Psychiatry & Psychotherapy Podcast - Working with Transference: Timing, Technique, and the Here-and-Now with Jonathan Shedler

Episode Date: August 14, 2026

In this practical Q&A episode with Dr. Jonathan Shedler, the psychodynamic psychotherapy cohort explores working with transference in real time, focusing on timing, technique, and the here-and-now. Shedler addresses how to recognize meaningful transference patterns, decide when an interpretation will open growth versus overwhelm the patient, and adapt the work across levels of personality organization (neurotic versus borderline). The discussion covers handling negative and erotic transference, protecting the therapeutic frame, triangulation, idealization and splitting, devaluation, projection, and projective identification. Clinicians will also learn to use their own countertransference as essential clinical data, the ongoing value of consultation and supervision, and how to respond to chronic reassurance-seeking without colluding.   Link to blog Link to YouTube video

Welcome back to the podcast. I am joined with Jonathan Scheller today. This topic is called Working with Transference, Timing, Technique, and the Here and Now. This was a part of one of my psychodynamic cohort special sessions. So you will hear a bunch of different people ask Jonathan Shedler questions. We'll be talking about the practical realities of recognizing and working with transference as it unfolds moment by moment in the session. Rather than staying at the level of theory, we will focus on clinical decisions therapists face in real time. How do you know when a patient's feeling towards you reflect a meaningful transference pattern? When does an interpretation open space for growth and when does it risk overwhelming the patient or derailing the process? We discuss how the work

changes across levels of personality organization, the handling of negative and erotic transference, the importance of the therapeutic frame, triangulation, idealization, and splitting, devaluation, projection, projective, and edification. We also explore the indispensable role of the therapist's own countertransference as clinical data and the necessity of ongoing consultation and supervision and how to respond to patients who chronically seek reassurance. This is only part of our conversation, unfortunately we had to cut out about half of it due to, you know, actual clinical cases being discussed. So I hope that this is enough to wait your appetite, to enjoy, to get something of value out of. As always, you're welcome to send me an email at psychiatrypodcast.com with any thoughts, reflections,

people, other people I should have on the podcast. I will leave it there for today and enjoy the episode. helping the patient to find words to describe their experience, you know, which is often metaphorical, or listening to the patient stories and understanding them metaphorically. So, for example, you know, a patient might talk about going to see their physician or, you know, and, you know, they thought it was a minor issue. And the physician, this is like actually literally happened. And, you know, the physician actually, like, got some very troubling test results, and it turned out they had something fairly serious. They hear that metaphorically. Well, they're telling me about their doctor's visit,

but they're telling it to me now, you know, during our therapy session. So I also hear it as a metaphorical commentary, perhaps, on the experience they're having here and now. So, no, I don't bring a stockpile of stories to tell patients. I get curious with them and try to, you know, expand the space for the patient to notice and intend to more of their experience. That's good. Yeah. Okay. What are indicators that it is an appropriate time to address the transference? So like when and often do you address it? And then how early? Yeah. Ooh. Yeah, that's a tough question. So first of all, we're always addressing the transference. the transference is never not there and the countertransference is never not there if there's two people in a room interacting and they're alive there's transference and counter transference so i would rephrase the questions like how do we make constructive use of the transference um well that's such a potentially big question can i can i break it down sorry yes please can i break it down a

little more just based on my cohort and thinking about like what was driving that you know this question in large part because as we said we have people from all different types of practice and different developmental points in their professional lives but this idea of like and you'll probably speak to this at many points today but how much of the time are you really focusing in on the transfer versus like the content of what's coming up. You know, like early on, are you allowing for more time for the story and the content? Or are you initially right from the beginning

bringing in issues of the transference and countertransference more overtly? We try to create a relationship where the patient can talk as freely as possible. Maybe we were like, really the instructions to the patient are, you know, whatever you notice here, whatever you become aware of here, whatever comes to mind for our purposes, it's important, try to say it.

So we're not overly structuring it, saying what the patient has to talk about. And then I'm going to divide your question into two sub-questions. As a practical matter, we have to be very, very attentive to negative transference. You can let positive transference ride. We'll deal with it later. but very early in treatment. I mean, really from the first meeting, the negative transference,

if it's not made explicit, if it's not conscious and talked about and acknowledged, can blow up a treatment before it even starts. So one version of a transference interpretation is, you know, you make some observation or comment or whatever, and the patient, you know, starts defending themselves.

and right right so there's a negative transference there you said what you said for whatever reason whatever clinical reason you had but the patient heard it as a criticism so we have to make that negative transference explicit right or it could sink the treatment you know so in this case it was really as simple as saying you heard that as criticism you felt like I was criticizing you right so I'm just taking something that's pretty close to the patient's conscious experience and I'm putting it into words. I'm saying, you know, I can hear this. You know, there's room to talk about this. Let's talk about it directly. So that's one version of, you know, attending to the transference. You know, I mean, any negative reaction that the patient has early on, we really want, we don't

want to brush over it. Like, we really want to recognize it, attend to it, put words to it, and invite the patient to discuss it. Now, there's another kind of transference interpretation, which I think is really your question, which is, you know, when do we, right? These are sort of the big, you know, the big guns of therapy. When do we bring this in? So there's the content of what the patient is saying. There's the transference of what they're doing with us and showing us in the room. That's actually more important. But what we're really listening for is when we can. here parallels, see parallels between the content of what the patient is saying about things that happen in other times, other places, other relationships, and what's happening here and now in the

room, right? That's the best kind of transference interpretation, the one that bridges the gap. So I have a patient who, it's been an ongoing theme, she's had a couple of previous failed therapy attempts, she'll sort of get a little disregulated, and then somewhere in there, she'll start to tell me about, right, her thoughts will go to a previous therapy when the therapist actually said in one way or another, like, this is too much. I can't, I'm not, like, I'm not up to handling this. I mean, so, so I make the link, you know, and I might say, you know, that, that came up, your thoughts went to this previous therapist just on the hills of, you know, of telling me

about this overwhelming experience, it makes me wonder whether you're concerned that you're going to be too much for me right here right now. So it's really very close to the patient's experience, but I'm making a link between something that happened in their past and then something happening in the room. So we want to listen for those links. And actually, there's three links. It's the links between things that happen in past formative relationships, often parents or siblings or an important teacher, things that are happening in current important relationships with a partner, spouse, girlfriend, boyfriend, important attachment figure, and the therapy relationship.

