Episode 267: Cohort Group Consultation and Reflective Function: Transforming Countertransference into Clinical Insight
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Introduction and Cohort Experience (00:00)
Puder:
Welcome back. I am joined today by Dr. AlIie Riege and Dr. Jeremiah Stokes. We are going to be talking today about the power of countertransference, of understanding your own countertransference. We're going to be talking a little bit about reflective function (RF), how that relates. Dr. Allie Riege is a cohort leader, and so is Jeremiah. This is the second year we've been doing cohorts with people that are listeners that join. And it's exciting to meet people that have been listening for a while or maybe pretty new listening, and we thought we'd come on and talk about the experience of that. And so, yeah, maybe I'll just have Allie start because Allie was once a cohort member, now has, for a year, been leading her own cohort. And what has it been like for you?
Riege:
Okay. Well, let's see. Being a cohort member initially was something that I had been looking forward to for a while. Just wanting to dive deeper into psychodynamic case conceptualization and really, case consultation with others. At that point, we hadn't really articulated reflective functioning and therapist reflective functioning as much, but then that sort of came to fruition during that time. That's my memory, at least. And diving far more into reflective responses and looking at how early childhood dynamics and personality may be contributing to how we show up in therapy. Our preferences in therapy, our interventions, ways we may unconsciously collude with a patient you know, ignore certain things, respond, value other things. And so that was, that was something that I really dove much deeper into there.
Riege:
And then, just sharing in this experience, hearing other people's cases, hearing their approaches and people with such different personalities and training that really just helped me think differently, more creatively. And then also, attending to group process. I think that’s something that I really try to highlight now, running a group, is this sort of the opportune time, really a wonderful opportunity to not only attend to the content of what we're learning, because we are learning a lot. And for a lot of people coming into the group there's been no psychodynamic education training. And so it's a lot of new material and it's very dense. And, as you've talked about a lot on your podcast, the huge gap between theory and application, I think is where a lot of people feel stuck.
Riege:
Like, “Okay, I am sort of starting to grasp what this means as far as personality and levels of functioning and transference and countertransference, but like, what now?” And so, that's a piece of it. That's a huge piece of what we're doing. Learning about that. It's didactic that way, teaching it, but also really trying to support group members in attending to their countertransference [see episode 41], their interpersonal process, their emotional reactions, feelings they're having, that are uncomfortable. Whether it's some sort of disgust, shame, embarrassment, envy, not wanting to come to group, wanting to speak up and not saying something feeling inadequate. All of these things that are constantly there right under the surface. And so having that be a real focus of the group as well.
Puder:
Yes. Really good. Yes. And Jeremiah, any thoughts as you listen to this?
Stokes:
Yes. I think that's a great overview. I think running this consultation group, it is evident that people are hungry. They're hungry for more depth, they're hungry for more understanding, understanding the nuance, understanding the complexity that is our patients. And so I think there's been, I've really noticed this drive for more depth with regards to case formulation. I think the other part of this, that has been fascinating to observe, is the growth that I have seen in cohort members as it relates to their own personal experiences. And Allie referenced what some of those things could look like, whether it's through countertransference or really engaging in a group in a really meaningful, connective way. I've seen professionals grow tremendously in terms of acquiring more knowledge of themselves and how that shows up in the work that they do with patients. And so I think what we've been able to facilitate in this group is not only expansiveness as it relates to understanding cases and psychodynamic theory and depth, but also just really helping people understand themselves in a personal context and how they show up with their patients.
Puder:
Yes, it's been a lot of fun. You know, I used to lead groups for residents. I know both of you have led other groups as well, in the past, but I think there's something nice about there's no grade, you know, this is not like a gatekeeping exercise like so much of residency. It's like you feel like you have to show up in a certain way just to get through. So maybe you hold back a little bit. There's a degree of vulnerability that isn't there. Was that, you know what I'm talking about, Ally?
