Episode 241: Depressive Personality Style with Jonathan Shedler
Transcription and footnotes edited by: Jonathan Shedler, PhD, David Puder, MD, Al-Baab Khan, Joanie Burns, Jonathan Nowlin
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An Introduction To Depressive Personality Style
Puder:
Welcome back to the podcast. Today I'm joined by Dr. Jonathan Shedler to talk about depressive personality style. He has been on the podcast before to discuss narcissism, obsessive compulsive personality, beginning treatment, and psychodynamic psychotherapy.
We will be doing a lot of role play today to try and give a practical understanding of depressive personality dynamics, how it shows up in therapy, and how to help the person get in touch with their own needs, desires, and frustrations.
Individuals with a depressive personality style are often professionally and socially externally “successful” with a warm, engaging, empathic presence, and invested in making other people happy. Due to adaptive childhood dynamics, they developed an accommodating nature and can get stuck in relationships—even therapeutic ones—where their own needs, desires, and anger remain neglected, disavowed, and largely unconscious.
Depressive personalities are distinct from clinical depression; someone can have a depressive personality without necessarily experiencing clinical depressive episodes. Paradoxically, individuals with this personality style often appear outwardly successful and high-functioning despite inner feelings of inadequacy and chronic dissatisfaction. They typically struggle to experience genuine pleasure or joy.
Within psychodynamic circles, the concept of depressive personality remains influential, particularly through the work of Nancy McWilliams, Otto Kernberg and Jonathan Shedler. They emphasize underlying dynamics such as internalized self-criticism, unconscious guilt, and enduring interpersonal patterns.
There are common patterns that show up in how they relate to others including:
Introjection: Internalizing negative experiences and anger
Turning against the self: Engaging in self-directed criticism and punishment
Gentle idealization of others coupled with profound self-devaluation
Transference may include gently idealizing the therapist while converting dissatisfaction into self-blame and guilt. Countertransference reactions involve protective impulses, feeling the patient’s disavowed frustration or feeling their helplessness.
This concept has a rich historical lineage. Emil Kraepelin first described depressive temperaments, highlighting their stable and chronic nature. Depressive personality disorder appeared as a proposed diagnosis in the appendices of both DSM-III-R and DSM-IV.
Depressive personality style is represented in the DSM-V as persistent depressive disorder and in ICD-11 as dysthymic disorder, but here we will discuss it as a personality style.
Can you talk about the historical context on how depressive disorder first came to be included in the DSM?
Shedler:
You brought up something that might be a useful little digression here about the impact of the DSM on how we understand personality. The concept of personality disorders actually didn't exist in the literature prior to DSM-III in 1980. The framers of DSM-III were very determined to produce a medical taxonomy of psychiatric difficulties. So they made a decision upfront: everything was going to be a disorder. This plays out in funny ways. For example, before DSM-III, people were anxious, but the concept of generalized anxiety disorder didn't exist. Anxiety was a state, not a disorder that you had. This shift really changed the landscape of how we think about mental health difficulties. They left personality out entirely—it wasn't even on their radar. They had basically completed the entire development of DSM-III without ever taking personality into account. Apparently, very late in the game, someone said, “What about personality?” So it was added as an afterthought, literally an afterthought. That’s why it was Axis-II in DSM-III through all the variants of DSM-IV. Since personality had to be made to fit into this taxonomy of disorders, they took the major personality styles that were familiar to psychoanalytic clinicians at the time, exaggerated their severity—sometimes to the point of cartoonish caricature—and called them “disorders.” All of a sudden, personality disorders became a thing on the map.
Puder:
I think it’s extremely important, in my mind, to have empathy for clients, to understand our reaction to clients, our countertransference, to deepen our reflectiveness into people’s experience, and to appreciate their individual personality styles. I like how you parse that out. Everyone has a personality style.
Shedler:
Yes, everybody has a personality. Every human being has a personality. But the unintended consequence is that now we have several generations of psychiatrists, psychologists, and mental health professionals who have no concept of personality—except when it’s a disorder. I do a lot of speaking, workshops, and podcasts, and this misunderstanding happens all the time. I'll say something about somebody’s personality dynamics or personality style, and the other person o will immediately start talking about personality “disorders,” as if that’s what I said.
The way I see it, there are certain recognizable patterns or constellations of personality functioning, that we see often enough that we can say: this is a recognized personality style. These styles all fall on a continuum of functioning from healthy, high functioning to really very seriously disturbed. Essentially, what DSM ended up doing was teaching generations of clinicians that if personality isn’t at the extreme of disturbance, it doesn’t count and we don’t need to consider it. So we can then talk about depression in isolation from the psychology of the person who has depression. We can talk about anxiety in isolation from the psychology or the person who has anxiety. But that’s not really a psychological understanding.
Depressive Personality Styles: Challenging Diagnosis And Therapy (00:08:55)
Puder:
Today we are discussing someone with psychological defenses— these inner experiences lead to more of a chronic depression beginning in adolescence, and continuing until they engage in psychological work. How would you say it differently?
Shedler:
It’s important to consider what personality really is—a consistent pattern of functioning that originates fairly early in life and consolidates by adolescence. And it subsumes patterns of how we relate to other people, relate to ourselves, how we cope with difficulties, our defensive processes, our organizing psychological themes, our motivation—basically everything that we talk about when we refer to somebody’s psychological functioning is really in the domain of personality. So when we say a depressive personality style, it’s pretty important to understand that it's not the same as clinical depression. It often leads to depressive episodes that you could diagnose as depression, but not necessarily. So you could have people with depressive personality styles who are not in fact suffering from clinical depression. In principle, you could see someone with a depressive personality style who’s never had a clinical depressive episode. And lots of people have chronic, consistent, recurring depression who don’t have depressive personality styles. They’re different things.
Puder:
So how would you define depressive personality style?
Shedler:
It's a pattern of functioning in the world and a way of experiencing self and others. Characteristic features include being very prone to negative affect especially shame, guilt, feelings of failure, and inadequacy. The most defining hallmark of a depressive personality is that, if you were a psychologically sophisticated observer looking at this person from the outside, you might think they were their own worst enemy. They tend to be inhibited in seeking and experiencing pleasure, excitement, joy, satisfaction. It’s as if there is something inside them that’s squelching their ability to enjoy these feelings. In some cases, it appears as though they are unintentionally seeking out experiences that are going to cause hardship or suffering or unhappiness.
In that respect, we can say they seem like their own worst enemy. People with this personality style actually tend to be pretty high functioning. It’s generally not a disorder. It’s, if you think of a spectrum of levels of personality organization from healthy through neurotic through borderline to psychotic, they tend to be in the healthy and neurotic levels of organization. Interpersonally, they tend to be warm, engaging, empathic, and pleasant to deal with. They tend to be people pleasers. When they come into therapy, empirical data shows us that clinicians describe them as good patients. They feel really good about working with them.
And the trap is the fact that the clinician feels really good—because the patient is easy to deal with. They’re accommodating. They’re appreciative of what the clinician offers. So the clinician tends to come out of the session feeling like there’s a connection, feeling like they’re being helpful to the person. The danger is that the reason the clinician feels good is actually not a sign of progress, but rather a symptom. The symptom is that they end up recreating the patient’s relationship patterns in the therapy relationship. And the patient’s relationship patterns are that they’re very oriented toward other people's needs and feelings at the expense of their own. So when they enter into a relationship, they tend, in one way or another, to devote themselves to making the other person feel good about the relationship, but often at their own expense. So the other person’s needs get met, but their own needs don’t necessarily get met. They come in and they repeat this pattern with the therapist, that the therapist ends up feeling very good about the therapy. And even though they both appreciate one another, the patient doesn't change. That's the trap of treating depressive personality style.
Puder:
It’s like there can be some gentle idealization of the therapist and if they have frustration towards the therapist, they usually turn that towards themself.
