to, but I can't trust him. He's going to hurt me. I'd rather stick with the tug of war than try to put it to a premature close. And anyway, I was going to say, you know, that's just not something I think would be therapeutic, the health one could kind of complicate matters.

Okay. Okay, let's debrief. Okay. Yeah, so, okay, so this is like something that you experience with patients. It's like the neutrality kind of can engender. So Nancy McWilliams talks about like it's the tetrad of the hero, the victim, the persecutor, and then she says the fourth, the uninterested observer, right, which the third. therapist can kind of get pulled into.

So that's like another level of transference, right? Yeah. But the key is to being, maybe the word is too strong, but almost passionately interested in your patient, concentrating on them, devoting your attention to them. And even in spite of your feeling as a patient that I speak slowly and without any affect, over time, belief is that that solid commitment to the patient is going to sink in at some level. But I also

want to say, I don't want to portray this as simply a corrective emotional experience, but it's important to maintain that focus, that concentration, and that commitment because patients push us out of that position. Patients provoke us by provoking countertransference reactions where we can get angry at them, we can reject them, we can distance ourselves from them. It happens particularly with narcissistic patients. We haven't talked as much about narcissistic patients, but let's for a moment, patients with classic boardline personality disorder have almost universally an insecure attachment style, as do patients with other severe personality disorders, but there are different subtypes of insecure attachment. And borderline patients,

classic borderline patients generally have what's called the preoccupied insecure, which is ruminating about the other person and the interaction. What is he thinking about me? How did he think about the last thing I said? Does he think I'm stupid? If the patient is worried about you and your responses, you have a ton of material to work with. So the classic narcissistic patient, has an insecure, dismissive form of attachment. You don't matter at all. I could care less about you. So what studies and clinical experience have shown

is that when the therapist is subject to that dismissive attitude of the patients, most often they mirror it and they back away and they become dismissive and devaluing themselves. That's why I say, for you, to maintain intense interest and commitment is not a given. A lot of therapists are derailed from that because of the countertransference reactions

that are elicited in them from the patient. Interesting. Okay. So, yeah, somehow their detachment as a sort of a mechanism of staying connectedness to mom, right? So it's like the classic picture is mom leaves the room. There's toys. They're distressed, but they're pretending as if they're playing happily with the toys, moms comes back and they don't even look at her.

But they really are in a distressed state. Their cortisol is high. So in a, that's more of that avoidant attachment style. So you're saying that that occurring in the room when they are like that, somehow that this is the way that I'm thinking of it's like our mere neuron representation. of that countertransferentially wants to distance ourselves or become a little bit more disengaged. Yeah, right.

So anyway, to get back to whether it's corrective experience, emotional experience or not, your ability to stay committed interest and devoted to the patient, in spite of all of the storminess and the kind of negative feelings that can arise and sometimes wishes to distance yourself, that in and of itself isn't enough. to make the patient sort of reconsider if somebody might really care about them. Because if you take the guy who saw my tears as mockery, you have to do some interpretation

before he can take in my commitment in him and interest in him. You have to help him see that he is putting in me something that exists within him. And like I said, when we were doing, or discussing the role play. The mocking person is part of his own mind towards himself that he exports to others. If we get him to see that it exists within himself,

then maybe he will be less inclined to automatically see others as rejecting and be able to take in their caring about him in a way he couldn't before. Okay. How does, how does this, how does this, the kind of the transference of omnipotent control, kind of fit into that, like where their agenda setting, boundary testing. Yeah.

I'm going to refer to your notes that you sent to me about topics in my camera in a way that's totally understandable. You wanted to talk about different types of transferences, devaluing erotic, childlike, regressive, rejecting, and the controlling omnipotent. But the first thing I want to emphasize is that given the internal fragmentation of the patient's mind, you can have rapid shifts from one transference to another. You were talking about that to some extent when you talked about going from idealization to devaluing,

but you kind of talked about that as though it was like a once-and-for-all shift. But depending on the circumstances, people can not consciously, but just in effect, hop back and forth from one way of experiencing themselves in relation to you to another, and it can be a little bewildering until you have time to think and observe it. So, given that understanding that transferences can shift a lot, and that's a lot of material for our reflection and engagement with the patient, the controlling or omnipotent transference makes perfect sense. it's a manifestation of the primitive defense mechanism of omnipotent control.