Why Vulnerability Feels So Hard for Clinicians (06:41)
Riege:
I mean, yes. It's certainly been. We've had many discussions about how challenging this has been. And I know most group members, most cohort members, have spoken to that, have said, "This has been maybe the hardest part of this whole group, allowing myself to be vulnerable, opening up a little bit more.” I think that many, many people that come have been in their own personal therapy before. And so there's experience with that, but this starts to elicit all types of emotions that I think make many a bit uncomfortable and unsure of what and how to share, particularly in the role that we're in, because so often wearing this hat or the role of therapist or psychiatrist, NP [nurse practitioner], you're not sharing or you're told not to.
Riege:
And that's something that we certainly work on through learning how to use countertransference, which is, I know is something that we'll talk about in a little while, and why it's so important to do some of this self-reflective depth work in this process in an effort to be able to use the countertransference and transference in our work. But I would say, I don't know what you guys think, but I would say that that's certainly been an area where most members have felt surprised and a little reticent to engage at times. Oftentimes, there's a trickle down effect of one or two people being willing to sort of jump in, dive in, and then others might open up more. But yeah, it's been, that's definitely an area that I think surprises people.
Disavowed Emotions in the Group and Their Link to Reflective Function (08:43)
Puder:
Yes. And I think that we're enculturated, at least in medicine, to really have a very strong social veneer. But having, if all you do is ever talk from the place of a social veneer, it's actually low reflective function. So, you know, if you're not able to say what you actually feel or what you actually have, maybe some embarrassment about saying, you can't really get in touch with your countertransference at all. Right? So I think this is the case for group members when they're like, “Gosh, I'm having this stuff come up for me, and it feels like if I share it, it's going to be too much.” But I really care about every single member that I've ever worked with. I think the best for them.
Puder:
They may fear that I'm critical of them. I'm really not. I really want them to thrive in their work and life. And I realize that we're all in process and there are some things that we're going to have lower reflective function for, and some things we're going to have higher reflective function for. But the things that we already have high reflective function regarding, then we may not need to discuss those things at all. You know, they're not distressing to us in the same way as the things, the memories, the events with patients that maybe don't come out as smoothly. Maybe there's a bit of difficulty even saying it out loud. Right? That's usually where the good stuff is and where growth can happen. And I was thinking about the place of disavowed emotion [see episode 222 and 255]. Maybe we should talk a little bit about that. Like how the group really will feel whatever is disavowed, and this is something that always surprises me. When someone, maybe they have a lot of disavowed anger, someone in the group is going to feel that anger. Do you know what I mean?
Riege:
Yes. Yes. It comes up all the time when someone's sharing a case. I love going around and just hearing one or two words of what's coming up for everyone in the group emotionally. Right? There's this, and I'm guilty of it too, there's this desire to like to leap in, to sort of intellectualize what might be going on here. But really making a point to say what emotion is being elicited for everyone right now. And oftentimes there, I mean, most of the time there's meaningful data and it might be about the patient that we're talking about, but oftentimes, it's about who's presenting and what might be there for them that is disavowed.
Stokes:
And I think when there is something that's disavowed emotionally, it's almost felt tangibly by the group. And what I've found though, is that oftentimes it takes processing with the group for each group member to sort of assess and evaluate, “What am I feeling?” And so, I found that, let's say there's a member who has disavowed anger, it may not be indicated from another group member immediately, it may take 30 minutes of group discussion and processing for us to sort of arrive collectively. It's like, “Oh, so that's shame, or that's anger that you're feeling.” And so I think when the group picks up on that, which is disavowed, there's an additional step in group processing where we all work together to sort of discern what we are actually feeling in the room. And I think that's really important when we're thinking about countertransference with our patients, because I think oftentimes we're picking up on, obviously things that are disavowed, but we may not know exactly what it is. And so we need time to process that. We may need consultation. These are the cases that we bring to consultation. And so I think that's the magic of the group, is when the collective sort of works together and explores, it can really help reveal these unconscious processes, I think in a way that you don't get an individual consultation.