So past relationships, important present relationships, the therapy relationship. And when you hear the same pattern and you connect the dots and say, oh, here it is, here it is, here it is in these three areas, here it is right between us. That's really the ideal kind of transference interpretation. It links it directly to things that are important in the patient's life. Is that an answer? Could answer? Enough answer.

Yes. Yeah. I imagine a piece of this is also informed by your conceptualization of their organization. Like someone who's who has a, more mature defenses, who's more on an inner neurotic range of functioning, it might be easier to have this discussion, more accessible to have this discussion earlier on potentially? Or is that not the case? No, that is the case. And as you go into the borderline range of functioning, actually, that shifts things. So what I just described, we call psychoanalytically a genetic

interpretation, not genetic in the sense of genes, genetics, but genetic in the sense of the person's developmental history. When you're dealing with somebody who's in the borderline range, they just, it takes it too far out of the here and now experience in the room. So generally, we don't want to make genetic interpretations. We want to focus, you know, certainly through the early stages of the treatment on what's happening right here, right now. So my first example about, you know, you felt like, you felt like I was criticizing you. That was yesterday. It actually didn't go very well yesterday because the patient's response was,

well, you were criticizing me. And then you get into what people who are writing about mentalization-based therapy, phonagie abatement in their group, you know, really very good at this. I mean, really staying in the here and now, you know, something like what, you know, I couldn't understand why it landed on you that way. why you interpreted it that way. I wonder if you could imagine other reasons why I might have

said that. It's like, because you're critical. You're like, well, yeah, okay, yeah. That's certainly one way to understand it. Just, you know, humor me. What else could you imagine? You're trying to sort of expand their capacity for mentalization. That is, their capacity to think in terms

of, you know, the other person's motives and, you know, intentions, right? And it stays very much in the here and now through and for quite a long time in the treatment. Thank you. That really answers that. You mentioned the past formative transferences, sort of the sources of what's coming up. When you're dealing with patients who aren't ready to go there, don't have the capacity to go there, do you bring it back to the here and now?

Like, for example, let's say you draw a connection to their father and you bring that up in the dialogue and they're not in a position. where they can receive that or process that. Do you then bring that back to the interpersonal dynamic between you and the patient? Yes. Yeah. Yeah, exactly. Right. So the problem that you have when you're dealing primarily at the borderline level of

functioning is if you look at it through a mentalization lens, there's really a deficit in their ability to imagine somebody else's internal states, motives, intentions, as well as a deficit in their recognition of their own internal state. You're really working on that. If you look at it through like a transference-focused therapy lens, they're really different sides of the same coin. What the patient is responding to is their projections. Rather that there's a certain rigidity to the projection where the projection isn't,

well, you know, this is how I'm interpreting it. the projection becomes no, this is a fact. So, yeah, if I tried to make a transference interpretation that had the genetic component that linked it to something outside the room and the patient couldn't go there, I would say, oh, you know, that was a mistake on my part. Let's come back to the here and now. And then, you know, then it becomes, how are you, how are you seeing me now? Like, what's your understanding of how I'm listening to you?

And when I'm thinking and experiencing when I respond to you, who are you right now? What are you experiencing on your end of the relationship? So, yes, short answer, you have to come right back to the relationship. And there's a general principle in all psychodynamic therapy, which is the process takes precedent over the content, in the process meaning what's going on interpersonally right here right now between the two of you. So, I mean, I really, really believe that the dividing line between a master clinician and not a master clinician

is the ability to shift from being immersed in the content of what the patient is saying and shift attention to what's going on in the room right here and now between us. and to address that. And anyway, like, if you guys take nothing else away from today, like that's the issue. Like, take this away. When you're feeling lost, you know, or bogged down or, you know, you and the patient are not tracking with each other

or you're not understanding something, let go over the content. And I just think, what's happening here in the room between you and, you know, between us? And you can even say it that way to the patient, right? something just happened between us. Like something just shifted now. You know, I'm not really, if it's true, I'm not really sure what happened, but something changed.

You know, did you notice it also? And, you know, help me understand your experience of what just happened. You know, who am I to you? Who are, you know, who do you think you are to me? So we're inviting, we're inviting reflection of the process. Sometimes you get a lot of pushback from the patient. That's not what I came here for. Why is that of interest?

Do you think they're the most important thing in the world? Like, why don't we want to talk about the relationship with you? And we need to know the answer to that. We need to be able to respond. And the answer is some version of, because by virtue of being human, this is how we're built. we tend to recreate and repeat relationship patterns throughout our lives, right? And we repeat them wherever we go.

And in your case, it's caused problems for you. And I'd link it specifically to, you know, why they're here. And you know, what happens between us here is a window into these relationship patterns. Right, if we could understand something about, you know, how they repeat here with us, right, that understanding would then spill over into your other relationships so that you had some freedom. You don't have to spend the rest of your life repeating the same painful or self-defeating patterns. So when we make these same transference interpretations or we shift the focus to the interaction in the room, we really need to know why we're doing it and we need to be able to explain it transparently to the patient.