The individual feels that usually through the way they verbally interact with the other, they have to control the interaction. Why does that make sense? If your mind is organized the way I described in the paranoid schizoid form, then by virtue of your projection of any of, aggressive stuff onto the other, others by definition aren't safe. They are either going to disapprove of you or abandon you or criticize you or hurt you. So as you get close to other people, what's the only reasonable thing to do? Control them. If in your gut you think they're a threat, you have to

have control. How does this manifest in a psychotherapy session? Can I give you an example? because take a few. Yes. Okay. Yes, please. So a patient started therapy, and she was such a classic example of seeing all the hostility outside of her. Everybody mistreated her family,

people she encountered, you know, the waitress at the restaurant, the checkout person at this. Everybody she felt was critical and disapproving and rejecting and meanter. Anyway, so she starts therapy. And for session after session, she comes in and talks nonstop with kind of a pressured speech, which helped me understand why for many years

she was diagnosed as bipolar. Pressured speech, you know, kind of a hypomanic style. Anyway, after the six or eight sessions of this, I did what is the main shift if we're considering the difference between TFP and more classic therapies, perhaps in particular classic psychoanalytic therapies, I shifted from following the content of what she was saying, because all the stories were the same.

This person treated me badly, that person treated me badly. You shift from the content to the interaction. This is something that most therapists have a hard time doing because you're taking the focus away from what they're saying to what's happening. and I said, can we think for a minute about what's going on between us? And she said, you're interrupting me. Yeah, I realized that, but I had something I thought might be useful to think about. She said, what's wrong with you?

You told me at the beginning of therapy, I was supposed to just come here and say everything on my mind. That's what I'm doing, you're interrupting me. So I also said that sometimes I might have an idea to think about that I like to introduce. So, you know, that's kind of what I'm trying to do now. Shaga, what's your stupid idea? She was very angry and devaluing. So this is where I'm going to say in like three minutes,

what took 20 minutes to go over with her, because you have to be so tactful. This is where you begin to challenge the patient's defenses of projecting everything on the other. I said, you know, if we think back on all these sessions we had, could we agree that the kind of pattern is you come in and you talk and there's really kind of no room for me to participate or, you know, my job is to sit and listen and take in. What's wrong with that? That's what you told me to do. I said, well, as I said,

nothing's wrong with it, but we might want to kind of understand something about it. And let's just start by describing what happens. Would you agree that, you know, your style of speech and talking, you know, without interruption. Let's just say maybe that has a little bit of a controlling quality to it. You have to be very tactful. I was kind of surprised because she said, well, maybe it is a little controlling, so what? So I said, well, you know, that's up to you. If you want to be controlling, you have every right to be controlling.

But I think it might help to think about what motivates that. and the impact it has in relations. And in a way that surprised me, she burst into tears and she said, if I didn't control you, you'd leave me like everybody else does. Perfect example of what I was saying. I'm going to put in control.

If the other is going to do something to you, you have to hold them in your grip. But ironically, it's the holding others in your grip that makes them run away from you. So that's an example of omnipotent control and how I might work with it with a patient. Wow. Oh, man.

Stirring up some stuff, yeah. I mean, the main point is I had to do with therapists have a great deal of difficulty doing which you say, let's stop listening to what you're saying and let's look at what's going on here. For some reason, that makes therapist nervous.

They don't think they have a way to do it. It made you nervous. Oh, no, it's just, it's, it's, there's something about, when I was a resident, I had a really good attending who was like, you know, the more you tell me about this person, it's like she's talking at you, not with you. And so is that, that kind of like omnipotent control through the speech? Is that, yeah, that's kind of why, here I have very strong feelings. That's why a lot of psychotherapy, has a real bad name within the world of psychiatry and in the medical world. A lot of our colleagues say, oh, you know, psychiatry isn't really medicine, especially if you're doing psychotherapy. Well, that really annoys me. But when I get residents coming to me and saying, well, I inherited this case, and she's been coming to the clinic for 20 years, and then the resident starts presenting material.

and all the patient does is what my patient was doing, and she's been doing that for 20 years with one resident after another. That's a waste of a valuable medical resource, my psychiatry residence time. He should just be a sympathetic listener. If that's what you want to give the patient, get her a reading group or something like that.