Puder:
Right? And the finding of the disavowed is an increase in the reflective process. Right? Like, if there is disavowed emotion, and if you just jump to intellectualization, you are staying at a level four or a level three RF. Right? And so intellectualization is disconnected. It's theory, basically. You're trying, it's distancing from the emotion. And this actually happens a lot in different therapy communities. It's like someone shares something and it's like, “Well, this reminds me of the self-object transference and blah, blah, blah.” It's like, that would be okay if it was connected with the emotion. But if it's just like, and then everyone's like, “Well, I have no clue what this person said, but you know, it sounds really intelligent.” So I think we can do a disservice to people or training because then they're not able, we should be able to talk in a way that everyone understands. And I've always thought about this for my podcast. Every podcast episode, everything I say, should be understandable. Ideally. I mean, some things are harder to understand than others, but my hope would be I wouldn't overly complicate the language for the sake of sounding intelligent. Right?
Stokes:
Because that's a defense. Right? And that's the beauty of the group. If someone is, in fact, intellectualizing, you have the group there to kind of stop and go, “Wait. What is this really about? What are you feeling underneath that?”
Common Therapist Personality Dynamics and Countertransference Traps (14:36)
Puder:
Yes.
Riege:
Yes. Something else that's coming to me too, that's somewhat related, is giving voice to these qualities that are pretty common to people in our profession and normalizing those, and not only talking about the strength in those qualities, but the vulnerabilities, you know, in terms of how that might impact the relationship. The ability to look at what might be meaningful data in the countertransference slipping into a particular role, responsiveness or enactment, without really understanding what is being pulled for. So, spending a nice amount of time on common factors of therapists, and obviously it doesn't relate to everybody, but at least a few do to all. And I know Nancy McWilliams talks about sort of the depressive personality style (McWilliams, 2011, pp. 248-250). And so, commonly a disavowed emotion that might be shared by the therapist, clinician, and patient is disavowed anger, an inherent sense of guilt that is unconscious.
Riege:
And so it's not coming into the space, what's needing to be talked about and is brought into the open is ignored unwittingly. And other common factors like this desire to nurture, a need to nurture, feeling responsible for the patient's wellbeing, feelings, this pressure to do and act. And I think that's why Nancy McWilliams’ texts, initially for so many people in the cohort groups, they feel so connected and seen by this idea of not needing to act, but needing to focus a little bit more on the emotional space containment. I find that so many of the cohort members come in and just feel a little at sea with this idea of, “I need to be doing something all the time. I have to make it better.” A desire to be liked, a desire to fix, and that isn't really achievable. That's not attainable, or you're going to end up going in circles with many patients without this greater awareness of, “What might I be reacting to and responding to that is both inherent in my own personality and drives and wishes but also what they're sort of pulling for in me.” And so, that's been a major shift, I think, in cohort development and in sort of what they're attending to.
Puder:
I'll be honest, sometimes I will find myself in my own head thinking, “I need to bring this cohort value. I need to say things that are going to help them, equip them. Am I doing enough?” Right? And then the problem with those types of internal thoughts is it takes me away from what someone is saying to the cohort. And so it's like I almost have to forget and have, “No, I've prepared. I've read the chapter, article, whatever we did before coming in.” But then I also have to kind of just see what people bring in and go with it and kind of forget my need to sort of teach, be a podcaster, you know, put stuff out there that's valuable.
Modeling Vulnerability and Not Knowing as Group Facilitators (19:06)
Riege:
Yes. Or have the answers. Right? That's why, that's like, I'm speaking of, you know, as a therapist, I feel I'll fall into that feeling like, “Oh gosh, they're looking…. I need to have the answer.” And I'm almost better in my role as therapist, being much more comfortable in not knowing. And then, in the cohort group, really having to remind myself, “This is the same thing.” Sure. I have training and I'm prepared in what we're going to be talking about and some experience that maybe I can bring to group, but that there's also… there needs to be space for my own not knowing. Right? And bringing that to group and making space for that.
Puder:
And there's a lot of collective wisdom in the group members.