Okay Let's jump into some more difficult ones Okay, we're going to ratchet it up It does right The difficult ones We started with some softballs for you How have you dealt with sexual transference Erotic

The patient's Transference towards you Sexual feelings How have you dealt with that in the past what's your approach it's just another transference to explore right so

I mean everything gets really really simple once you have an understanding of the concept of the therapy frame the therapy like people trainees especially often misunderstand

you know they think the frame is a series of rules to follow and it's not it's not rules It's, the frame is like sort of the rules of engagement for the therapy relationship, you know, what we do here and how we do it. So part of the frame is, you know, what we do in therapy is we talk about things, right? Anything that you think, feel, anything is fair game for therapy discussion. In fact, it's something invited in that we want to hear about, right, within the rules of engagement, which are we, it will stay in the realm of thoughts and feelings and fantasies and not be acted on.

Once you understand that as the therapist and you're like, you know, rock solid, this is what we do. Well, then it's thoughts and feelings and words like anything else, and we treat it like any other transference. But I think behind your question is, right, when you, as you start getting into the like borderline range of functioning, right, you start to get patients that don't really, that really don't separate thoughts and feelings from actions, right? Now we're dealing with those projections. You know, no, you really do want to sleep with me or, you know, whatever form it takes. I'm curious in you know regarding this question people in the more neurotic range where they might have you know more of a sense of like oh this is this is inappropriate to this setting and so so disavow you know sort of have that that part of them either it's you know too shameful or disavowed and so it's it's there but it's unsaid and how if you're attuning to that that might be something coming up but. how would you approach that? Well, yeah, that's a really good question. I mean, this is, when you think diagnostically, I don't mean DSM diagnostically,

I mean psychoanalytically, case formulation diagnostically, like this is a real dividing line between neurotic and borderline level of functioning. The neurotic level functioning, I mean, the person typically feels guilty and ashamed and hesitant, and, you know, they're not going to come out with it directly, especially these sort of cross-sex therapy pairs, where the patient thinks it's inappropriate. But now you're dealing with old-fashioned garden variety, conflict, and defense.

I feel certain things, I have certain desires, wants, and something inside of me says, but no, it's not okay. You shouldn't feel it, you shouldn't talk about it. The borderline patient is more likely to act it out, right? right not right it's not it's not it's not it's not buried and under the surface right i mean they're being openly seductive right or openly you know um openly salacious right so the the neurotic level is you know it's harder for the therapist to deal with because often the therapist also feels uncomfortable with the topic but the way we deal with that kind of neurotic conflict for you know for

anything is, you know, we listen to the derivatives, which is to say that, you know, the metaphor, we pick up on it. And, you know, we really want to signal to the patient. You know, first of all, we hear it. Second of all, unlike the patient, you know, hopefully, we're not passing judgment on it. And third, like everything else, it's something to be curious about that we can think about, right? Like it might hold some meanings. You know, so sometimes I use humor. like I was treating a pretty high-functioning person. And it was the situation you described. But she was pretty, you know, she was pretty straightforward about her.

She's like, like, oh, you know, yeah, I mean, I could never tell you about, you know, I could never tell you about, oh, I remember. She's like, you know, well, you know, I have some thoughts and feelings, but, but. you know, it wouldn't be, it wouldn't be appropriate for me to say because, you know, you know, rules and boundaries and frame. She had the idea of frame, but was misusing it here. You know, it's like it's not appropriate for therapy. And I just like used a little humor and I'm like, I think you must understand that the rules are for me, not for you. I'm the one who has to follow the rules.

You get to say, you know, you get to say whatever you think or feel. So we just sort of broached the topic that way, and it took quite a while. But you really want to continually invite it into the room and communicate to the patient. Yeah, this is just one more pretty normal common human response and so much more grist for the mill. I think there was an example. in one of my groups where it was like an overtly, it wasn't like a psychodynamic case. I don't know, does anyone feel like they have an example

that they feel doesn't fit this kind of approach and maybe they just want to share it? Okay, no one. Be brave. It comes up all the time. Look, look, you guys are, just from my take of your little postage stamp windows on the screen, I mean, like, you guys are young.

good looking. It's going to come up. It is coming up. You may or may not be attending to it, but it is going on between you and patients. Do we, or do you want to give, and do you want to stay with this, given more of an example, David, or do you want to, do you want to pivot to like to the countertransference regarding sexual transference here? Countertransfer? I think, okay, so I think it could be a little bit different if it's like someone who's coming off of meth and you're in the inpatient as a psychiatrist, you know, and it's obviously just inappropriate. It's like, okay.

But you're not doing psychotherapy under those conditions. You're doing, you're managing, right? I mean, this is psychiatric management. If you're doing psychotherapy, right, meaning you have an ongoing relationship, right, you are both expecting and planning, you know, to meet, on a regular, ongoing basis. And the purpose of the therapy is deeper self-understanding, self-awareness. Right.

And not for its own sake. I mean, deeper self-understanding, so the person can be, can sort of free themselves from being sort of destined to live out the same unhappy patterns over again. And so the person can be more whole, just say, you know, more. If the person is, if there's splitting or dissociation, you know, more whole and integrated, if the person is in, right, that's borderline range. In the neurotic range, the person is, you know, conflicted, right? Certain parts of their experience are, you know, welcome and, you know, get to be seen and heard from others not.

Right. We want to hear from all of the sides of the conflict. Right. When you say more whole, right, the person's sense of them. encompasses more of their experience. Let me say that. So if it's that kind of therapy, then sexualized transference is just one more kind of transference.

Right, what do we look for in the transference? The person is repeating difficulties in their life. It's not a one-time thing. I mean, it's a pattern that we can see recur, and ideally they can see recur. We're listening for that theme. but we're also looking for the convergence of that pattern with a pattern that's happening in therapy. So this really depends on their capacity for insight and reflection.