But, you know, we are trained to help people, not just to absorb, I mean, not just be a sympathetic ear. We're too highly trained and too valuable resource. That resident should be saying, what is it you're doing here with me that we could understand might be related to the fact that you don't have a lot of other people you're close to in your life?

That's good. Ben, I feel like I want to get to some other sort of other stuff to kind of, that might relate, because I feel like erotic transference can sometimes have that flavor where it's like out of the fear they want to control. Interestingly, I've had,

I've done episodes on transference here and I've had people reach out to me by email saying like, hey, I find myself in this situation. I'm a patient. I have this therapist who's, you know, 50 years older than me, but for whatever reason,

like I feel like erotically charged towards them and how do I make sense of this? Sometimes I'll say things like, well, maybe, you know, have you told the therapist this? But I'm curious how you have dealt with this over the years, and I know it's like something people might have interested in hearing. Oh, sure. And it's also important because you have to distinguish

between the erotic transference, which is based on loving libidinal feelings, and the eroticized transference, which has the look of an erotic transference, but that is perverse and destructive. We can talk about both. But basically that patient you initially referenced, he says, you know, he's 50 years older to me,

but I have these loving feelings and sexual feelings. How can I understand that? She should mention it to the therapist. And generally, those feelings are based on what we'll just go back to again and again, which is an internal representation of an idealized object that doesn't exist in reality, but that the person is projecting onto you. So when a patient, just to give you an example, a patient of mine came in and said, you know, this has got to be our last session.

Why? Because I have to confess, I'm in love with you, and it's hopeless, because you could never feel for me the way I feel for you. And it's embarrassing and it's humiliating. So one approach to say, you know, I realize how uncomfortable this is, but the great thing about psychotherapy is we can talk about everything, understand things, help you move forward. Nothing's going to get acted upon. So I said, you know, I know how hard and awkward it is, but can you, you know, you've been

coming here for a couple of years, but, you know, and so I'm sure you have some sense of who I am. But on the other hand, you know, since I don't. talk about myself. There are probably a lot of things you don't know. And I'd like to hear more about how you imagine me and how you see me. And she started describing somebody that was so perfect, so ideal, that even as she was listening to herself, she began to chuckle and say, I guess that kind of person couldn't really exist. So that's just a simple simplification, a sort of a reduced version of how one might deal with that. I mean, part of me is like, well, maybe you are a great human.

You know, here you've dedicated your life to helping people, and you've written books to help other people learn how to help other people. So, like, what's reality, you know, maybe you are this archetypal male, right? I think that's idealization. You know, I mean, obvious, I mean, why should I? I'm thinking about a supervision I did last week. Maybe I'm trying to put the focus off myself. The therapist, who's really good therapist,

was presenting a case. It had to do with the therapist being made to doubt themselves. But the reason that came to my mind is, you're saying, yeah, I have written books and I have, you know, dedicated a lot of my life, certainly not all, to helping other people. But, you know, I have my flaws, I have my weaknesses, I have. Then why don't you tell me some of them? I mean, it would be helpful for me as a patient to know your flaws. Why don't you tell me your flaws? I'm more interested in the fact that you can't imagine them, because if I just give you a list of my flaws, you're going to go on

with this idealization and find somebody else to pin it on. So I think we'd be better off looking at how you manage to blind yourself to anything that might be less than perfect about me and stay stuck in that perfect view. And we should also think about how important it is for you to do that, how much it means to you, how sad it would be to get beyond this idea somebody could be the way you're imagining me. I'm just convinced that if you don't tell me some of your imperfections, I'm just gonna inevitably not be able to unidealize you.

So I think that the only way I can get to a more balanced view is by you telling me the truth. Well, let's look at what's going on right now. Clearly, I'm not so perfect because you're having to increasingly control me to get what you want from me. So if you're putting such increasing demands on me, it sort of implies,

I'm not going to give you what you want. That in and of itself is a problem, isn't it? Well, I think the very nature of the therapy relationship is you're not going to be able to give me what I want. It's going to end some time. And our age discrepancy, at some point you're going to die before, you know, what if I need you 20 years from now, you know? All right.