Shedler:
Yeah. The typical manifestation in therapy is, they feel they’re not doing it right. They’re not being a good enough patient. They’re doing something wrong in therapy. So you often see it in therapy in a very direct form, like the therapist makes a mistake, which is inevitable. We all make mistakes every day. There's no such thing as a therapy session without a mistake, I don't think. And typically the patient either glosses over it, brushes past it, or patient actively takes responsibility for it (“Oh. It's not your mistake. I didn't explain it right. I gave you the wrong impression. I wasn't forthcoming enough. I didn't tell you all the information. It's on me as a patient, not on you.”). But it’s subtle because they’re usually higher functioning, at a healthier neurotic level of personality organization. It’s not idealization in the sort of icky way that you would see in narcissistic or borderline functioning. It’s generally in a very engaging and appealing sort of way.
Exploring The Inner World Of Depressive Personality (00:15:34)
Puder:
So we have a role play.
Shedler:
I love it.
Puder:
I have a character. I've been working on this all week. Maybe I've been working on this for years. Maybe this is like early on in the therapy and so we could just start it off.
I'm gonna try to get into person here.
I like how you said you have to embody something that's real. When we were talking about this, at first I was thinking about doing Abraham Lincoln and having Shedler do some therapy for Abraham Lincoln, because I think he did have real depression episodes and I think he had a depressive personality. I really think he did.
Shedler:
Don’t know!
Puder:
I've been reading a biography on him. But I will not be Abraham Lincoln.
Shedler:
And the reason for this is that when we treat patients of our own, we draw on our own immediate personal experience. If we have a real patient in mind, we form identifications with the patient. We unconsciously identify with them, even if the patient never says the specific words that come out in the role play. There’s a way we can speak from within that person. It is not a conscious, planful process. If we’re a dedicated therapist, there’s a way we just take in our patients. And try to understand them, or not even understand—experience them—from the inside out, rather than just as an observer from the outside looking in.
Roleplay Begins:
Puder:
You know, Dr. Shedler, I wanted to reach out to you, but I know you were on vacation. I felt bad wanting to reach out to you, wanting to disturb your vacation, so I didn't. But I feel, I had this email, I started to write it, but I felt kind of guilty for interrupting. Well, I don't know if you were on vacation, if you were lecturing. But anyways, my father passed away last week and it brought up a mixture of things for me.
Shedler:
Well, I mean, I'm hearing two things, I'm tempted to ask you to tell me about what it brought up for you. But I’m also hearing this happened while I was away, and it sounds like you were feeling bad about wanting to get in touch with me.
Puder:
Yeah and…I think as a therapist myself, when I'm on vacation, it’s like, I appreciate being on vacation. So I think I was just kind of leaning into that a little bit. And then I've had patients who reach out during vacation and sometimes you gotta talk to him and stuff. It's heavy. It’s mostly for my father, it’s weird. Everyone wants me to feel sadness. Everyone is like, “Oh, you must feel so sad.” We even had a funeral. It was pretty short. I would be like, “Oh, yeah, yeah, I feel sad,” and I would tell them that. But really what I felt was guilt that I didn't feel sad. And I felt more like I should feel sad, but I don't feel as sad. So…
Pause Role-Play:
Shedler:
Just stepping out of the role play for a second. How long have we been in treatment? How well do I know this patient?
Puder:
Let's say this is like the third or fourth session.
Shedler:
Oh, it's very early on. So I don’t know. I don’t have a lot of history.
Puder:
Yeah. So you can ask the history.
Shedler:
Okay. So that’s all I needed to know. I’ll jump back in.
Resume Role-Play:
Shedler:
I gather you must have had a complicated relationship with your father.
Puder:
Yeah. And I know the first couple sessions when we were meeting, it was mostly about patient issues. In my mind, I don’t know why I go there, but I almost don’t wanna burden you with the story of my father. Which I know you've like– consciously in my mind– you have been doing this a while.
Shedler:
But something in you feels like it would be a burden to me to hear about it, to listen to you.
Puder:
Yeah. So my father left our family at around sixth grade. He was in and out of our life afterwards. He probably had true bipolar. I didn't know that back then, but I know that now.
Shedler:
Undiagnosed bipolar then, I imagine.
Puder:
You know, I think for the first decade of my life, he probably drank himself out of any mania. But then he developed chronic pancreatitis and he couldn't drink, or he'd get acute pancreatitis and end up in the hospital. So eventually he became sober. And when he was sober, he was very miserable.
Shedler:
Miserable. Meaning how so?
Puder:
Well, he was always angry even when he was an alcoholic. But when he was sober, he would kind of go between up, out, having sexual flings with men and women. I would go to my grandma’s house every other weekend, and he would be there. And he would just really stay in his room.
Shedler:
When you say he was miserable, I'm understanding that to mean he was miserable to you. Maybe miserable to the whole family, but he was miserable to you. He treated you, I’m gathering, in ways that made you feel miserable.
Puder:
Yeah. He would call me “little bastard.” He met my mom during a fling. I don't think he really wanted me, mom didn't abort me. He would remind me of that.
Shedler:
Do you think he wished that? That she had aborted you?
Puder:
I think he felt trapped. And sometimes I feel responsible for his unhappiness. I know as a therapist now, I probably shouldn't feel that way, but it feels really true. He blamed me for that.
Shedler:
He blamed you for his difficulties, his instability?
Puder:
Well, his difficulty was my mom, which I can get to later. But yeah. So I mean, there were memories of him yelling.
Shedler:
At you?
Puder:
At me, spit flying. His face close to mine, you know? Hard to predict.
Shedler:
Was there physical abuse also?
Puder:
Yeah. There was, yeah. I mean punishment– just punishment that was random. It was chaotic. It was not, it was not like I did anything bad, per se. Or maybe I did, but…
Shedler:
Could you give me a for instance? Whatever comes to mind, just now. Just so I can get a better idea, when you say there was punishment, an idea of what you mean.
Puder:
He would come home, hadn’t been home for days, and he would be in a tirade. And he would just nonstop be ranting about how unclean the house was. And it’s not as if I didn't try to clean the house, I think this was around when I was like nine.
Shedler:
It was your responsibility when you were nine to clean the whole house?
Puder:
Well, my mother was at that point so heavy that she couldn’t get out of the couch very easily. I hate even talking about it in that way, but the reality was she was pretty physically weak compared to– so she couldn't really get up. And so…
Shedler:
I'm assuming if she was too heavy or too weak to take care of the household, she wasn’t really able to take very good care of you either.
Puder:
I hate to even get into this but we would live in squalor. It was outright poverty. We'd move every month. I think when I just turned 40 and I just realized I've lived in 39 houses. So I officially passed the number of houses that I've lived in.
Shedler:
It sounds awful.
Puder:
I have worked since I was 12. So, I would go to school, I'd work, do sports, go to work, come home at 11. Mom would talk to me from 11 to 1:00 AM.
Shedler:
Talk about what? Yeah, I'm sorry, go ahead.
Puder:
About her issues–things that have come up in the day, and…
Shedler:
About her issues. You mean her worries, her problems? Things that were bothering her?
Puder:
Her anxieties. The weight that she carries.
Shedler:
So I mean, you’re like nine or 10 years old, it sounds like. Well, you're a therapist too. I'm sure you know the concept. It sounds like you were—became responsible for taking care of your mother like you were the parent, rather than vice versa.
Puder:
She had a lot of reasons. She had a lot of anxieties and I think she needed someone to talk to.
Pause Role-Play:
Shedler:
So let me make an aside for the listeners, because I haven't really done much by way of intervening yet. I’m still getting the lay of the land, the psychological lay of the land for this patient. But I'm about to– this is going to be my first actual intervention. So I'm just sort of flagging this. I'm about to do something that follows from an understanding of the personality dynamics that I see emerging. So jumping back in:
Resume Role-Play:
Shedler:
I can’t help but notice I commented about your experience, the burden of being in the role of having to take care of your mother, and your response was about your mother.
Puder:
Yeah. And I think you gotta understand how hard, how difficult her life was. And she would tell me about how difficult it was, and she would tell me about– there would be men that would come and stay with us for a couple weeks at a time. And I would hear them– at first nice noises, giggling sometimes.
Shedler:
You mean men that she was involved with?