Riege:
Yes. Oh, yes.
Puder:
Yeah.
Stokes:
And yeah, and I think that as the group facilitators, that's our way of practicing vulnerability. Right? So being present, understanding the fact that we don't know everything, our own shortcomings, I think that requires us to be vulnerable. And so I think, in a way, we're sort of modeling that. I think there's a lot of power, for example, in saying, “I don't know.” There's times where I'm asked a question in group or when I was teaching classes, and I don't necessarily know the answer to that. And I think there's something that can be modeled through that level of vulnerability. And so I think, as group facilitators, we're essentially doing the same thing.
Puder:
Absolutely. So, okay, getting back to countertransference a little bit, I guess we're still talking about countertransference, but we're talking about group, maybe group level countertransference. What emotion is disavowed? What emotions are felt? Why do we feel the way we do? Right? That's the reflective function question. So, if all you do is feel anger and you have no clue why you feel anger and if you were in the adult attachment interview (AAI), and they'd [ask], “Well, why do you feel anger?” It's like, “Well, I don't know. You tell me, you're the expert.” It's actually a [score of] -1. Right? And so, on the score from -1 to 9. So the question is like, “Well, how do you get in touch with the ‘why’?” that you're responding to this client? Right? And I think that the “why” can lead to increased empathy. Okay. So the journey through the why, the journey through increasing reflectiveness leads to increased empathy [see episode 260]. So what do you guys think about that idea? How does it lead through to increased empathy? Do you see that?
Stokes:
Well, I think when we're questioned about the “why”, it forces us to try to have a deeper understanding emotionally of what's underneath all of that. Right? Whereas, for example, if we intellectualize a response or if we have purely an intellectual analysis of what's going on with our patients, I think we lack the depth in truly understanding their experience. And so I think by doing a search, and I think this can happen with the group, when the group sort of shepherds us into doing an internal search, we're able to sort of, through the emotional process, we're able to discern what exactly that's all about. And the true meaning underneath that.
Riege:
And it allows this different information to empathize with. Like, you might be experiencing the emotion that the patient is feeling. And so, you're really attuning to that level of pain or fear or shame, and you're feeling that deeply. And so that allows for, hopefully, for them to feel seen in that way. But, there's another level of empathy that can come from countertransference information and our reactions. And that is sometimes what they're eliciting in us that might be a reaction, whether it's projective identification or a role responsiveness. And what are they trying to communicate to me right now that they don't know, that they can't articulate, that's outside of their conscious awareness? And it might be rage or a desire to flee, like, leave, “I can't wait till this is over.”
Riege:
Or a desire to just fix everything. You know, frustration like, “This problem is clear. Let's solve it.” but containing that. And here's where you get to more of the empathy of like, “Okay, on the one hand, this might be what many other people in this person's life feel. And so they're moving through the world in conflict, like desperately wanting closeness, but this is what they're eliciting in people. You know, they're not knowing fully how to get those needs met in a way that they would want to. And at least for me, that does create a significant degree of empathy. Now, what next, right? How to use that depends on the patient's level of functioning, their attachment injuries. Like, can they tolerate some sort of, I don't know, cognitive dissonance here?
Riege:
What's the ego strength like? Or is this somebody who really just needs containment right now? For me to contain what's happening and provide some stability and not react in a way that I'm being pulled to react? And so, I think the patient communicates what those needs are. But yeah, so there's these various ways, many ways that the countertransference can show up, whether it's attuning directly to what they're feeling and being able to connect with them there, versus, interpersonally what the stuff, what the frustration or suffering might be for that patient as well as the people in their lives and what they're reacting to.
Stokes:
I think on a simple level, being able to just ask as the therapist, “What am I feeling? What is in the room right now? What is being invoked within me?” And I think oftentimes clinicians, they lack that first step. And I think that's the gateway to empathy. Right? Is being not necessarily “What is the patient feeling,” although that's needed as well, obviously, but “What am I feeling in response to what's just been disclosed? Is this more of my stuff? Is this perhaps how other people in their lives experience them? Is it a combination?” Yeah.