But that's a pretty fertile ground for interpretation. And the interpretation, you know, you think about it in terms of scaffolding up to the interpretation, and the scaffolding is clarification, confrontation, interpretation. in psychoanalytic work, you know, clarification is, you know, this is happening. Let's bring it into focus. Let's, you know, let's recognize this. So, I mean, there might be, you know, they might be telling you about one of these difficult triangular relationships with, you know, that they get into.

And you say, you might, the clarification might be, you know, that sounds like another one of these triangular relationships that always involves some, you know, sticky situation with a third person. The clarification doesn't ask the patient to do anything. It's just, it's just sort of bringing something that we think is important into focus. Or if it is asking the patient, it's asking to elaborate and say more and, are you getting that right? Are you getting that wrong? Right? Can they clarify the experience? The confrontation is, what about that? Let's think about that. We want the patient. Confrontation is not confrontation between therapists and patient. It's asking the patient to confront themselves with more of their experience, right? Basically to pay attention to it. Let's pay attention. Let's really think about it.

interpretation is making a link that's not already apparent. And in the example you gave, it says, you know, I might say something like, see, once it's established, here's the triangular relationship that, you know, that you're describing, here's the kind of, it's the kind of thing that gets you in trouble for, you know, this or that reason. You know, here it is, it seems to be happening again in this sort of situation you're describing. Once that's the scaffolding, once that's established, then you're in a position to say, you know, it seems to me that there's a way that that same thing is happening here between us. You know, what do you mean? I'm just making this up, but you know, you're telling me about how, you know, this person is in the position, you know, of having to see or hear about what's going on between you and this other person. And this third person is in, you know, this third person is, you know, seeing things that, you know, either trying to draw them into something or trying to let them know they're not included in something,

or whatever's going on. You know, there's something in the way you and I are talking about it. And it's just like, it seems like I'm in that same person situation. Do you see how there's something simple? similar happening in what you're telling me about. And what happens between the two of us right here as you tell me? Now I'm the witness to something. And then it becomes a question of how much curiosity, right,

because what we're really after is curiosity. We're always testing the limits of the person's capacity to get curious about themselves. Do you see how this is happening here and there? Oh, I never thought about it that way. I guess I am putting you in that position. What about that? Let's think about that together. You know, help me understand what that means for you,

just right here, right now. So that's a way of working with it. And I will add, I know there's other questions, but the thing that gets in the way for therapists, especially younger therapists, you know, is we're like, we're uncomfortable with our own text. feelings toward the patient. I'm not supposed to have it. I'm only supposed to have like benign

physicianly or therapist-e feelings toward the patient. No, we're supposed to have the full range of all of the normal feelings that we have in all of human life, right, within the frame of anything I think and feel is fine, but there's a frame about, you know, what we do and don't act on. So then I'm like, you know, feeling attracted to this patient, or I'm feeling put off by, repulsed by this, whatever it is, more than I normally would. My internal process as a therapist is I shouldn't notice that. Say, okay, well, how much of this is about me? You know, my life situation, the kinds of things I'm attracted to or put off by, turned off by, how much is it about something going on in the relationship with the patient? Right? And I'm doing that internal work. And that's,

that internal work is what prepares us, right, to say something that's helpful to the patient. If we back away from it, oh, I'm not supposed to think that. I'm not supposed to be attracted to my patient. I'm bad thought. I shouldn't think that. Then we close off a channel of information because our feelings are in part, you know, created in response to something happening in the relationship. I saw somebody wave a hand, Daniel. Yeah, thank you. I'm, this all makes great deal of sense. I find myself sort of wondering about the issue of the behavior itself. Like, how much of that comes into the interpretation? Because I could sense myself, like putting myself in Carly's shoes feeling really uncomfortable about that content part of it.

Yeah, and that's the work we have to do, right? The question becomes, why is the patient doing that? and then how do we work with them so that they can start to get a sense of why? So you just put a hypothesis on the table. The hypothesis is either true or not true. We don't know in advance. You have to explore it. So one hypothesis is there's something performative. It's a defense against talking about, it's a defense if, you know, if they weren't doing this,

what else might they be talking about, right? So if there's something that starts to feel, you know, sort of repetitive or scripted, right, in how the person presents, and then we think, oh, okay, you know, that's not free. We're looking for free association, which is, you know, just really say whatever comes to mind,

be open to attending, right, to whatever we notice, but the person isn't doing that. So we could think of it as a defense or resistance, right? Another hypothesis is they want to enact something with you. They're trying to titillate you. They're trying to get a response. I don't know, so that you should feel left out, not them. There's a whole lot of hypotheses.

So, you know, one option, you know, might be just in a very wide open way. I say, but, you know, there's a way that you're, you know, you've told me about this situation, the situation, that situation. You know, now, again, you know, there's a way, it seems like it's, you're telling it, you know, in a way that seems like,

you know, I think I should say directly, in a way that, you know, seems like you want to tell it in a way that's titillating for me. You know, I'm curious about that. Help me understand that. And,

And of course, when we say, help me understand that, what we really mean is, you know, let's hear more so that we both have a chance to understand it, right? We, you know, we, we ask the patient to help me understand it, but part of what we mean is, let's look at it and think about it so that we can both understand it. So, you know, help me understand that. You said, well, I didn't, the patient says, suppose, why I didn't really think about it that way. Yeah, I know, but now that, you know, I've put it on the table. and right, right, it's out in the open is something that we can think about.