Puder:
Yeah. Yeah. Like…
Shedler:
Romantically or sexually.
Puder:
Oh. Oh, you could hear, you could hear them through the walls-
Shedler:
This was happening–
Puder:
Holes in the walls. Yeah.
Shedler:
So this was happening right under your nose in your house?
Puder:
Oh, yeah.
Shedler:
Your father’s out running around with other women, I guess was how I understood what you said. Your mother’s bringing other men into the home and there's something that doesn’t quite add up for me. Like, she’s overweight and too heavy or too depleted to take care of you. And yet it sounds like she has energy to bring in, not just one man, but it’s like a regular thing with different men.
Puder:
Yeah. And she would meet these men online. They would travel sometimes from cities away, lived with us for a couple weeks. I mean, these were not like my teachers, my coaches, who I looked up to. These were men that I hated or just disliked.
Shedler:
So who was taking care of you, because that doesn’t sound like your father was doing much of that. It doesn’t sound like your mother was doing much of that. Was there somebody in your life who was there for you and there to take care of you?
Puder:
I think I kind of figured out how to take care of things. I felt a lot of responsibility.
Shedler:
You mean, you were the person taking care of you, and it sounds like, in important ways, trying to take care of your mother and trying to take care of your father too.
Puder:
I mean, I think at around that time– like see, I feel like I'm really giving you too much here.
Shedler:
What do you mean, what do you mean “giving me too much?”
Puder:
Well, I mean, it feels like I'm burdening you too much. I feel like this is gonna be too heavy for you- like, it’s gonna be like a lot…
Pause Role-Play:
Shedler:
Just as an aside, this is very fast. I mean, if this were real therapy, this would likely unfold over more sessions. But, I want to illustrate working with something here. If this were in real life, this would be pretty abrupt.
Resume Role-Play:
Shedler:
But I wonder if something is going on here between us that is similar, or a continuation of what you're describing growing up with your parents. Because your mother was supposed to be taking care of your needs, physically, emotionally. But she would burden you with her problems, her anxiety. She’d keep you up until 11:00 p.m. and I get the sense that it felt like your role was to not burden them, right? To protect them from having to deal with your needs, your feelings, your distress. The little kid having to fend for yourself. You were protecting them from your needs. And I wonder if there’s something like that continuing here, with us, when you say you don’t wanna burden me, or it’s too much for me.
Puder:
Yeah. I may have misspoke earlier. I would get home from work at 11:00 p.m. in high school and junior high school. And then I would be listening till 1:00 am. I may have misspoke, so I apologize for that. But…
Shedler:
You assume that—well, there it is again, actually—so you assume that you misspoke, rather than that I misheard or I misunderstood.
Puder:
Well, if you think that you’re like my parents at all, like that's not the case. I mean, you remind me more of– I had a good basketball coach. I wasn’t the best basketball player.
Shedler:
Well, yeah. The ways that I might be like them, or not like them, that’s something else we can talk about. But just at the moment, what I was really getting at wasn't so much whether I am like them in reality or not. I was noticing your impulse to want to protect me, or your feeling that what you were telling me was too much, too much of a burden.
You know, it brings us back to where we started, which is that your father just passed away. I mean you must have very complicated feelings about it, to say the least. And you felt like reaching out to me. It was the same thing with that…. you shouldn't burden me. I was away, maybe I was on vacation, maybe I was teaching, whatever. But you felt you shouldn't ask for that from me. And I wonder, when you start to tell me about how difficult things were for you growing up, how alone and uncared for you were… your thoughts go to, it's too much for me, you shouldn't burden me with this.
Puder:
Mm-Hmm. Yeah. And like, I think–
Shedler:
Like therapists only want happy patients who are feeling good and don't have any actual difficulties to bring into therapy.
Puder:
Yeah. I think that I guess I'm getting confused. It's like I know logically I should not feel like I'm burdening you.
Shedler:
Well–
Puder:
And somehow, I feel almost critical of myself that I'm feeling that way. But then I can also see how deeply that resonates with so many things in my life. So–
Shedler:
What it brings up… it’s bringing up more for you.
Puder:
Yeah. Well I talked to you in the first couple sessions. Like whenever my patients are doing well, I don’t feel much gratification– I feel like that’s expected. They’re paying me, but when they don’t do well, I really, really ruminate.
Shedler:
When they’re doing well, it’s not to your credit. It’s hard for you to feel good about it, or feel like this is something you helped to accomplish. But when they’re not doing well, it’s your fault.
Puder:
Yeah. And so I've been thinking about that as kind of a theme of our first couple sessions. And I've been thinking about, hmm, maybe there’s some deeper reasons for that. So with my dad’s death, I feel maybe this is a good time to look at those deeper things. And I think it’s coming out. Yeah. I'm aware. Okay. So I may have some transference as well towards you. Now, I'm not as articulate as you are about these kinds of things, but I can see it happening right now consciously, like in my mind. I'm feeling guilty about multiple things in life.
Shedler:
You mean just here, just now between us? You’re feeling guilty? Or are you referring to other things also?
Puder:
Yeah, I'm feeling guilty in the here and now. And just sharing this, which is kind of how I felt growing up as well and how I feel with my patients. So there's like– I'm seeing that overlap.
Shedler:
Yeah. You were even feeling guilty about your reaction to hearing about your father’s death, guilty that you weren’t sad enough or weren’t reacting the way you think you should have.
Puder:
I think most of the people who are close to me don’t really know much about my childhood. I’ve kind of kept that in a separate container, because things are so different now. I think most people, most of my friends, they came from good backgrounds. They wouldn’t relate to the squalor, the decaying wood, the holes in the wall, the cockroaches on the ground, the duct tape. So I think most of them expected me to feel sad when he passed. And so most of them would get sad for me. But I think there was a part of me that kind of felt relieved.
Shedler:
Yeah. I could imagine. You got there first, but I was about to say, maybe you don’t feel sad.
Puder:
Yeah. He would come visit and he wouldn’t really interact that much. It was kind of hard to have a conversation with him.
Shedler:
And so I imagine there’s a lot of feelings in the mix, you’ve said there are complicated feelings. But among that mix of feelings, I imagine there’s a part of you that must be glad to be rid of him—therefore the relief.
Puder:
Ooh. I would feel– I’m glad to be rid of him– I don't know if I'm there yet. I mean, I do feel some relief.
Shedler:
Well, maybe I jumped the gun. Maybe—tell me more about the feeling of relief—I mean, I jumped the gun and put words in your mouth that don’t fit.
Puder:
Yeah. Well, thank you for that. Yeah. Letting me have the space to kind of get in touch with what I feel. So I haven’t told you this about him yet, but he would call me and I would get these calls. He would be gone for weeks. I would get these calls from him. He’s probably on a payphone– and then he would be telling me on the phone and now, I think back, was he on drugs back then? I didn't know. But back then, I’m young, and he would say things like, “I'm gonna kill myself.” And he would keep me on the phone and I wouldn’t say, “Oh, you're the best dad ever,” but I would say, “Dad, please don’t kill yourself. Dad, please don't kill yourself.” And so, yeah, there's a weightiness with, with those memories.
Shedler:
What I’m hearing is how you ended up being the emotional caretaker for two parents. Like you were trying to be a little kid, and trying to be a therapist to both of them at the same time.
Puder:
Yeah. Of course, back then, you never have the right words to say to make them feel better. And so–
Shedler:
It was your job to make them feel better.
Puder:
Well, what I’m saying is as much as I tried, I don’t feel like I ever really was able to do that.
Shedler:
Yeah. But I’m wanting to highlight something that I think was implicit in what you said. That you tried and you never could succeed, or never could succeed enough. But implicit in that is, it just seemed very natural and normal, that it was your job to make them feel better. And now you’re telling me how you failed at the job. You didn’t, you never could quite accomplish it, but it seems like in the background it's the default that of course it’s your job to make them feel better.
Puder:
Yeah. And now, I do that for my work. And yeah. I think the patients that I'm not good at doing it with gets to me. But–
Shedler:
So when the patients don’t get better, they’re like your mother or your father that you could just never do enough for. You could never succeed in making them feel better.