Let's get back to here and now, not 20 years from now, you're saying to me, tell me an imperfection. If you don't tell me an imperfection, I'm going to keep idealizing you. That's of interest to me, because if you have to control the other to feel okay in the relationship with them, including me,

what does that mean about who the other really is? I guess you're thinking that I'm not so, Perfect, because I'm not giving you what you want, never will, and that the only way for you to get it is to demand it and insist upon it. That doesn't seem like a very harmonious relationship. Toucha. Okay. You always have to stick with what's going on in here and now.

Oh, that's good. That's good. Because it's that omnipotent control transference there leaking back in, right? Yeah, anytime you have that controlling, It implies there's no trust of the other. But let me just think one more thing. The funny thing about the erotic transference is it's harder for patients to work with them,

the paranoid transference or the negative transference, paranoid negative, sort of the same. So the therapist comes into supervision. You know, it's terrible. You know, my patient thinks I don't care about them and thinks I, you know, mock them and things I secretly, you know, don't like them. And, you know, you have to keep in mind.

And this is a very simple concept. They're not talking about you. They're talking about what they're projecting on you. They're talking about an internal element of their mind that they're sticking onto you. It's not you. Oh, yeah, well, that's perfectly logical because I'm a nice guy and I don't dislike my patients and want to get rid of them. Then the therapist, the year later comes in, this is terrible.

My patient is saying she's in love with me, which we don't always get to. I'd say most cases don't get to an explicitly erotic transfer. but then the therapist is, what do I do? Now, you have to say, as I said to you, look at what they're projecting on you. This therapist who thought it's totally unreasonable to think the patient sees them as a bad guy. The same therapist might think, oh, they're in love with me. That's kind of logical. I'm a nice guy.

Oh, man. Yeah, you have to get them to see. That's not the real picture. Yeah. Yeah. I once had a supervisor who said she was a patient at one point and she said that her she had some you know these kind of feelings towards her therapist and the therapist turned her and said look I could be a one-eyed cyclops and you would have these feelings um that's interesting

I wouldn't say that you know why that's telling the patient you're wrong to have these feelings I think it was more, I think the tone was more like these feelings that you're having towards me are more to do to the process of what's occurring in therapy than the, um, the me as a person. I could see a moment for that, maybe, but I don't like to say the patient. Your perception of me is wrong because near, like going back to the guy, am I a friend? or am I a foe. You want him to struggle with it internally. Instead of saying your negative view of me

isn't really connected to me, it's all projection. That's saying, you know, that's your problem. And the real problem is figuring out whether to believe in or not what you're projecting. And I don't want to short-circuit that process by saying, you know, it's all you, you know, get over it, problems in you. You want them to be more reflective.

You don't want to short-circuit the reflectiveness of what's going on. You want to entertain the possibility that maybe you are an uncaring mechanical robot who treats all his patients the same way and has no feelings for any of them. To honor that projection, as I said right at the beginning, paradoxically, is a way to increase the patient's nascent, sort of fledgling a little bit of trust in you, when you can say, you know, let's think about that. Let's reflect on what you're feeling.

Let's not dismiss it at priori. Okay. So I think there's a couple questions we should definitely sort of hit real quick before we kind of wrap this thing up. One would be the frame. Yeah. And I think a lot of the transference occurs in the frame. So I think we could probably devote two hours

just to this. But attendance of therapy, reporting thoughts or feelings, the fee. How do you do, how do you do, like, contacts between sessions? Like, what if... Did I go into an example of that? You go ahead. Okay, because that's so important. Our position in TFP is that therapy takes place in the sessions

and communication outside of the sessions. is something we don't do except for two reasons. What is practically like rescheduling or if you're having a true emergency. Now, we can go back to what a true emergency is, but anyway, let me give you this example. A therapist comes into supervision. Mid-career therapists, analytically trained, doing a kind of a typical psychodynamic therapy with a 40-something-year-old woman who is depressed a lot of the time, not successful in her work and not successful in her love life, can't get an intimate relationship going. Anyway, in the course of the therapy, the lady starts sending emails to the therapist. It begins as a trickle, but it becomes a flood. So the therapist comes