I wonder what your thoughts are about this. And so that's part of the scaffolding. That's, that's clarification. This is what, you know, here's something I want to bring into focus. Confrontation, which really, confrontation is just clarification plus an expectation that the patient should pay attention. That's really all it is. And then we see where their associations go on what,

comes up. We tune our ears to, is this taking the place of something else that they might be talking about? Is this repeating something else? If it starts to sound like it's taking the place of, you say, you know, I notice there's, you know, there's a kind of pattern. You know, almost, you know, to make one random example, like, almost like you feel like your role is to entertain me or you to perform something for me or to keep me titillated. I wonder what that's about. And then we listen to what they say, and maybe we get to be able to say something like,

maybe it's easier to do that than to pay attention to whatever else might be coming up. Huh. What I wonder about that? So we're just continually inviting the patient to take things that they do pretty reflexively and automatically and slow down enough to pay attention to them and to recreate some space to notice more, just a bit more than they noticed previously, and to think about the bit more, and to put that into words. And that's the process that's transformative. We're trying to create spaces, you know, pauses. between things that otherwise happened very quickly and automatically, pauses to notice and reflect.

And out of those pauses, right, comes the understanding and the freedom and flexibility to maybe be able to do something else. A lot of great information. You've alluded to some countertransference. And so I think the group is curious, you know, how you've dealt with countertransference, particularly idealization, and if there has ever been any sort of idealization dynamic with a patient that you can recall, if you'd like to share about that?

Yeah, well, for me, idealization is like waving a flag, red flag, because I know what comes on the hills of idealization, right? I mean, there's sort of milder, like, neurotic level idealization, which we could say as, you know, positive transference. The patient wants to feel cared for, feel like they're done. in good hands, feel like they're, you know, somebody who knows what's what knows how to help them. But then there's idealization in the sense of, you know, a border-to-level defense, which is half of devaluation, you know, which is the defense of splitting.

So when we're, is that, is that what you're referring to? Yeah. Yeah. So there's something very seductive about the, right, it comes up, especially with narcissistically organized patients. There's something very seductive about the idealization because if we have our own narcissistic vulnerabilities and we all do, it becomes very tempting to kind of join the patient in this mutual admiration society. We're like, we're both, you know, we're both so special together. But you have to remember you're on one side of a split.

you're now the good idealized object. And where they're splitting, you could very easily, you will. If the treatment goes well, you will end up on the other side of the split. And you'll become the bad devalued object. So, again, how do we work with splitting? Actually, David had a wonderful podcast with Frank Yomans. And I thought Frank Yomans did a masterful job of illicit. illustrating, working with a certain kind of splitting.

Something that often goes along with either idealization or stick with idealization is a kind of omnipotent control. It's not just that you're seen as idealized. You're expected to behave in a way that's consistent with the idealization. And you find there's a way the patient is managing you. into being that idealized person. And what Frank did in the podcast that I, I mean, illustrated so masterfully,

is, you know, he noticed, right? This is the countertransference. Right? If you can notice the seduction to feel like, yeah, I am a better and smarter therapist than the last five people this person saw because I'm really that good. Right?

I get pulled into that, right? hopefully just momentarily. And I'm like, oh, yeah, I know that feeling. Hopefully you notice that. Then the next thing is, you know, it seems that like then I noticed that I'm feeling managed. I'm supposed to talk about certain things and I'm not supposed to talk about other things.

I'm supposed to talk about things in a certain way. I mean, so we can make that. Because there's something very limiting. about this. You have to be the idealized object, right? In a way, you don't get to be a full human being. You don't get to make mistakes, which we all have to make mistakes because we're human. If you do make mistakes, they can't be acknowledged and recognized, right? They have to be sort of reshaped into something that the patient can idealize. So what Frank does is bring that, you know, more into focus, you know, like, it wouldn't be okay for me to fall short in this way. And, you know,

like, you know, I forget the specifics, but the way that you're feeling managed. And basically, what he does is say, but, you know, there's more to it than this. You know, you see me as, you know, wise or the one with the answers or whatever it is, whatever form the patient's idealization takes. But, you know, there's another side to this. Because, you know, I mean, in seeing me that way and in sort of shaping on conversations so I could be, you know, so that I am that to you, you know, it suggests that there might be another way of, experiencing me in the background that's dangerous or, you know, that you need to protect yourself from. No, no, no, you're the greatest doctor.

Well, yeah, but that's not the whole truth, right? That you're, you know, the fact that you're managing our interactions in the way that you're It tells us that this is a part of you that's worried about another side of me. What about the side of me that screws up? What about the side of me that misunderstands? What about the side of me that gets it wrong? It seems like there's a way that we're doing something here to protect yourself and me from encountering all of that.

So basically what he's saying is there's two parts of the split. You know, for you, it's I'm this or I'm that. You know, but for me and maybe with some work for both of us, maybe we could see that it's, you know, some of this and some of that. Right. So he's always inviting the patient to bring together the split experiences that the patient is really working to keep apart. Okay.

So let me jump back to your prior example. patient says all my previous therapists, I was too much for them. She's telling you this story of her awful trauma. She's saying, I'm remembering back as I'm telling you the story, how this previous therapist said, like, this was too much for me. Is that a subtle idealization of you? Or is she fearful of you abandoning her? No, she was terrified.

Well, okay. Is she, like, she was, yeah, it wasn't, it didn't have a narcissist. flavor but a patient but a patient who met you know like i've also had patients like you know i've seen five therapists in the past and they didn't understand me and they weren't good enough you know but you know now i know i know good hands right that's that's that's the idealization what is the so is it more of the abandonment fear do you think from my patient from your patient that you would abandon her like these previous therapists abandoned her in the mystery yeah i think it was two things one was the abandonment fear right

It wasn't a fantasy. It had really actually happened. And the other was her own fear of overwhelming pain, rage. I mean, just overwhelming feelings. So I heard it as, I'm afraid I'll be too much for you if we get into certain things. I'm afraid it's too much for me. I'm too much for you. I'm too much for myself.