Puder:
Yeah. I guess I'd never seen– I should have seen it like that, but I've never seen it like that. But, yeah. It's kinda like that.
Aggression In Therapy (00:44:21)
Pause Role-Play
Shedler:
For purposes of the role play, suppose we skipped ahead about 10 sessions and your father’s death is still in
the air.
Puder:
How do you feel it’s going so far?
Shedler:
I think you’re doing an extraordinarily good job, maybe a little bit over the top in terms of the history, but an extraordinarily good job of inhabiting a certain kind of depressive person. What I'm thinking, and I didn't say during the role play, but it's going on– to let you and the listeners into what's going on in the back of my mind– so here's a personality dominated by guilt, dominated by a sense that they’re falling short, or something about them is bad, isn't good enough. Somebody who had that kind of depriving childhood would feel that. This is a combination of what we call anaclitic and introjective depression. There are two different things going on. I mean, one is the absence, the loss, of a real caretaker that every child needs.
And that loss stays with us. It gives rise to an emptiness within that is a hallmark of a particular kind of depressive personality. You sort of feel depleted and empty and try to fill that hole by bringing other people into your life and connecting with other people, except it doesn't quite fill it. And the connections are kind of a one-way street, not because the other person is necessarily requiring that it's a one-way street, but because the patient is making it a one-way street: It's about what they can do for the other person rather than what they can get and take in that meets their own needs. So that would be a kind of anaclitic– we call anaclitic depressive style, where the person is very sensitive to loss and relational disruptions.
But that's half of it, right? The other half that we didn't get to in this role play– which is why I was thinking of skipping ahead some sessions– is if somebody is mistreated like that, somebody berated, yelled at, the way your father– the way you were describing– it would be less than fully human to not feel angry, resentful, deprived, enraged about that. It is not just that you feel the people you needed to rely on didn’t do right by you, didn’t care for you well enough. It’s that they didn't do right by you, in this particular history that you're giving me.
Of course there'd be anger and resentment and I think we just heard just a whisper of that when your patient said, “Well, I felt relief when he died.” And of course, behind that word “relief” is a whole universe. If you're relieved about something, that means that there was something that you were experiencing as a burden, something you resented. You just hinted at that with the patient. And here's where you did such a good job of being this kind of patient. The patient is also very defended against their aggression. So they have a kind of introjective version of depression too. They have a kind of impossible internal dilemma. And the dilemma is that they are angry, but it's not okay to feel or express that anger. So when its extreme form, what this looks like in life is, that the person ends up becoming a kind of a doormat in other relationships. Not necessarily because they're surrounded by people who want to take advantage of them, but because they can't tap into constructive aggression to assert, express their needs, their wants. And so they go without.
Puder:
And this is where Otto Kernberg's thought, which was so interesting– when I asked him what was the main thing therapists need to learn, and he said, “I think the most important issue is first of all, comfort with one’s own aggression.” I had just prior asked him about depressive personality style, which Nancy McWilliams says is the most common personality style in therapists. So when he answers with the importance of getting in touch with aggression, I am now connecting that with what a person with a depressive personality style needs.
Shedler:
Yeah. So that raises another issue. Let's definitely make sure we get to talk about this. People gravitate toward roles in life that are consistent with their personality organization and their enduring psychological themes, conflicts, and defenses. Anyway, that said, depressive personality style is the most prevalent personality style among people in the mental health professions. And we'll talk about why, but let’s stay with your patient for just a moment, and then we can expand to how this plays out in the profession. So the person is in a really impossible dilemma, which is that they are angry, but it's really not okay to feel it, let alone express it. And well, what becomes of it? Where does it go? Because the one thing we understand psychologically is that "out of sight, out of mind" doesn't mean it’s gone. It's still there. It's still having its impact. And you actually did a beautiful job illustrating it. If you are angry with someone, if you really don't like someone and you're angry and you wanna punish them, what do you do? You treat them really badly, you blame them, you scold them, you shame them. You find fault with them constantly. You're depriving them—you don't want them to have a good time. If something bad is happening with them, you want to rub it in. Basically, if you're really angry with someone and you act on it, you treat the person like shit. Hopefully, most of us have the capacity, at least professionally, to feel angry, to be aware of the internal experience, and not have to act on it.
If you were really angry at someone and you acted on it, that’s how you might treat them. And what we see in this, what's called the introjective version of depression, is the person with depressive style is treating someone like shit—but it's themselves. And that's where you see the self-criticism, the self-deprivation, the self-punitiveness, which is empirically the hallmark of this personality style. So it comes up immediately in that role play, but in a very small way. And it's not present and palpable enough yet to work with in the session. So I let it go by. But the patient really wanted to call me. You wanted to call me when you heard your father died, and the reality was, for whatever reason, I wasn't there for you.
I took the time off. That wasn't your doing. I wasn't available to you. And I could easily imagine—it's not a capital offense, it’s a misdemeanor maybe—I could imagine that a patient in that position could feel upset with me. Why was I not available? And then your impulse, when you wanted to reach out to me, was that you were doing something wrong. "Oh no, you shouldn’t do that—you shouldn’t contact me when you’re upset." So, what happened immediately was that thought, "I'm doing something wrong," transformed into, "Oh, you can't contact me; you wouldn't be doing something wrong." And that's a very, very small instance of that kind of criticism or punitiveness directed at the self. So if we cast that in high relief, it’s not that the therapist is doing something bad. In your mind, it turns into you doing something bad. And there's the reversal.
Puder:
Yep.
Shedler:
And it takes a lot of doing in therapy. And I was thinking about this before the role plays, it's very hard to illustrate because it doesn't happen in a single compressed segment. But–
Puder:
I was thinking, man, we could, we could stretch this out for hours, right?
Shedler:
Yeah. There's a lot here. That's why I thought it might be good to jump forward some sessions. But the issue is that the therapist is going to fail in many ways, not necessarily intentionally, for reasons that are perfectly reasonable. I've had interactions like this– I can think of as a very specific patient. The most recent one being someone who's also a psychologist, a very good psychologist, by the way. And I'm not there when she needs me and expects me. And she feels bad about wanting something from me. And we had this discussion that was like– let me see if I can recapture it, it's kind of slipping away as I'm trying to put words to it.
Puder:
It could have been a little bit dissociated because it was so painful, right?
Shedler:
Yeah, oh, it's coming back. So, I got something wrong—I misunderstood something she said. That was the reality; it was actually my failing, a small one, a lowercase "f." Yet, she immediately took responsibility for it, similar to how you did in the role play: "Oh, I didn't explain it right."
Puder:
Yeah, and by the way, I did that on purpose. I've been thinking about this case a lot, and much of it is actually very true. It's not a patient, nor is it myself, but it's someone close to me whose story I know very well. So, when I speak about it, if you as a listener felt I was embodying it accurately, it’s because I genuinely care about this person who went through this experience.
Shedler:
That's why it's so important that there's a real person behind a role play, not a made-up case. I realize I'm thinking with my patient, I'm trying to also protect her confidentiality.
Puder:
Absolutely.
Shedler:
So let me just make up a kind of an equivalent example.
Puder:
And I'll say for the record, I got permission from my person.
Shedler:
So let's say I missed a session or I was late for a session. Or actually, let's use the example that you gave. I was away, I had something else scheduled and I canceled the appointment in advance—a good example. And I wasn't there for her when she wanted to reach out. And then she reacts very much like you did: “Well, I really wanted to reach out to you, but you were away and I didn't want to bother you.” And I said, “It must have felt pretty shitty that I wasn't there when you thought you could count on me.” She said, “Oh, well I know you have your own life and you were doing some important thing and you were teaching and I understand. And of course you didn't plan it that way, so of course I understand.” And I said to her, “everything you said is true. I did have a prior commitment, I did let you know well in advance. I was taking care of other business. It wasn't meant to harm you. All of that is true. I objectively had something else that I had to attend to.”