for TFP supervision and says, you know, what do I do? I don't know what to do with all these emails. He hadn't yet established the frame that you and I have been talking about, like, limiting communication. So in the supervision, I said, well, I think you should say to the person you're going to recommend some modification in the form of therapy. You're going to do, you're going to make it more structured. You think that would have, you're going to explain to her. You think that would have more benefit. And part of the increased structure would be that these communications between sessions stop. And as I said, you know, only occur under two circumstances. So that evoked, and by the way, if you want to evoke transference, just stick to your

frame of treatment. All my supervisees say, all your patients have strong transferances to you. My patients just talk about all kinds of other stuff in their life. They don't have transfers. You want transference? Go back to the frame. Be careful about the frame. So anyway, the therapist says this lady, you know, okay, so this, you know, revision in our model of treatment is that, you know, we don't have all those email contacts. And that evoked transcript, what, you're abandoning me, you don't care about me,

and this allowed the therapist to analyze what was central to their interaction and to her pathology. She was finding in him through her behavior that I can send an endless number of emails to my therapist,

and the godlike perfect giver therapist will accept them and take them in and maybe respond to them. That was the enactment of an unrealistic internal image of the perfect provider. Why was her life a failure? Because she was going through life, expecting to find a boyfriend who would be that perfectly giving. Why was she a failure at work? She expected herself to be perfect in ways that were not realistic.

She was always critical of herself. So when the therapist said, you know, we can't, you know, continue with all these emails, that brought to the forefront what had been enacted, which was her wish for somebody perfect, and what needed to be analyzed was the fact that this wasn't going to happen. And the way they were doing therapy was perpetuating an illusion rather than looking at it and understanding it and moving beyond it. Okay. That's good. That's good. Okay, let's, I'm not going to say too much on that. I just want to kind of, as we're kind of wrapping up our time. Yeah. I want, and I really appreciate it. And there's a lot of things here that I think it's going to be of great value to my audience. And thank you so much for your time and thoughtfulness and everything. But I wanted to see if there's anything else that kind of like is on your mind that's, you feel.

feel like you just want to definitely talk about it. And then, yeah, is there anything else there? The one thing I don't think we've talked about enough or one of a number, but the main thing is the difference reading a classic narcissistic personality disorder patient and a classic boardline personality disorder patient. I referred to this a little bit when I talked about the difference in attachment style, the borderline preoccupied versus the narcissistic dismissive. But if we look at the internal structure of the narcissistic patient, at the core, we find the same identity diffusion, the same kind of stew of unintegrated representations of self and other, you know, idealization devaluing, feeling good, feeling bad, having dependency wishes, rejecting

them, having fears, having desires, all that turmoil of unintegrated, affects exist in the narcissistic patient, but the narcissistic patient unconsciously in their mind create a structure that seals over and hides or prevents access to that inner turmoil. Recall that structure is a pathological grandiose self. It's a self-story, a narrative of the self that provides a sense of unity and integration of the self, but it doesn't correspond to reality. It reassures the patient that they're okay, but it doesn't hold water. Simple example, the failure to launch young adult. The guy who finished college, because of his own self-criticisms and insecurities, can't get involved in any kind of work. So he kind of retreats to the base

or the attic of the parents' home and says, I'm writing a novel. So what sustains his self-esteem? I'm a novelist. I am writing a novel. So that's my purpose. That's my what defines me. But years can go by and nothing much happens. And they're falling far behind the curve. They hold on to their identity as the undiscovered novelist. for dear life. And when they come into therapy, you have to help them move beyond their grandiose narrative and get in touch with all the painful longings

and insecurities that they have, that they're defending against by this narrative that seems to reassure them, but doesn't have grounding in reality. It's harder to work with narcissistic patients than with boardline patients. One of the things the mentalization people said that really kind of like was like an aha moment for me. And I think you just reset it in a different way.