Stokes:
Then I think that can really inform the next intervention. You know, there's ways to do that. Like, “I'm feeling a lot of anger in the room right now, and I'm wondering if you are angry? Does this story, I'm wondering if this story is sort of eliciting a sense of anger within me. I'd like to process that with you.” And so, I think a simple identification of the emotional experience that is being invoked and then verbalized, I think is a really simple intervention that can go a long way.
Puder:
Maybe I can give an example. I'll read a little passage here from Nancy (McWilliams, 2011) talking about countertransference, specifically a narcissistic personality disorder [see episode 171]. Okay? And I'll show this for those of you that are on YouTube:
Related to these phenomenon are countertransferences that include boredom, irritability, sleepiness, and a vague sense that nothing is happening in the treatment. A typical comment about a narcissistic client from a therapist in supervision: “She comes in every week, gives me the news of the week in review, critiques my clothing, dismisses all my interventions, and leaves. Why does she keep coming back? What is she getting out of this?” A strange sense that one does not quite exist in the room is common. Extreme drowsiness is perhaps the most unpleasant of the countertransference reactions to narcissistic patients. Every time I experience this, I find myself generating biological explanations, “I didn't get enough sleep last night. I ate too big of a lunch. I must be coming down with a cold.” And then once the patient is out the door, and another one is inside, I'm wide awake and interested, occasionally, once countertransference to an idealizing person is a sense of grandiose expansion of joining the patient in a mutual admiration society. But unless the therapist is also narcissistic, such reactions are both unconvincing and short-lived (p. 187).
Boredom, Irritability & Dissociation as Valuable Clinical Data (28:46)
Puder:
So what I was thinking about with this one, specifically, is boredom. It's hard to say as a therapist that a patient bored you. It feels very risky to even tell yourself that that's the case. Right? And so she's saying to herself, what she inevitably tries to do is say, “Oh, you were just tired, or you had a big lunch.” Right? She's trying to find any reason to explain it. But there's something about when you're listening to someone and they're talking from a grandiose facade, and you're not really meeting the real person in the room, you're not reading the real emotions, the deeper emotions, like the shame or the vulnerability that you inevitably believe could be there. You might become a little bit tired and fatigued. Right? So if you're my patient listening to this and you remember me yawning during a session, I may have just been sleep deprived. I mean, really, that could be the case for me. So don't beat yourself up. But what I'm saying is that with the same person over and over again, if you find this reaction, it's like, “Oh, is this because we're not really talking about what's really vulnerable?” Right?
Riege:
Or that, “I'm not really here. I'm not really in the room to this person.”
Puder:
They're talking at you, not with you.
Riege:
But I think it's a good point. Right? Like, “Is this something that I feel somewhat frequently? It's familiar to me. Versus, “Is this something that's noticeably outside the norm?” I remember one really jarring instance. My patient, at the time, was violent, was really quiet, and was pretty withdrawn. But I felt like outside the window, I could see the tree outside and it suddenly felt like it was not really there, was I really here. And this sense of my insides, like maybe I was going to, I don't know how to put words to it, combust, cease to exist. Right? It was real annihilation anxiety, which later I could put words to. And understanding that the patient needing to withdraw was so necessary for safety and sort of grounding himself. But also there's that empathy of that tremendous amount of fear and confusion in the moment. Which again, if that was something that happened frequently then I might think about what else might be going on for him. But certainly in that situation, he was communicating something to me that he couldn't put into words.
Stokes:
And I wonder in that case example, from McWilliams, it's almost like this feeling as the therapist of dissociation, you're dissociating. Right? And so, it's almost like you're probably encapsulating how other human beings feel in this patient's life, because if this patient is constantly self idealizing, we know with idealization, there's automatically going to be devaluation interpersonally. And so, does the therapist feel so small that they simply have to dissociate and disconnect from that experience? And that may feel like what it means to be that patient's kid or that patient's spouse. And so I think it is really important to look at all of the details, the character structure and what does it mean to be in relationship with you because we are in relationship with our patients. And so how do I, as a representative of your world, what am I embodying as I work with you? Because chances are other people are feeling something similar. And I think it's our job though, as professionals, to really draw the insights to help produce that data for the patient.