But—"What does that have to do with how it might feel on your end when I wasn't there? All of that is like your logical, rational mind telling me about external reality. Of course there's good reason I was away, I wouldn't just not show up for a session just for the hell of it. But who says your reactions to that are, like, only what's logical and rational and reasonable? Maybe there's some other parts of you in the mix that are harder to hear from, harder for both of us to hear from.” I didn't even bring up anger. She’s giving me a very reality-based, rational explanation for why of course it made sense that I would be away, so she shouldn't have a reaction to that. But that doesn't subsume the full range of our experience. We have lots of reactions that aren't so logical. And so what I'm doing is, in working with somebody like this, the anger and aggression is not going to come out naturally and we really have to very actively go out of our way to invite it in.
So an example I use in my chapter is that– I think you read it was– the therapist is late and the patient says, “Oh, I understand if you were running late, it happens. No worries.” Oh, I think it even came up in our last role play the last time I was on your podcast. And nine out of 10 times, the patient's lets the therapist off the hook and and just wants to move on to the real work. But that is the real work. The fact that the patient is so ready to let them off the hook and not bring in any other feelings except their positive feelings. That's where the acting is. That's where the work takes place.
Puder:
Maybe, we can go back into the role play and it could be a couple sessions later. It could be the same session. But maybe yeah, I'd be curious to kind of play that out some around the theme of the difficulty of reaching out. Let's go into another session and I'll bring up, kind of another kind of moment between us, and we'll see how you deal with it.
Shedler:
Yes. And just to make it crystal clear, this is the essence of depressive personality style and the essence of the problem. The challenge that we're trying to address in therapy is that the person is not getting their needs met in life—but the person who's obstructing getting their needs met is themselves. It's very, very difficult to get what you want, if you can't allow yourself to know what you want. This is the essence of the problem. The patient in therapy isn't getting their needs met, for whatever reason. We don't hear about their disappointment, their frustration, their resentment, their irritation, we don't hear about it. We have to actively pursue that.
The Betrayal Conflict And Struggling To Name the Harm (01:01:10)
Resume Role-play:
Puder:
Okay. You know, I had a dream between sessions that maybe I'll start out telling you that. Would that be okay? I don't remember a lot about it, but I remember I was in this church. It kind of felt like it was almost falling apart like an old church, like it was kind of like ruins of a church. And I go into a confessional and I start talking and then I realize that you're on the other side. And I feel like maybe watching some of your X stuff, your posts kind of triggered that from the night before. I remember reading a couple of them about the frame, about the importance of keeping the frame. And I was like– I went to bed and I had that dream.
Shedler:
Could you connect the dots for me? What about my post about the therapy frame, what about that do you think led to the dream?
Puder:
You know, and I think in session, I've never felt like you've been critical of me. But I think there's something about when I read some of the posts, I feel a sense of like, oh gosh.
Shedler:
Do you mean since you're a therapist too? Like you're not doing it well enough?
Puder:
Since I'm a therapist. Yeah.
Shedler:
You heard my post about as a criticism.
Puder:
Yeah. Like, I almost need to go into a confessional and just kind of–
Shedler:
Confess, repent your sins.
Puder:
Repent. Repent my sins. So, that's what I'm coming in with a little bit this week. And then I know we've been kind of talking about getting in touch with my frustration and anger. And I had one memory that came back to me, which actually felt like a tinge of frustration. I think I was about 14 or 15, and I was getting something from the back of the car– from my mom's car. And I got really close to stabbing myself with a needle. And I'm like, “Mom, why is there a needle in the back of the car?” And she said, “Oh, I needed the needle for something medical,” that she was going through.
Shedler:
You mean it was a syringe?
Puder:
It was a syringe, yeah.
Shedler:
I was picturing a sewing needle for a moment.
Puder:
Oh, a sewing needle. Yeah. No, so she had picked up HIV at this point. And so when I remembered this, I remembered at the time I had felt immediately like awful that she had HIV and that she had to deal with that. But in the– when it came to me the other day, I got tight in my chest because I was hanging out with my niece who's about the same age that I was. And I was like, I can't imagine putting them in potential harm's way to get HIV. And somehow that hit me for the first time.
Shedler:
That she was endangering you.
Puder:
Yeah. Yeah. I mean, I could have poked myself. I was so close to poking myself.
Shedler:
You said at the time that you felt, what did you say? That you felt guilty or…
Puder:
Oh, I just remember feeling at the time, like I just was really upset that she had to have HIV in the first place.
Shedler:
You were feeling bad for her.
Puder:
Bad for her, yeah.
Shedler:
That eclipsed, I guess, other feelings that were there, which was that she put you in harm's way.
Puder:
Yeah. And somehow, it didn't really occur to me. I mean, I think it occurred to me, she's putting me in harm's way at the time, but it didn't occur to me until I had my niece, who was my age at the time, hanging out with her.
Shedler:
You hadn't connected those dots until then?
Puder:
The memory came back and I was like, “Oh, like what? What was she like? Why did she, like, why was she so careless about my life to not clean up after herself when she knew she had HIV?”
Shedler:
She was putting your life in danger.
Puder:
And like, as I say that right now, I feel like in some way I'm betraying her, which is a weird feeling, like, but I feel also, like she was kind of betraying me. I mean, part of me doesn't want to believe that she would be so careless. But then the other part is like, she was so careless.
Shedler:
It gets a little confusing about who's betraying whom.
Puder:
Yeah.
Pause Role-play:
Shedler:
An aside for the audience here. So, there's a kind of clinical dilemma that I'm working through in my mind, which is—it would be very, very easy to go into this experience about the syringe and the feelings and meanings connected to that. And it would likely be very rich and a constructive area to work. But the transference takes precedence. And this is on the heels of a dream that he recognizes is about me. This is followed by the syringe.
Puder:
Okay. I got it. So let's enter back in.
Shedler:
So I'll take responsibility for that. You're really embodying the role. And part of that role is that it's up to you to fix it. But actually, if I'm a therapist and we're doing this role play, it's up to me to fix it, right? That we got away from the dream and the feelings about me.
Puder:
Well, okay. Yeah. And patients do that, right? So that's like, of course!
Shedler:
So that incident is really filled with feeling, and there's two competing therapy principles here. One is that we really want to follow the affect and stay with what's emotionally meaningful, emotionally charged for the patient. That’s clearly the syringe memory. But the other principle is we want to track the transference, especially the negative transference. And especially with somebody with a depressive personality style where it's so hard to see and so hard to get a hold of in the treatment. So, I'm trying to balance those two considerations. You could make an argument for going either way, but I think the transference is important. So we'll pick up the role play, but I'll jump in, okay? So we just left off with– it's kind of confusing who's betraying who.
Resume Role-play:
Shedler:
This experience with the syringe and HIV, it's really important. It's a big deal to have a mother with HIV, especially, I guess, because of her own recklessness. I do want to come back to that. But it's on the heels of remembering this dream that you think had to do with me. That feeling of being criticized by seeing one of my posts on social media. I wonder if you could help me connect the dots. They must have something to do with each other.
Puder:
You know, it's so interesting. I hadn't had this thought and you always say just share whatever comes to your mind. Like, if it comes all of a sudden, right?
Shedler:
Yeah.
Puder:
And so I had this thought that I think connects the two. There's a verse in the Bible, and it says if you hate your brother, you commit murder. And it has always been a part of my ethic to not hate anyone. And so I think after I had that thought about my mother that was the same day that the dream came after. And I thought, like, I'm gonna tell you about this because I had some frustration towards my mother. But then I think for some reason that sort of thought process comes through my mind that it's something bad to have any anger or like hatred, or– I'm not saying I hated her, of course. I'm just saying for some reason that that thought comes to my mind.
Shedler:
Comes to mind in connection with me?
Puder:
Yeah. Because in the confessional, I would be confessing that I murdered my mother with my hatred. That's the connection I'm drawing.