But it was like people with BPD, they crumble when there's an attachment injury. boyfriend breaks up with them. They get suicidal. NPD, they crumble when there's a self-image injury. Lose a job, wake up to the reality that, no one will read their novel, you know, like the incongruencies. That's kind of what you're saying, or would you put some... That's an interesting, I hadn't thought of it exactly that way.

I think that makes sense. But in that formulation, what I don't find is what in our model we see as the protective, pathologically protective of the narcissistic. narrative because the way you just formulated it, the Borlaude patient is going to get in touch with all their anxiety and distress when there's a relationship failure. And the narcissistic patient will get in touch with it when there's a kind of a functioning or performance failure. But in our experience, the narcissistic patient, the very ill ones, managed to avoid those moments of crisis by an entrenchment in a narrative.

that can go on unabated for years, and so it's not as easy to access their distress. Okay. Because in the midst of the losing of the job, the narrative psychologically stabilizes them. Well, you know, I give you an example. First of all, if it's the kind of narcissistic patient, I usually do they don't have the job to begin with.

So they lose their job, and instead of saying, I'll give you an example. You know, I guess there's something wrong with the way I performed there. It's like, you know why they fired me because I'm the only person there who was truly honest. They all would compromise. I would never make compromises.

That's the only reason that firm makes any money. All the other people there would look the other way when something wasn't done right. I don't have that. You know, I'm above that. So, sure, they didn't like me. They didn't like me because of my level of honesty, not because there's anything wrong with them.

The problem is with them and their lack of honesty and their compromising nature. So you see how the narrative, the narcissistic, grandiose narrative, repairs the injury instead of opening it up. Yeah. Yeah, that's really good. But it's still that like borderline level of functioning with the splitting, the good, bad split,

with the identity diffusion. When you help the person see beyond their grandiose narrative, when this lady began to see, maybe it's not so simple that she's just morally superior to everybody else in the world, she begins to get in touch with longings to connect to other people, wishes for dependency that she's never been able to act on because she's too afraid of getting rejected. And the mid-phase of working with narcissistic patients is extremely painful and distressing to them. And you have to overtly empathize with that and say, you know, you're getting in touch with stuff now that's making you feel worse than when you

began the therapy. I'm sorry about that, but I don't know any other way to really get better except that I'm getting in touch with all this stuff that I think was there from the beginning, but that you were fending off. I really appreciate your time. I know we're wrapping it up here. if someone was listening to this and they were like, you know, I really want to do a training in that. Like, you know, what is the pathway to become someone who's a certified transfers focused therapist? Well, I hope people might want to do that. I do find it a helpful form of therapy for many people and an interesting way to do our work. So I would direct the person to two organizations. One is a group called TFP New York. You can just Google that group, and we can direct people towards trainings.

And the other one is the International Society for Transferance-focused psychotherapy. The website there is ISTFPP.org. And on that website, there's also a lot of information about trainings, but we're very eager to train people. We enjoy it, and we find the people who come for training, usually find it rewarding. So I hope, and maybe you could post those websites. Okay, that's good.

And then I think we should just say this for the record, because you're going to have a lot of people who reach out to you who want you to be their therapist. Do you have openings at this point? Or if a patient was listening to this, they were like, I need this type of therapy. Where do they go? Yeah.

First of all, I don't have any openings. At this stage of my career, I'm devoting myself more to teaching and supervision than to practice, so I'm sorry, I don't have any openings. But I would go for referrals to the TFP. New York website or to something I mentioned to you, David. It's a wonderful organization, part of the Department of Psychiatry here at Wild Cornell Medical Center called the borderline personality disorder resource center. website is bpd resource center.org. And over the years, we have established a database

of clinicians not only in this country, but in many other countries who are trained to treat Oraline personality disorder, because even with all the advances that have been made over the last decades in understanding BPD, how to treat it, and teaching more and more therapists about it, there is not an adequate number of therapists for this patient population. So if you're looking for a referral, go to BPD Resource Center.org, or if you're looking specifically for TFP, you could go to TFP, New York. Awesome. Thank you so much. Appreciate you. Love to have you back on. Well, I have a feeling that could happen because you make the two hours go by very quickly with interesting questions and comments you add. So thank you. All right. Well, thank you so much

for your time. Welcome. Bye-bye.