Riege:
And David, you brought up a good point that I want to give a little bit more attention to is feeling bored, or these reactions that maybe a really seasoned psychodynamically trained therapist is more open to but for so many, feeling, dreading a patient coming or feeling judgmental of them, or disgusted is something that, you know, most people feel like, “I shouldn't be feeling this way. I should have this unconditional positive regard.” I feel like that's what every basic level training is. This is what you need to do, how you need to see people, treat people. And so it's dismissed right away. And I think that the cohort space really digs in for that. It tries to pull that out and normalize it, not have shame around it. I know I certainly try and make a point to talk about my own reactions frequently, just to sort of, I don't know, make it okay. Because yeah, they are frequent reactions.
Puder:
Yes, we can have strong thoughts, strong feelings. Of course we do, because patients come in with strong feelings and complex childhoods sometimes. We talked about with countertransference with [Frank] Yeomans this year, concordant versus complementary [see episode 254].
Puder:
Concordant, that the therapist is feeling what the patient is feeling. Complementary, that the therapist is feeling what the patient's early object felt like. So it could be like they're picking up, they're feeling what the father felt like to the patient. The father felt maybe sadistic and angry and violent, and all of a sudden you could have some desires to raise your voice at the patient. Now, if you had that and you weren't thinking psychodynamically, you would have a lot of shame about feeling that way. And you might push that into your unconscious. If you're curious about it, maybe it can give you some information on how to have empathy for what that was like for that kid growing up in a family where the father was sadistic and yelling at him, and how awful that must have been. And suffocating, maybe even panic oriented. And so I think it can give us clues on how to have deeper empathy, maybe empathy where the empathy gaps even are….
Riege:
Or help them own that, own that emotion themselves. Maybe it wasn't a parent that was feeling that way, but the patient themselves, and they just felt it was not safe, and it still doesn't feel safe to feel any of those things. And so, is what I'm feeling right now really a projection, not necessarily a relational pattern that's being elicited?
Puder:
Right. And we don't know. We're speculative and we're curious.
Riege:
Yes. And that's to bring the space. A patient of mine who was like, “I can tell you're angry with me. You're angry with me,” and I genuinely feel no anger and was just floating the idea that they might be angry or, that's too strong a word, like a little bit annoyed, a little bit frustrated. That can be terrifying, but such a vital part of the work that we're doing together.
Stokes:
And without that curiosity, without doing a deeper dive with what we're experiencing, we write it off. I think oftentimes clinicians will just say, “Well, I'm just bored. They're just a boring patient.” And we know that there's a lot of data there. It means a lot more than “they're just boring.” They may also happen to be boring, but why are you embodying that experience? And I think it does… one of you mentioned curiosity. I think it's so important for us as clinicians to maintain almost a childlike curiosity throughout our entire careers, especially as it relates to countertransference.
Curiosity About Enactments and Our Own Developmental History (37:32)
Puder:
I think coming back to how reflective function can actually help us make sense of countertransference. It's because part of what's higher reflective function is allowing yourself to see something translucent, not clearly. And so, we could, to have an open-mindedness and speculation around what these things might mean actually is a higher reflective function stance. And also, to tie in to developmental ties to ourself, what is it about our own childhood that led us to feel the way that we felt with that particular patient. I was thinking, I was practicing this with myself with one patient recently, and I was going through, “Okay, what are all the things that led me to have this huge reaction to this person?” And one of them was the death of my grandfather.