Shedler:
Maybe I misunderstood. I thought the confessional was your thoughts about hearing my social media post as a scold, that you're not doing it right. You're not maintaining the therapy frame properly. That that was your sin. That was your original sin before—
Puder:
That's what I thought. But in session right now, and I hadn't planned this. I hadn't thought about the connection. But the connection is that niece incident, that memory was the day before too. So I'm thinking that maybe the confessional– and I had thought at the time, I'm gonna talk to Shedler about this incident because of the new memory with my mom and the HIV syringe, and just thinking about being upset for my niece, like, oh my gosh. How could anyone have harmed my niece like that?
Shedler:
It's easier to be angry on your niece's behalf than on your own. Your niece wasn't the one being harmed and who could have jabbed herself with an HIV positive needle, right? I mean, it was you. It is easier to be upset on her behalf. And—just so we don't lose this, because I feel like it keeps slipping away and maybe we both have a role and it slipping away—that the starting point for this was you feeling scolded by something I posted on social media, or feeling you were being told you were bad. And it's in the context of, actually you are the one who's been wronged, who feels wronged. I think there may be more to this than meets the eye. That social media post really didn't sit very well with you.
Puder:
Yeah. I feel bad even for snooping on social media. In between sessions, I feel like I'm complicating the work here. I feel like I should be–
Shedler:
Another transgression on your part.
Puder:
Oh, I know, I know. And I feel bad that I'm recognizing that I'm double transgressing myself with this.
Shedler:
No, I'm not saying it's a transgression. I'm saying that you are talking about it as if it's a transgression. Like it your mind, it’s a transgression that you felt bad about my social media post. And it’s a transgression that you even saw it in.
Puder:
Okay, okay. I think there's part of me that sometimes—and I know I shouldn't feel this way—I feel like I'm gonna tell you something and you're gonna get really angry at me. Like, really angry. I feel like it's coming.
Shedler:
I guess we'll have to see…
Puder:
Oh, see, there's a part of me that thinks that there's gotta be something that I could tell you that, or I don't know. I just imagine maybe—I'm imagining incorrectly. I'm sorry. I'm confused about…
Shedler:
What just happened here? Just at the moment when you said it feels like I could get angry or blow up at you at any moment. I haven't yet. But you feel like the next one is gonna be the straw that breaks the camel's back, and I'm gonna erupt at you. And I said, "Well, we'll have to see." Something shifted right then. I'm not sure what came up for you, just in that moment.
Puder:
I feel like me sharing that would make you upset. I'm blaming you for something that you haven't done. Like, I'm accusing you–
Shedler:
You’re worried that I would get angry, that I would berate you or explode at you. Sharing that is–
Puder:
That feels dangerous to me.
Shedler:
Feels…?
Puder:
It feels dangerous.
Shedler:
You think I wouldn't want to hear your thoughts and feelings about me.
Puder:
It feels like maybe I'm blaming you for accusing you of something, or–
Shedler:
Well, that's a possibility. You might be worried or blaming me for something that’s coming from somewhere else— that isn't really about me. It's also possible that you're picking up on something about me in the background that we haven't talked about explicitly. Maybe there is something you're picking up on.
Puder:
Are you secretly angry at me between sessions?
Shedler:
I am leaving it open because we're really talking about your experience of me. And you seem to have the idea that it wouldn't be all right with me to tell me about things I do, or fail to do, that disappoint you or are upsetting, or make you feel bad about yourself, or make you feel like I'm secretly angry and I could explode at any moment. I think that if I answered your question, I think it kind of steers us into a dead end. And that it forecloses the opportunity to find out more about what's going on in your mind and in your experience.
Puder:
And I feel crazy even saying these things out loud because I know that you're professional and you're an expert. I'm sure you don't dislike your patients. And I have no evidence to support that. And I also realize I may be laying this on too thick and I may be laying on too much of my own worries.
Shedler:
I get the sense that you're working so very hard to be very reasonable and very fair with me. And what if you weren't so reasonable and fair with me?
Puder:
I think if I wasn't reasonable and fair, I think you would find some other patient to fill my slot or something.
Shedler:
You think I'd want to be rid of you.
Puder:
Yeah.
Shedler:
What an awful feeling that would be, to feel like the person, even the person that you come to for help, doesn't want to deal with you.
Puder:
I think it's just really weird to be in this role where I'm the one talking and all day long, I listen to my patients. I listen to my family.
Shedler:
Well, I think that's very comfortable. We both know, we've talked about this. It's a very comfortable and a familiar role. You were training for it, for that role since early childhood. What I'm starting to understand in a different way now is there's something about being here with me as a patient that's very fraught for you. You didn't say this in so many words, so if I'm not getting it right, I hope you'll correct me, but it seems to me like there's a way you're sort of walking on eggshells here. That at any moment, I might explode at you or punish you or throw you out of treatment entirely. And I know it hasn't been in the forefront of your mind. It's not like you're deliberately editing and censoring and curating your thoughts at every moment to be careful not to offend me, or not to say the wrong thing. But it seems like that's been with us in the background.
Puder:
Yeah. And I think that this is different because I think with my teachers and coaches, that I got good things from, of course I'd find that thing that they're interested in and read a couple books on it, be able to dialogue on the thing that they're into. And I think that–
Shedler:
Your role was to be a very good student, or very good athlete, and to be very appreciative.
Puder:
Yeah. And I don't want to come across as unappreciative.
Shedler:
I wouldn't like an unappreciative patient.
Puder:
See I know there's a little tongue in cheek in there. I'm really trying to get into this role, but I'm also realizing how hard it is to get into the role.
Shedler:
The role is one where you don't have to feel like you're walking on eggshells or taking care of me or protecting me from my feelings.
Puder:
I think there was something very hypervigilant about me when I was young. To be in that role with my dad, with my mom. It’s hard.
Shedler:
Well, I mean the word “hypervigilant”– it's technically the right word– but there's something that's, like, pathologizing about it. Your describe it as hypervigilant, whereas in fact you were doing what you had to do to function and survive in that environment. It's not like you had a lot of choice, you know? It's not like as a small child, you could have just picked a different family, or replaced your parents. You didn't have any choice. You had to function as best you could with the parents you had.
Puder:
Yeah. It's so interesting how my language pointed at me, at all times.
Shedler:
Yeah. Almost like it was your failing or your pathology, that you had to be vigilant in the ways you were. Versus that you were growing up with two angry, volatile, neglecting parents who could explode. Certainly your father could. And at any moment he could also just disappear and leave you to fend for yourself for weeks on end… as they both did. And it's like there's sort of two parts of you here. I mean, there's the adult rational mental health professional who thinks about things in a very rational and careful and accurate way. But then in the background, there’s a part of you that's expecting the same treatment from me, and feels like you have to be just as careful and just as cautious as you had to be growing up. A part that feels like you could say or do the wrong thing, and then I wouldn't be here for you either. At best, I wouldn't be here. At worst, I would actively attack you. Or I should say, I would actively attack you, too.
Puder:
Yeah. Something about you commenting that “hypervigilant” for me, it kind of puts it like something is bad with me. Whereas, I was responding the best I could in that environment and that was what was helpful at the time. And so I'm repeating that here.
Shedler:
I think that you were doing the best you could to survive that.
Puder:
I guess where I get confused is it brought me a lot of good things to be very good at reading people. Like my mentors, I had some good English teachers and stuff where I was like, for me, kind of getting onto their page. It gave me really good things to be able to read them and–
Shedler:
Yeah, I think you're 100% right. There's no question about it. It’s kind of your superpower, to be able to tune into other people that way. But like all superpowers, it also comes with a huge cost. Which is, you were focused on what you think the other person needs and wants, and your needs and wants go on the back burner. Or don't get on any burner at all.
Pause Role-play:
Now, this was the place, if we had started with the first session and we had kind of gone through the process of why the patient is here, what is the purpose of our therapy, what are we trying to accomplish here together… we would have done all of this beforehand. This would be a place that I would refer back to. I'm just making this up now because we didn't have that conversation. But by objective external criteria, you're doing pretty well in your life: good practice, successful in your career, married, wife, family, but things feel empty and dark and sad and joyless on the inside. That's why you're here. If that was the reason the patient came—there could be many, many reasons—if that was the reason, I'd want to make a very explicit link between that and what we're talking about now. This is a sort of little micro instance of this superpower. He knows he is very, very good at accurately reading and responding to other people. I don't want to diminish that. I mean it’s true, right? He has that ability. And that's why a lot of people with depressive personality style are drawn to the therapy professions.