And really, I mean, it's good, much better. complicated than that, but really, at a very basic sense, the solution to that is the therapy frame. Well, you know, everything, I never said this to her, but it was always my everything that we say and do here is thoughts and words. Like, you know, really within our, you know, 45-minute session, I mean, really, what's the worst thing that could happen? Are there any examples of devaluation that have occurred in your practice and how did you deal with them? If it's really sort of borderline or narcissistic devaluation, and this really applies to any kind of projection or projectivated vacation, right? The difference being projection, the patient sees you with somebody that you're not, right?

And it's pretty insistent that it's true. projected by identification is they do that and they also somehow manage to get you feeling and maybe acting like the person that you're not right so it's a defense for two right it it pulls the therapist into it in one way or other the patient pulls pushes you know manages you into the role that they're projecting there's there's really only two things that you can do that are wrong if it's a devaluation it's usually know, pretty offensive. Like, nobody likes to feel devalued.

Like, you know, we get angry or, or, you know, or we start to feel, you know, inadequate. What if the patient is right? Like, what if I'm totally missed the mark? What if I'm, I shouldn't, I'm not good at doing this work, but maybe I shouldn't be a therapist at all, right? So there's two things that therapists are pulled to do that we want to not do.

And, you know, one is to take on the projection. And we start feeling really, you know, in doubt about ourselves, or helpless or hopeless in our ability to do the work. And we have to let ourselves feel that. That's part of it. I feel that. Hopefully, we then, you know, bring an observing ego online and say, well, wait a minute, I don't feel this way with all of my patients.

there's something going on with this specific patient, what is it that's going on between us? What's happening? Why am I feeling this way with this person right now? So then I shift from I'm a crappy therapist to maybe this is information about the patient and about what's happening in the relationship. So, sorry, I'm getting, I'm getting a little, let me stay focused. Can you get this? This is good. Oh, go ahead, David. Sorry. Oh, I want to get some like Like, was there examples that really stung or like, like... Oh, yeah. Let me come back to that.

We just read, there's a principle here at the night. Let me... So there's just the two things we don't want to do. One is we don't want to, you know, we don't want to be taken over by the projection and, you know, and basically say to the patient, you know, yeah, you know, you're right. I am these bad things. and continue to feel and act that way.

So we don't want to be overtaken. You know, if we're swallowed up by the projection, that's one thing that happens. The other thing that happens is the therapist gets really offended and, you know, angry. And, you know, and Glenn Gabbard has this wonderful phrase. He says, you know, the therapist wants to take the projection and cram it back down the patient's throat. I'm not the one being, you know, angry and, you know, oppositional and impossible. you are, and here's why, and you did this, and you said that, right? But that's not helpful either. So to answer your question, how do you work with it? We say, we talk about containing the projection.

Containing the projection, right, is not agreeing with it, you know, and basically conveying to the patient, yeah, you're right, I am this awful person. And it's not cramming it back down their throat and, you know, sort of counterattacking and turning the tables on them. containing is, right, I'm not in a hurry to disabuse you of your idea. This is how you're experiencing me, right? That would feel like really crappy if this literally came up yesterday. If you have a, if you had a therapist, you know, who you think is in this, you know, to just to have the upper hand, you know, to handle you and manage you, right, that would feel really shitty.

So notice I'm not saying that it's true that I'm in fact doing this and what I'm really doing is jockeying for the upper hand. I'm also, right, but I'm also not saying it's false and trying to convince the patient otherwise and say let me tell you why it's not true. What I want to do is allow them to have their perception of me. this comes back to the therapy frame, right? There has to be a mutual agreement, right?

Things, shit's going to happen. Things are going to go wrong in the session. A mutual agreement. Whatever happens, we'll continue to meet. We'll make our best effort to talk about it with each other. That's what we do here. That's different from all the rest of life, all the rest of life. You have your projections and act on them and play them out and then the same pattern repeats over and over again. Here we're going to do something different. You're still going to have your projections and play them out and repeat them over and over again. It's still going to happen. But we're going to talk about it. We're going to explicitly make it part of our treatment contract and part of our frame that one of the things we do here is talk about what happens

in our relationship. So containing the projection is allowing the person to have their experience, neither agreeing nor disagreeing, you know, empathically recognizing their experience. what I tried to do when I said, like, that would feel really shitty. If you think that I'm in attack at the upper hand, I mean, what a horrible position that would be in. Right. And I'm not being, I'm like playing coy. I'm like sincere. Like, that would genuinely feel like shit. But I'm also leaving it as an open question. That's her experience. It's a fact that it's her experience. But it's an open question. What's happening between us that's, you know, that's leading her to have that experience of me, right, and whether there could be the

potential to have other experiences of me. So that's what containing the projection is. So don't do two things. Don't let the patient should have bowl over you and get you feeling like, oh, God, I am no good. But don't be in such a hurry to disabuse the patient. of their mistake either, treat it as something like, let's let them have their experience and let it become a topic for exploration. So to answer David's question,

suppose the patient responds by saying, you know, ha, see, I knew it. You are trying to get the upper hand. Well, I didn't actually say that. I mean, I'm hearing you and I'm getting that. That's your experience of me and why it feels like shit for you. I mean, and getting that's your experience,

I didn't say that that's what I'm thinking or doing. I'm focusing on your thought. I didn't say that was my experience. I'm focusing on the experience you are having. And then if you have a particularly difficult patient like the one I had yesterday, it's like, well, that's another way of getting the upper hand. But most patients aren't that difficult, thank God.