Puder:
He died. He was mugged outside his office. And as I was sort of contemplating, free associating, in my countertransference sources, one patient who I thought was going to be dangerous towards me, remembered that my grandfather was mugged and eventually died by it. He inhaled the old fire extinguisher fumes and got fibrosis in his lungs. It took a while, but initially when I had a very strong reaction to this patient and my sense of safety. And I even found myself, as I was exiting my building, looking for this guy. That that was a lower, that was almost like I was embodying the level of paranoia of this persona. Only later did I have that free association with Jeremiah. We're on a walk. I talked about it, shared it with him, and it was deepening to have a deeper reflectiveness on what was going on. It lessened the intensity of the countertransference.
Puder:
So some things from our developmental past pull us in very powerful ways, and they remain outside of our awareness. It's, we're, we're in a more reactive position where this is how enactments happen in therapy. An enactment is when you start behaving in a different way towards this client because of this strong countertransference reaction. So anytime you find yourself behaving in a different way that you normally wouldn't behave, be curious about it. There was an analyst who once said that, I don't remember who it was, but he said, something like, it's not that you will be able to achieve some countertransference nirvana and get to a point where you will never enter into an enactment. You will always enter into enactments. You just have to be curious about why they're there and start to deconstruct that with supervision with cohorts like this. Hopefully the enactments don't get to a place of you doing something that would be unethical. Right?
Riege:
Yes. And that's, I think that's such a meaningful part of the cohort group is the curiosity of all members asking these different questions and looking at what role might they be responding to? And, at times, it can feel very healing. Right? Like, “Okay, my job aligns with my value system.” And then you miss out on important information of what the patient's communicating to you about what their needs are. And it's really your own needs being met. Not that they both can't be simultaneously. More often, I think oftentimes both things are happening and that's inevitable. And there's nothing wrong with that, but I think group members can offer these different perspectives or curiosities as to these reactions. I mean, how many times have I been totally blind to my own experience and situations and see it clearly in someone else, and then someone else brings it to my attention? And you feel kind of like, “Oh, how did I not?” But it's just, I think it's the way that it's part of being human and having a necessary defensive process that we all have.
Puder:
And if you're a little bit depressively oriented and you have that kind of introjects of negativity, you could really beat yourself up over having this kind of countertransference type of enactment. Right?
Puder:
Or if you're masochistic, you could beat yourself up and then feel like that's necessary to have meaning and purpose.
Riege:
Yes. Yes. The only way you're doing your job or something like that.
Puder:
I had a group member who said, in group, we were talking about masochism. We were in a masochism chapter. She said, “You're trying to buy love and the currency is suffering. You're prostituting yourself to buy love.” And I was like, “Oh, that's so good. I gotta write that down.” That's so deep. Right? That's talking about if you have some, a little bit more of a masochistic personality, you'll do anything to buy love. Right? And suffering might be the currency to buy love. And if you are receiving a currency for love, that's inevitably a form of prostitution. So really deep.
Riege:
Yes. I think too, someone with more dependency needs or, sort of interpersonal style that way, and the pull to take charge and how that can feel. Like, “Oh, I've been struggling with this person. I haven't known what to do. There's all these symptoms. I feel like I'm putting out fires and here's a way for me to take charge.” And by increasing your own reflective function, thinking about your early childhood roles and also your own personality dynamics, is that a vulnerability of your own? Right? If taking charge feels really good, “I don't like feeling sort of powerless. I feel like I'm failing this person, and it's evidence I shouldn't be in this job.” Whereas, really this is just a communication from the patient of how they've been trying to get their needs met, but often help-rejecting. Right? “I don't actually want you to, you can tell me all the solves help me and nothing's really going to change. So, not to have so much judgment of yourself, but have much more awareness and how that can really be liberating.
Puder:
Yes. The dependency of someone with a more dependent personality could elicit a countertransference of wanting to help them. Right? Wanting to save them. Yes. And one time, a resident of mine entered into enactment like this, where she was buying the patient or helping the patient buy plane tickets, helping the patient do things that were beyond the scope of what was normal. Good natured, not too harmful, but at the same time, let's be curious about that. Like, “Okay, what is it about this particular person where you feel they're powerless to do this themself. Right? That they need you to do it for them?” What kind of, and if you're in private practice, another masochistic thing is sometimes, under charging or never charging certain people or seeing certain people that are maybe abusing you in some way. Right?