They have a kind of hypertrophied capacity for empathy, which can serve them very well as a psychiatrist or a therapist. But it can also come with a terrible price. So what we want to do at this point is link it specifically back to why he came to therapy. We can say, here's your superpower: You're very, very good at reading and responding to what other people need, but it comes at this terrible cost. The cost is that we—and I mean both of us, him and me both—–don't always get to hear what you need and want. What would make an interaction feel satisfying, or make life feel satisfying and meaningful, allow for pleasure and joy, for you. So I'd link these things because they're the flip side to the same coin. There's the superpower and there’s a real liability, not a liability that affects other people so much, but that gets in the way of you being able to live a life that you can enjoy. Whatever we had agreed is the purpose of therapy, why he came in the first place—I would take advantage of this opportunity to make the link to that. “This is why we're here.”
Resume Role-play:
Puder:
Yeah. I think when I hear I should, it's interesting because I know that I need to get in touch with my own feelings and desires. And I think that was one of our initial goals that we identified. And also why am I extending myself too much at work. I think part of the conflict is I've always had the philosophy of serving others has intense value and to kind of put myself second or to diminish my own ego and the importance of it.
Shedler:
Yeah. You had the philosophy, a lot of people find meaning, deep meaning in living their lives, in choosing to live their lives that way. That's an option. What I'm concerned about, I think what we're both concerned about for you, is it's not clear, as of now, how much that's really a choice versus something that happens in an automatic, obligatory way. Like for instance, you saw a social media post of mine, you didn't like it, it felt critical. It makes you concerned about well, maybe you're not in the right hands after all. Maybe I could be–
Puder:
Oh, no, no, no. That's, that's not what I was thinking.
Shedler:
I know you didn’t say that. I'm saying it.
Puder:
Okay. Okay. But I like the post. It just was convicting that like, I came in talking about how I overextend and maybe I need to charge–
Shedler:
Well, what I was getting at is I'm not sure that if you were upset by the post, or if it made you worried that you’re not in good hands here, I'm not sure it would have felt okay just to say so. In fact, I'm pretty sure it felt not okay to say so. And to respond to what you said about your philosophy of how to live your life, it may be a valid choice, but for you just here and now, I'm not sure how much choice there's been. And I think that's why you came to therapy in the first place. It's entirely different to say here's something, here's the thing I want for myself. Here's something I desire. But there are other things that are more important to me that preclude that. And I'm going to make a choice, and I know this is something I want, but I'm going to choose something else that's more important to me. That’s different than not being able to want it in the first place.
Puder:
When I hear this, what I think about is that quote I've memorized from Dostoevsky: “I'm not worthy of happiness. My life is a series of errors, and perhaps this misery is what I must endure to atone for them.” I don't know why, but that resonated back in the day, like in college, and I memorized it. It's interesting because I feel like I reincarnated from some awful person to go through some of the suffering I went through.
Shedler:
It resonated because in a very important way, I think it speaks to the story of your life. This was the family you were born into, your role was to suffer and bear the suffering for all your parents' failings. And to feel like that was your lot, and what you deserved.
Puder:
Yeah. And so I think it's like something is shifting there. And maybe that's kind of– coming back to the dream– it feels like that kind of ruinous building that I was in, it feels like something is shifting. Maybe I can kind of look at things a little bit differently or maybe it makes me…
Shedler:
Well when you said the ruinous building that you were in in the dream, it seems like you just linked that to, it was right on the heels of just saying directly how ruinous your childhood was. It seems like you just connected those dots that you were literally living in ruins in childhood with holes in the walls and cockroaches and hypodermic syringes in the car seats, and your childhood and your family were the ruins. And in the dream, the dream depicts you as enduring this and confessing your sins.
Puder:
Oh, yeah. Somehow I still am blaming myself in the midst of that.
End Role-play:
Shedler:
Okay, let's step back. So I'm being a bad therapist because I got kind of caught in the roles between talking to you as interviewer and to the listeners, versus the role of being therapist. And if it were therapy, it really got a little too intellectualized and away from the immediate experience. So not a very good model of doing therapy in this, you know that last–
Puder:
Which part? I think you're being hard on yourself here. I think it is really good.
From Obligation To Freedom: Therapy’s Role In Personal Choice (1:35:03)
Shedler:
The part about the philosophy, because it's really about– I got a little didactic and explainy…”
Puder:
Oh, really?
Shedler:
A little, I thought so, yeah.
Puder:
Okay. Well, I think what I've realized is that as I reread this stuff over and over again, I'm like oh, people really adopt the philosophies based on their personality.
Shedler:
People adopt a philosophy that solves–
Puder:
That solves their personalities—
Shedler:
—psychological conflict. Oh yeah. Your choice of career, your choice of partner, your choice of lifestyle is a compromise.
Puder:
And that's not to negate a philosophy being true or not true because it still could be true.
Shedler:
Right, it still could be a perfectly reasonable and valid and meaningful life choice. But we have to understand that all life choices are overdetermined and reflect something of our own psychology.
Puder:
But what I think I appreciate– what you said there– is even with this guy, you wouldn't want it to be unconscious. You would want him to have a choice if he's going to choose to be sacrificial or if he's going to choose to be in touch with his aggression and have a boundary with his time.
Shedler:
This is ultimately the goal of psychodynamic or psychoanalytic therapy, and I would say of all good therapy that's aimed at self-understanding. The goal is to expand freedom and choice so that things that were previously automatic or experienced as obligatory become a matter of choice. That's the goal of the work—to expand freedom and life options. And the person might, in any given circumstance, make the decision to do whatever they would've done before therapy. But now it's a decision. It's a decision made freely.
I'm a little mindful of the time—I want to make sure we get this out because we haven't named it explicitly—but this is what you and I were working on in the role play. This is really the essence of this depressive personality style that we're speaking about: typically, a child growing up feels deprived or mistreated in some way—neglected, or in extreme cases, actively abused. But in the more common case—like if you were looking at the family from the outside, like a social worker doing an investigation—the parents could look adequate, maybe not neglecting in any externally obvious way, but emotionally neglecting. The child's experience is that they're not getting what they need because the parents aren't coming through. The parents are inadequate in meeting the child's needs—but that’s an incredibly, incredibly dangerous thought for a small child. It's extremely rare for a young child to consciously think, “I have bad parents. My life and my well-being are in the hands of people I can't count on.” A three- or four-year-old simply cannot tolerate this thought.
The child's solution to this horrible, impossible dilemma is, "Well, I'm getting mistreated, so it must be my fault. It must be because I am bad." So the child concludes that they're bad instead of the caretakers. In a very paradoxical way, there’s something hopeful in that for the child. It allows the child to sustain hope, because if the reason they aren't cared for is because they're bad, then it's potentially under their control. They could become good, and then they'd have parents who love and take care of them. So in the child’s thinking, if it's their fault—if it's because they are bad—at least there's a spark of hope that their parents could be good parents after all, if only the child weren’t bad.
If the child thinks their well-being and their survival is in the hands of people they can't rely on, that's just devastating. So that's the essence of this personality style. And then it comes out years later, in therapy as an adult. The therapist had to miss a week and isn't available—when your father died, for God’s sake. And your thought is, "Oh, I don't want to burden him." We could draw a line from that childhood experience—"I'm not getting what I need, and it's because I am bad"—to "I shouldn't call my therapist; that would be a burden."
Puder:
Yeah. So it's like the anger is turned into guilt. The transference is set up so that there's a gentle idealizing and anything bad from the therapist goes on to themself.
Shedler:
The criticism of the other is turned into self-criticism. What initially starts as, "This other person—my therapist—isn't here for me when I need them," becomes, "I'm too much of a burden. I'm asking too much. Something must be wrong with me."