What advice would you give to the therapist who's like more, who has a very sort of maybe some depressive personality style stuff that's very innerly critical? Yes. Evaluation feels very, it's hard for them to even hold that. They ruminate on it outside of sessions. What would you say to that person? That's a great question because it's the most common. configuration. So most therapists, you know, like most like pretty solid good therapists so they differentiate, tend to have, you know, some version of a depressive personality style,

like, you know, hopefully a neurotic level depressive personality style. I mean, when a patient projective identification is like a really interesting thing. The patient doesn't project into a vacuum. The reason it becomes a projective identification and the therapist feels something is because the projection hooks something that's already inside of us that's already there

and sort of waiting to be activated. So the patient finds a way to tap into something that's already inside of us. And now it becomes a, you know, potentially

it could become a very difficult enactment because the therapist is very likely to feel that way, especially, like, I was going to say early in your career, but this actually continues for much of your career. I mean, this is really tough, challenging work. We are always faced with something new and different that we haven't seen before. It's an occupational hazard for therapists to be questioning and doubting themselves. And we also get in a certain, like, you know, special way of beating ourselves up, like some common variants are.

Like if the treatment goes well and the patient seems like getting better, it's like, you know, we credit the therapy and the method, but if it's not going well and the patient is not having good reaction, we blame ourselves, right? That's a pretty common trap that we fall into. So if we really know that about ourselves, you know, hopefully we can take some distance, right, and say, oh yeah, you know, I recognize that again.

Sometimes, though, that's really where either your personal therapist or a supervisor comes in. Sometimes you really need a clinical supervisor to help you take distance from that, you know, to step back from it rather than being lost and, oh, my God, you know, I suck and I really don't know what I'm doing, right? sometimes you need a third party involved or a second party to say, but wait a minute, you know, you don't always feel this way. You didn't feel this way about the patient you told me about two weeks ago. Something is going on here with this one. And then you start to step back from it. So it's shifting from a position of a, in classical analytical language, an experiencing ego. You're lost in the experience to an observing ego, where you're going to,

going to sort of step back from the experience and observe it and think about it and try to understand something. But it really does take another mind involved some of the time. So I would say we never really outgrow the need for clinical consultation. You know, I would say like for, I don't know, the first five years of your career, like post-licensure, it would probably be a good idea to have a supervisor or a clinical consultant, you know, for regular meetings. And, you know, if you're like senior in your career like me, like I don't have regular weekly meetings with someone. But there's always somebody that I can contact when I feel like, you know, this is like a struggle. I need another, I need another mind here. And so you really never outgrow

the need for clinical consultation. And if you're working with borderline level of patients, and that includes the more severe end of narcissistic pathology, then you really need that supervisor because the projections, the projective medications are just so powerful. You get just sucked into it and you need someone else. And the interesting thing about every evidence-based treatment for borderline personality, the thing they have in common is they all have extensive consultation, or supervision for the therapist. That's true if it's psychoanalytic, like TFP,

it's true for Marshall and it hence DBT. Right? Like, that's the common thread. Yeah. Chinette here says, how do you respond to a patient who is very sensitive to judgment and asking for reassurance about how you view them? Do you provide reassurance?

No. If you provide reassurance, it's tempting. You know, most of us go into this field. You know, we're like pretty tender-hearted people and we want to help other people. And, you know, you see somebody in pain and looking for reassurance and really, you know, kind of tugs at your heartstrings. And you want, you know, you want to give them that reassurance. And they'll feel better in the moment.

But, you know, what we have to keep in mind is we're just participating in a, pattern, right? The, right, the, you know, the, you know, the cure giving, given the reassurance is, in fact, the disease. It leaves untouched and unexplored. What's going on in the patient that they're so continually in need of reassurance? And, you know, we can think of this as a projection also, but more often, like, healthier neurotic level projection. The patient is, the patient is very worried that you're thinking ill of them or judging them harshly. But we, as the therapist, have to remember, the call is coming from inside the house. The judgment is coming from the patient.

They hear it, right, as if it's coming from us, or at least they worry that it's coming from us. but it's coming from inside of them. And, you know, so with a, like, a healthier-level patient, you know, one way of working with it is we want to help them to become aware of that, right? If the call is coming from outside, there's never a solution. You know, every new person is like someone who's potentially judging them that they need to, you know, be reassured by and it never ends. You know, so something I say fairly frequently when this comes up, like the,

like the patient, it often takes the form that patient's hesitant to tell me something. They think I'm going to think less of them. I'm going to judge them for it. And, you know, one very gentle way of interpreting that kind of projection, right? That's the transference. The projection is the transference. Is I might just say something like it, it's hard for you to believe that I wouldn't be judging you as harshly for this as you're judging yourself. In other words, a very gentle way of saying,

maybe this doesn't belong to me. Maybe this is something that belongs to you. And what I'm trying to do is open the door to be able to hear about the person's internal harsh judgment. And the whole interconnected network of things that that relates to, their associations, their memories, their fantasies, Somewhere along the line, they've internalized a relationship with some important detachment that's critical or judging. But now that judging and criticizing is theirs, is them judging the filth.

When we can start making these links, you know, you're feeling this way. We would like the patient to say, oh, you know, that reminds me. I don't know why this comes to mind right now. That reminds me this time, you know, you know. I spilled the milk and my mother like punished me and I couldn't watch TV for a week. Right. And then you get to make the links. It's like, but, you know, I would sort of be appreciative that they came with that association.