Puder:
And sometimes, in group, these things come out and it's kind of like it allows the group member to grow a little bit. You know, like how many hours of charting is too much per night? Probably somewhere above 20 minutes is too much. Right? Where you get some group members that come out and they confess, “I chart for three to four hours every night,” and it's maybe a more obsessive need. Maybe it's a need to feel in control when they feel out of control. It could be a lot of different things. It could be, but inevitably the group can maybe come around them and help them through that. So, yeah. What Jeremiah, what's coming to your mind right now as we kind of, I imagine we're going to wrap this up eventually.
The Healing Power of Group Consultation for Therapists (46:51)
Stokes:
I think we're really speaking to the benefit of the group. You know, it's like, as a clinician, I think through this process, you're learning about your personality, character style. You're learning about defensive processes that come up. Let's say, for example, there's an enactment that takes place with a patient and maybe you don't even realize it's an enactment. You share it with the group, and you have seven or eight people, all have these insights that ask these questions, which then probe deeper self-reflection for the group member. And so, I think the benefit of this group is to take these processes that number 1, we are more unconscious to, which is normal. But number 2, they're pretty complex and there's a lot of nuance. And so having the support and the guidance of the group can really help a person, I think, do a deep self-exploration that can really benefit the work that they do with their patients.
Riege:
Yes. And not to mention, experiencing what our patients are experiencing, like really getting to viscerally feel what it's like to feel exposed to really try and know parts of yourself that maybe you hadn't before. That type of curiosity. And even if there's a history of being in therapy, it's a different experience. And so I see that as such a significant, at least personally, it was such a significantly positive part of being in group and challenging, which was such a good thing.
Puder:
Yes. That's good. Okay, so we talked about some countertransference. We talked a little bit about how reflective function can potentially increase our countertransference responses. We talked about some of the things where group can really facilitate that increased reflectiveness and how understanding your own story can be part of increasing your understanding of countertransference, why it's necessary. Yes. And I think this is good discussion. We don't have to accomplish everything here. I always want to accomplish everything. Any final thoughts?
Riege:
Yes, I think we'll need more time, not the same episode, to talk, to dive into some of the other concepts that we really focus on. You know, levels. Assessing levels of personality functioning and that working with people in that borderline range in particular, and neurotic, across the spectrum, but giving more time to that. But yes, it'd be great to do it again.
Puder:
And I think in the way that I like the cohorts being run is like half the time we're talking about the material that we read, a chapter, and half the time we're doing reflective type of thing. And I think that that's really potent, is to have people write out something before they come in, read each other's responses, comment on it. There will be some reflective function you know, where people are sharing with the group members what they wrote, where there's like 50 comments before the group has even come. Like people are reading and commenting on each other's posts. Which I think is really, really great. And then the processing of that deeper reflectiveness, you know, and slowing the process down, allowing for that sort of group thing to happen.
Puder:
Some questions are like, “Describe your most difficult patient.” “Describe your Big Five.” And we did the Big Five with every group so far. Just to kind of understand ourselves more, understand each other's Big Five personality type or it could be just reflecting on this chapter and what it stirs up for you personally, on a personal level, getting away from just the pure regurgitation of the information [see episodes 92, 95, 97, 98, 99, 100, and 101]. So. Great. Well, we will leave it there for today. Thank you so much for listening in. And if you're interested in becoming part of one of the cohorts, you could go to psychiatrypodcast.com. There's a tab on the top that says cohort. If you get this, and we've already filled, we're doing rolling admissions. We will definitely keep your name and I'll have Jonathan personally call you in future years to invite you to the next year of the cohort. I plan on doing this for a while. Hopefully it'll grow. We'll leave it there for today.
References
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press. https://www.guilford.com/books/Psychoanalytic-Diagnosis/Nancy-McWilliams/9781462543694