Puder:
I think it's really helpful. I hope this episode has been helpful for listeners; it’s certainly been helpful for me to study and think through it carefully. I think the questions listeners might still have are about "the how," right? People always ask about "the how." In this conversation, they've been witnessing how to do it—how to help someone with these struggles. So any kind of–
Shedler:
Yeah. So we…
Puder:
Anything we haven't covered?
Shedler:
We have to recognize the core enactment, which is that the patient is going to treat the therapist in a way that makes the therapist feel good. It's easy to enter this kind of therapy pseudo-paradise where we both feel wonderful about each other: the patient is so appreciative of us, and we're happy with the patient because they work so hard in therapy, they always pay their bills promptly, they arrive on time without fail, and they're consistently appreciative. As therapists, we feel especially competent and helpful—like we're really effective therapists with this patient. But what quietly slips away unnoticed is that the patient isn't actually experiencing meaningful change in their life outside of therapy. That's the real issue.
To put it in biblical terms, if we've created an illusory paradise in therapy, we need to invite the snake into that paradise. It's not really a paradise; it's an illusion of paradise. We need to welcome the patient's anger and aggression into therapy, because it's already there—just not in a form that's being recognized or acknowledged. We need to make it increasingly possible for the person to bring in a wider range of their emotional experience, which of course must include the entire spectrum of human emotions: anger, resentment, rage, envy, punitiveness, vindictiveness. These are all human emotions, but the person with a depressive personality style doesn't experience it that way. They think, "Maybe they're human emotions for other people—but not for me. I would never feel that way." We want to help them experience and integrate a fuller range of their emotional life.
Puder:
Yeah. I think another way of saying this might be the most empathic thing to do, would be to invite that other side. It would be unempathetic for you not to invite it.
Shedler:
Exactly. And here's this enactment… this is where therapy goes south in treating patients with a depressive personality style, because the therapists are very likely to have a depressive personality style too. It's a perfect mesh and if you think about it, the therapy professions make an invitation you can't refuse for somebody with this personality style. What do you get if you go into the mental health profession, what does it give you the opportunity to do? Well, you get to focus intensely on other people's needs, not that that's bad on its own, that's the job. But you get to focus intensely on other people's needs at the expense of your own. You get to constantly fault yourself, however good you get at the work. Because perfection isn't attainable, as I said earlier. We're all making mistakes in every session all the time. You get to fault yourself perpetually for falling short of some unrealistic, unattainable, internal standard.
Puder:
A Jonathan Shedler, super ego!
Shedler:
Hah! Well, you put your own needs on the back burner. And here's where I see this—I'm so glad you brought this up because I see this all the time: the misuse of empathy as a defense for the therapist, against the therapist's own aggression. So what happens in therapy is the therapist is very, very, very empathic to the patient's hurt feelings, broken feelings, the sort of needy child-like feelings of needing to be taken care of. The therapist has empathy for that part of the patient—but no empathy whatsoever for their envy, their anger, their aggression, their resentment, their vindictiveness, their competitiveness, their rivalry. All of those things are there. How do I know those things are there? Because they're human. But the therapist has zero empathy for that. So it's empathy, I would say pseudo-empathy, as a defense both against the patient's aggression and maybe more importantly, as a defense against the therapist's aggression.
Puder:
And as someone who studied micro expression, a 10th-of-a-second flashes of emotion on people's faces. And every person has expressions of anger. Not everyone knows that they have the expressions of anger.
Shedler:
And it makes a world of difference because that's information, it's information in the interaction eith the patient, it's information in the countertransference. We don't want to shut down that channel. There are three major channels of communication going on in therapy. I don't think you talked about this, but this really comes from Otto Kernberg’s writings. One is the content of what the patient says. The other is the nonverbal things they express through facial expression, body language, tone of voice. That's the second channel. The third channel is the countertransference, what they evoke in us. If we shut down that channel, we shut out important information that otherwise should come through that channel. And we're really, really limiting our effectiveness as a therapist. We're having these reactions to patients for a reason. It's information.
Puder:
Can I show you the micro expression just for those who are watching the video here? So this, I actually filmed a lot of people watching YouTubes, and so this is what it looks like right here.
Shedler:
Very serious looking person here.
Puder:
But do you see the down and together of the eyebrows? Like, it's like one 10th of a second. Yes. Boom. That's the micro expression of anger.
Shedler:
That's a lovely example. And a therapist who wasn't defended against that might register it even if subliminally, maybe they didn't get the specific movement, the eyebrow. But they saw something.
Puder:
They saw something. Yeah.
Shedler:
And that's a good place to say—to just slow down there—and say, “something just happened here. Your expression changed. I wonder if we could just slow down here and notice what might come up.” So we notice what the patient evokes in us and then we use that– that becomes a signal to us to invite the patient to slow down and notice more.
Puder:
I could get onto other tangents here, but I think we gotta wrap it up. This was wonderful. I hope that people appreciate Jonathan Shedler and the expertise that you bring. Appreciate you coming back on. And we will be posting this on X. We'll be posting it on YouTube if you want to watch the video. I know a lot of people just watch the podcast, but if you wanna watch the video, you could jump on there. And yeah. Any closing words?
Shedler:
Yeah, just on a personal note, I have to say, I was very aware coming on the show… the last two podcasts of yours that I watched were Otto Kornberg and Frank Yeomans, and boy those are big shoes to follow.
Shedler:
Kernberg is a living legend for a reason. I mean, I could just– almost did actually in real life– but I could sit at his feet and just listen to him and take it in. And that actually happened, except it was at a dining table, but my experience was I could just sit here forever. And I think Frank Yeomans is one of the most gifted master clinicians who's publicly out there teaching. I mean, every time I hear him, it's a pleasure and I learn something every time. So I was very acutely aware, these are the people I'm following on your podcast.
Puder:
Oh, man. And I think I really appreciate– you sent me a message like that was a historic interview. And I think if anyone hasn't watched Kernberg or Yeoman's, both of them are amazing. Actually, when I was reading through the journal articles looking at transference focused therapy, if you read the methods section for a lot of these studies, Yeomans is the supervising therapist on these studies. Like he is the guy. And then Kernberg is just masterclass. I think you sent me a message, like “I understand everything he was saying and I love it.”
Shedler:
Yeah. It was kind of scary.
Puder:
Which I'm like as I get deeper into this material, most of it's understandable. And it makes so much sense. It makes so much sense.
Shedler:
Well, I'll just share with the audience what I wrote to you privately. So I remembered when I was a 20-something year old grad student trying to read Kernberg’s books. These are books written in the late seventies or early eighties. And for anyone who's tried to read Kerneberg’s writings of that time in the original, it's really, really, really hard to read. It is not an easy read. It's incredibly challenging and demanding. And I actually had the depressive thing, I was reading his book, and I'm like, “Oh my God, I feel stupid. I'm like, I'm not up to the work of this profession. If this is what it is, I’m inadequate.” So fast forward a few decades and now it's like, “no, I'm pretty much tracking with everything.”
Puder:
Yeah. I was not expecting an interview. That's the wild part. I was expecting a phone call where we would talk about an interview and then I would spend like a couple months reading and rereading. And so I jump into this and it's like, okay, here we go.
Shedler:
I think that interview and the fact that you made it happen, whatever it took, I think it's a historic event.
Puder:
Oh, and I'll say for those of you who have listened to it or listened to this, my new sort of approach to the write-ups is to do a really nice transcription where then I put in footnotes and I put in the footnotes for the beginner. It's not for the expert, it's for the beginner. So if you are confused, if you wanna go back, listen to this episode, something was confusing, you wanna go back, look at the transcript, eventually we'll have one up there with footnotes, Kernberg, we have one up there with footnotes on my website psychiatrypodcast.com. It's free for anyone. All my stuff is free.
Shedler:
I highly recommend it for whoever's listening.
Puder:
And we'll continue to produce good content. I think we were gonna go through every personality style eventually. So five years from now, we'll be done.
Shedler:
David, thank you so much. It was a pleasure to be here.
Puder:
Alright, we'll leave it there for today.
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