And I'm saying, you know, it's like, it's like that part of you that spilled the milk and got that harsh response. And so that part of you is here in our relationship. There's a way you're expecting the same treatment for me. And the patient starts to differentiate what's past, what's present, what's another relationship, what's this relationship, and that's really the work. And that leads to psychological change that the patient takes outside of the consulting room. right something is shifts and is different about them right that changes how they relate to other people in real life right so the goal of the work isn't we're not doing this so they have a better relationship with us although that's the vehicle you know we're doing it so they can have a better

relationship with us because that understanding and knowledge of where things go wrong and how and why right then transfers over into real life and the patient is different and then you start really enjoying their company because they're like become really cool and interesting and you like seeing them. And around that time, the patient decides that their relationships are really going well and they're better and they don't need therapy so much. And that's like the tragedy built into being a therapist, you know, like just and I guess being a parent also. Like, you know, like just around the time that you're really getting something out of this relationship too, because they're so engaging and open and peasant.

Around then is when the patient starts thinking and should be thinking, yeah, I think I got what I needed here. I think Dr. Lattal had a question. Maybe you could delineate it a little bit, Dr. Lattal. She said, is this consistent with children? Oh. You know, I don't know. I don't work with children, so I can't really speak with any expertise.

I mean, with children, we're, I mean, we're kind of often trying to develop a, maybe sort of a precocious capacity for self-understanding in the service of overcoming a particular symptom or difficulty. I mean, so we are working toward understanding, but it's really a whole different way of working. Okay. Yeah, I'm not the ideal person to ask. we don't have to get too far into that but you know going off of what you were just talking about what if you know there's a transference there in like the reassurance seeking but like the you know the patients like I'm you know I'm boring you right like I'm just I'm worried that I'm boring you you don't want to see me all these things if we provide the reassurance we are entering into an

enactment right right we're we're living the transfer and the countertransference versus understanding. So you're not providing the reassurance, and I understand the reasoning behind that. But what if, like, what if you are feeling all of their fears, right? Like, what if, in the moments when you're feeling incredibly bored and they're worried you're bored, or you're feeling sleepy, or whatever, or you're feeling like they are too much,

or you just want them to go away, and that's their big fear, right? Like, you're not going to say that, obviously, but how do you approach those? Well, you might say it, actually. So we don't want to, unless the patient is, you know, functioning at a psychotic level, and even then there's some truth to it. I mean, you know, however distorted the patient's perception of us might be, you know, it's also based on, you know, some reason. reality that they're picking up. And, you know, the truth is we're not always at our best.

Sometimes we're tired. Sometimes we're preoccupied with something in our life. Sometimes we actually get bored, right? And it's about the patient. I mean, we never want to, you know, sort of damage their reality testing. We never want to gaslight them by, you know, denying the data of their own senses. So sometimes it's actually very appropriate to say, you know, yeah, you're right, my attention wondered. Or, you know, yeah, I'm not my best today. You know, I am tired.

I mean, sometimes we want to acknowledge that. I mean, if the patient is saying something that's true, we don't, you know, we don't want to contradict the data of their senses. But then it gets into a much more complicated transference, countertrans issue, which is, so I have to think about as non-defensively as I can must during the moment. Like, did my attention wander? Am I bored? Am I feeling overwhelmed too? And then I want to start to try to disentangle. Is this something I'm bringing with me?

Or is this something specifically in response to, what the patient is doing. And it gets into the question of self-disclosure in therapy. I would say if there's a principle involved, what can be helpful to disclose in the therapy is our reaction to the patient in the here and now of the session. What's generally not helpful to disclose the patient as information about us and our lives.

So suppose I'm feeling bored and it's not because I'm preoccupied or worried about my taxes or like there's something about what's happening in the room. So, you know, you're picking up on something. I mean, I was feeling well tuned out and my attention was wondering

and you have to be so careful. Patients are so many patients are so primed to hear something like this as, you know, shaming or judging them. And we're 100% not after that. We're after curiosity. So we have to be very alert to the patient's, you know, readiness to feel shamed. You know, my thoughts were when wandering in a way they don't usually. and you know

some of that is me and some of that is us I wonder if we could think together about what might be going on here that

resulted in this what experience I'm having what experience you're having of yourself of me can we expand the field of what we're going to talk about from am I or am I not bored because they're boring,

can we expand that to, well, okay, you are being boring just here, just now, but that's the beginning of a conversation, not the end of the conversation. So something I often say to the patient, a patient is, you know, we all have our like little, you know, lines and phrases that you know, that come up. And it's like, you know, that's the opening sentence of a whole chapter or maybe a book. And often the patient wants to treat it as, you know, the final, you know, sentence in the final period. Well, I'm boring. And I might say that.

It's like, you know, you're treating it like it's the final concluding sentence. I think we might look at it as the, you know, opening topic sentence. There's like a whole book to be read here. That's so good. There's something going on between you and me here that we're both experiencing in the ways that we do. But, you know, just right now, I don't think either of us understands that something. Here's something we can talk about and think about. And I'm also thinking I'm not saying it because this would really start to sound shaming at this juncture.

I'm not the only person that this patient bores, right? Right, right. Yeah. Great. Well, this has been just been wonderful. I think we got to wrap it up so you can get to your next thing. Yeah, thank you so much for coming on, Dr. Shudder. I know we have some super fans here. Some people who are very excited to be with us. And I won't embarrass them by calling them out by name. I'm looking at all the icons or what do you call them, the emojis? Thank you. That's lovely.

And I was just for say, you guys have been, I mean, just a lovely group. This is, like, really fun for me. And everybody who asked questions was asking really good, thoughtful questions. And I can tell that, you know, this group is really thinking clinically and psychologically about the issues, which is really nice to see. Like, it doesn't go without saying in training these days. Like, there's something special here. Awesome. Well, okay, we'll leave it there for today, guys.

Thank you. Good to see all your faces. Thank you, Dr. Shedler. Thank you guys. Thank you so much. Thank you so much, Dr. Shephan. Yes, thank you so much. It was wonderful. Thank you all. Yes. I agree. It was good for me too.